Head and neck masses are classified as sebaceous cysts (epidermoid cysts), cervical lymphadenopathy, benign lipomas, lymph nodes, thyroid swellings, or tuberculosis lymphadenitis that may be painful or painless, adherent or fluctuant. In spite of this, they have distinct prognoses and pathological features. The anatomical location of the swelling and other demographic manifestations of the patient provide valuable information about the cause and type of swelling. Computed tomography (CT), magnetic resonance imaging, positron emission tomography-CT, and ultrasonography are the gold standard imaging methods for the head and neck examination. These methods are used according to the region considered for the study. Fine-needle aspiration cytology of lymph nodes is known to be effective, simple, and sometimes the only tool for the diagnosis of lymph node malignancies. This review highlights the epidemiological aspect of head and neck masses in the Indian population. The presence of external superficial mass (lump or nodule) in the head region is a frequent reason for patients to seek an ear-nose-and-throat (ENT) consultation. Some of the common causes for a bump on the scalp are acne, eczema, psoriasis, pilar cysts, hives, or ringworms. Other possible etiologies may be infections, congenital lesions, benign growths, or malignant tumors. The common causative factors can be addressed at home, and in the case of inadequacy, the patient can contact a healthcare professional. Additionally, if the bump is caused by skin cancer, the patient requires urgent medical attention.Similarly, neck masses are commonly encountered by a medical practitioner in clinical practice. A mass in this region has important implications owing to the complex anatomy of the head and neck. The presence of significant underlying structures has great physiological importance too. As a result, the causes of neck swellings may have multiple reasons, and each having a distinct pathology and prognosis while infectious swellings, lymphadenopathies, and benign and malignant neoplasms are the most common causes. Factors like the anatomic location of the swelling and the age of patients offer valuable information about the etiology and type of swelling. For instance, a swelling appearing after the age of 40 is more likely to be malignant. Furthermore, rigorous clinical evaluation along with imaging or pathological investigationslike fine-needle aspiration cytology (FNAC)/biopsy is required to make a diagnosis, to depict the form and origin of the swelling .Surgeons often encounter head and neck masses in their clinical practice. Swellings in this area have serious implications due to the complex anatomy, as well as the physiological importance of the underlying structures. Furthermore, the presence of multiple structures in the neck results in a difference in the origin of the swelling, and each variety has a distinct pathology and prognosis. The most frequently occurring forms are infectious swellings, lymphadenopathies, and benign and malignant neoplasia. The anatomic location of the swelling offers valuable information about the etiology and type of swelling, as the patient ages. For example, a swelling appearing after the age of 40 is more likely to be malignant. For diagnosing a neck swelling, a rigorous clinical evaluation is required that may be accompanied by sophisticated diagnostic technologies to achieve firm evidence and certainty about the type and origin of the swelling, such as the use of imaging or pathological investigations like FNAC/biopsy to confirm a case of recurrent neck mass .Imaging methods are an important part of the diagnostic process to evaluate a neck mass. Ultrasonography is the most relevant screening tool in contrast to other imaging modality and it is recommended for the initial workup due to its non-invasive nature and the absence of ionizing radiations. Subsequently, if the physical examination fails to diagnose the neck mass, then FNAC is recommended, which is preferred as the first line of inquiry in the diagnosis of head and neck swelling .Sebaceous cystGiant sebaceous cysts are uncommon in clinical practice while they are the most common presentation in young adult males . These cLipomaLipomas are the most common benign mesenchymal neoplasms that can appear anywhere in the body where fat is present. They are advanced adipose cell tumors that mostly affect the upper back, leg, and abdomen. In the case of the head and neck, the posterior neck region is the commonest site of involvement (about 13% of lipomas are found here) . The cliMost of the lipomas can be managed without surgical treatment while surgery is required when there is diagnostic uncertainty, lack of homogeneity on palpation, a broad neck mass >10 cm), rapid progression in size, associated discomfort or cosmetic concerns, or a deep-seated lipoma (intramuscular or intermuscular) [ cm, rapiLymph node swellingThe term lymphadenopathy refers to the swelling of lymph nodes as a clinical indication of neck inflammation . Cervica [The number of lymph nodes involved in a person's body may indicate the origin of the pathology. Some levels for lymph nodes in the head and neck and their corresponding areas of pathology are mentioned next .Level IA: Submandibular RegionCancers of the floor of the mouth, anterior tongue, anterior mandibular alveolar ridge, and lower lip have the highest risk of metastasis affecting the level IA nodes, while cancers of the oral cavity, anterior nasal cavity, soft tissue structures of the midface, and submandibular gland are prone to metastasize to the level IB nodes.Level IIA and IIB: Upper Jugular GroupCancers of the oral cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, and parotid gland are highly susceptible to metastasizing to the level II nodes.Level III: Middle Jugular GroupCancers of the oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx are the most common sources of metastasizing to the level III nodes.Level IV: Lower Jugular GroupThese metastasize from cancers of the larynx, hypopharynx, thyroid, and cervical esophagus.Levels VA and VB: Posterior Triangle GroupHere, there are high chances of metastasis from the cancers of the nasopharynx, oropharynx, and skin of the posterior scalp and neck.Level VI: Central Compartment GroupThese nodes are at the highest risk of harboring metastasis from cancers arising from the thyroid gland, glottis and subglottic larynx, apex of the pyriform sinus, and cervical esophagus .Thyroid noduleA thyroid nodule is described as a single lesion within the thyroid gland that is palpable and/or ultrasonographically distinct from the surrounding thyroid parenchyma ,13. ThyrThe probability of the nodule to transform into malignant increases in the presence of following features: (1) extremes of age (70 years); (2) male gender; (3) size of nodule >4 cm; (4) rapid growth (maybe suggestive of anaplastic carcinoma or lymphoma); (5) family history of thyroid malignancy or genetic disorders ; (6) prior exposure to radiation, including radiotherapy to the head and neck ; (7) a painful thyroid nodule that may be a sign of subacute thyroiditis (single or multiple); most thyroid nodules are painless and the presence of pain may be indicative of the cause of the nodule. Additional indications for biopsy include an inability to obtain an adequate sample by FNAC after several attempts, or when a nodule with malignant features is seen on ultrasonography .Salivary glandsSwelling in the salivary glands is an unusual occurrence in the head and neck region in terms of the frequency, variability, and peculiarity of its pathological process. Several salivary glands are present in the lips, cheeks, mouth, and throat. Tumorous growths can develop in any of these glands, but salivary gland tumors are most frequently found in the parotid glands; the majority of these parotid tumors are benign whereas some may transform into malignant. Numbness, burning, or prickling sensations in the ears, or a lack of facial expression are some common symptoms of parotid swelling while the tumors may also present as a non-painful swelling in the face or jaw. Usually, the first step of management for this tumor is surgical removal that can be prescribed as adjunct if the tumor is malignant in nature. Since management of these tumors is associated with the risk of developing a fistula and tumor implantation in the case of neoplasm, they are rarely exposed to incisional or needle biopsy techniques. Cytology studies can help to distinguish between parotid/non-parotid lesions, benign/malignant lesions, and acute/non-severe inflammation; consequently, a definitive course of action for the therapeutic management of the patient can be planned. FNAC is a useful tool for subtyping parotid gland lesions; however, its accuracy and sensitivity are variable. AlGhamdi et al. reported overall sensitivity and specificity for salivary gland masses as 90.3% and 100%, respectively. The positive predictive value, negative predictive value, and diagnostic accuracy were 100%, 57.1%, and 91.4%, respectively .Nodal tuberculosisendemic in many parts of the world including India; therefore, meticulous surveillance, thorough clinical assessment and testing, contact tracing, and confirmation of diagnosis are essential for treatment regimens and effective eradication of the disease [Tuberculosis (TB) continues to be  disease . In the  disease . Earlier disease . FNAC re disease . A cultuCharacteristics of head and neck mass that need immediate action include the following: (1) no history of any recent infection, and if so, infection is unlikely to be the etiology for the neck mass; (2) persistence of the mass for two or more weeks or uncertain duration; (3) reduced mobility of neck mass ; (4) firm texture of the mass ; (5) neck mass with a size >1.5 cm ; and (6) ulceration of the skin overlying the neck mass. Metastatic cancer may rupture through the capsule of the lymph node and directly invade and necrose the overlying skin. Consequently, ulceration overlying a neck mass may be indicative of a cutaneous malignancy with direct extension into the neck .Epidemiology of head and neck massesIndia is a vast country with a heterogeneous distribution of population. The prevalence of the above-mentioned lesions greatly varies in different parts of the country, which is associated with multiple epidemiological factors. One of the studies reported that approximately 7% of all cases of epidermoid and dermoid cysts are associated with the head and neck region . A recenA study led by Bajpai et al. reported the prevalence of lipoma in the Indian population; the mean age of the affected patients was 41.9 ± 3.5 years after an evaluation of 53 cases of oral lipoma  . This stSeveral lines of evidence have been reported on the occurrence, incidence, and pervasiveness of lymphadenopathy in the Indian population -32. A stThyroid disorder is another disease that is most frequent in the Indian population. Recently, the health burden of this disease has been found to increase . StudiesImaging techniquesRadiology has become central in the diagnosis and management of patients in almost all subspecialties, but especially so in oncology . ComputeCT scans are basically used to determine the primary location of head and neck cancer, nodal disease, and perform staging as part of the TNM  staging. A CT scan provides a better assessment of the infrahyoid neck with less artifact activity in contrast to MRI . It can Core biopsyA core biopsy is another way to diagnose the neck mass. A core biopsy obtains a bigger piece of tissue by using a significantly longer needle. It is well tolerated while having fewer side effects. Numerous complications including bleeding, bruising, discomfort, and infection are associated with core biopsy. In spite of this, the non-availability of a surplus amount of tissue is another problem associated with this diagnosis .Open biopsyAn open biopsy is a more invasive procedure to diagnose a neck mass in which an incision is created in the skin to remove the tissue. The chances of complications with open biopsy are higher because of the invasive nature of the procedure. Several complications including anesthesia, infection, bleeding, discomfort, scarring, and nerve injury  are associated with open biopsy .FNACFNAC is an outpatient cytological procedure used for the diagnosis and management of suspicious nodules in the head and neck region. It is simple, comfortable, easy to administer, and a reasonably precise technique. It is safer and does not require anesthetic protocols. In addition to these, it provides quick results with no complications . FNAC ouAlthough FNAC of neck masses is very reliable due to limited false-negative diagnosis, certain patients may experience a pause in diagnosis or treatment due to a false-negative result. For this reason, while a satisfactory and negative FNAC is reassuring in certain cases, it does not rule out the requirement for more medical procedures in a patient with concerning signs and symptoms. Following an FNAC that yielded insufficient findings or diagnosis of benign pathology, a repeat FNAC could be done to ascertain malignancy. Consequently, if a patient has concerning signs and symptoms, then an open biopsy is being considered . Repeat Adult neck masses in the Indian population are caused by head and neck malignancy as well as infectious causes like TB. Clinical examination should be done carefully in all patients who represent a neck mass, accompanied by focused inquiries. It is important to proceed with investigations until a definite diagnosis is achieved. Suspicion of malignancy is the mainstay of investigations for all patients with a neck mass, even after CT scan and FNAC. Ancillary monitoring should be done without terminating the malignancy investigation.


Abdominal pain and flank pain cause a significant proportion of emergency department (ED) visits. The diagnosis often remains unclear and is frequently associated with repeat visits to the ED for the same complaint. A rare cause of left upper abdominal and flank pain is compression of the left renal vein between the aorta and the superior mesenteric artery known as nutcracker syndrome. Diagnostic findings on ultrasound include increased left renal vein diameter proximal and peak blood flow velocity increase distal to the superior mesenteric artery. We describe such a patient presenting to an ED repeatedly with severe pain mimicking renal colic before the final diagnosis and intervention occurred.A 16-year-old female, long-distance runner presented four times complaining of intractable left upper quadrant abdominal pain radiating to the left flank after exercise. On each visit urinalysis revealed proteinuria and hematuria, and on two visits abdominal computed tomography revealed no kidney stone or dilatation of the collecting system. Ultimately, she was referred to vascular surgery where Doppler ultrasonography was used to diagnose left renal vein compression. Transposition of the left renal vein improved Doppler diameter and flow measurements and eliminated symptoms.Emergency physicians must maintain a large list of possible diagnoses during the evaluation of abdominal and flank pain with a repetitive and uncertain etiology. Nutcracker syndrome may mimic other causes of abdominal and flank pain such as renal colic and requires appropriate referral. Abdominal and flank pain are common complaints in patients presenting to the emergency department (ED).In this case report we describe an adolescent female athlete who presented on four different occasions to the ED with presumed intermittent renal colic due to kidney stones, associated with hematuria and proteinuria. After significant delay, she was ultimately diagnosed with NS and received curative surgical correction.The patient was a 16-year-old female, long-distance runner with a body mass index of 19 who complained of left upper quadrant abdominal pain radiating to the flank after exercise. She presented to the ED on four occasions over six months with normal vital signs and a complaint of severe pain that resolved with opiate pain management. Abdominal examination each time was not consistent with an emergent surgical problem requiring immediate consultation. Each time urinalysis showed proteinuria and hematuria. On two visits a non-contrast abdominal computed tomography (CT) was performed, which revealed no kidney stone, ureteral calculi, or dilatation of the collecting system.On the first three occasions after pain management she received instructions to follow up with primary care for further evaluation. After the fourth episode the patient was referred to vascular surgery with a clinical suspicion of NS. Doppler ultrasonography in the standing position demonstrated compression of the left renal vein by the SMA with a hilar  left renal vein diameter of 9.12 millimeters (mm) and aortico-mesenteric  diameter of 2.1 mm (ratio 4.34), as well as an aortico-mesenteric peak velocity of 141 centimeters per second (cm/sec) and a hilar peak velocity of 20.1 cm/sec (ratio 6.97). The patient ultimately underwent renal vein transposition to a lower aortic position with elimination of her symptoms and resumption of her running career.Abdominal and flank pain account for up to 10% of all ED visits.The SMA originates from the aorta behind the neck of the pancreas at the level of the first lumbar vertebra and creates an angle at its origin from the aorta known as the SMA angle or aorto-mesenteric angle.Rarely, the LRV arises posterior to the aorta and compression of the LRV may occur between the aorta and vertebral body, which when symptomatic is known as posterior NS. Presence of LRV compression without symptoms is referred to as nutcracker phenomenon.8What do we already know about this clinical entity?Nutcracker syndrome (NS) is caused by compression of the left renal vein by the superior mesenteric artery, causing episodic severe left flank pain.What makes this presentation of disease reportable?The patient had repeated clinical presentation to the Emergency Department with symptoms that mimicked renal colic despite lack of imaging evidence to support that diagnosis.What is the major learning point?A wider differential diagnosis that includes NS could expedite accurate diagnosis, especially in patients with negative imaging studies and repeated visits.How might this improve emergency medicine practice?Emergency physicians should consider a wider differential diagnosis for patients with left flank pain resembling renal coli.Symptoms resulting from LRV compression in NS were first described in 1950 and have been demonstrated in ages ranging from childhood to the seventh decade.12Compression of the LRV resulting in NS may be demonstrated by venography, CT arteriography, Doppler ultrasonography (DUS), and magnetic resonance imaging.8Nutcracker syndrome is associated with non-glomerular hematuria due to ureteral varices resulting from elevated LRV pressure.Abdominal and flank pain are common complaints in patients presenting to the ED. Frequently, diagnostic testing is inconclusive resulting in an unclear diagnosis and repeat visits to the ED for the same complaint. In the face of this circumstance, emergency physicians must maintain a wide differential diagnosis and low threshold for referral to appropriate specialists. Nutcracker syndrome symptoms and signs may mimic other, more common causes of recurrent abdominal and flank pain such as renal colic due to kidney stones and should be considered by emergency physicians in the differential diagnosis of such patients when diagnostic studies are inconclusive.


Granulomatous chronic invasive fungal rhinosinusitis (GCIFR) is a rare entity with scarce cases reported mainly in subtropical areas. Its prevalence among individuals with clinical suspicion of fungal rhinosinusitis has been reported in approximately 20% in subtropical populations, unlike North America with a prevalence of 0.5%. It is typically associated with Aspergillus flavus and the presence of noncaseating granulomas or Langerhans giant cells on histopathologic examination.We describe a case of a patient with clinical history of recent SARS-CoV-2 infection and development of intense cephalalgia, visual impairment, palpebral ptosis, and limitation of extraocular movements. MRI demonstrated the presence of opacification of paranasal sinuses, and a left intraconal abscess. A surgical endoscopic approach was performed and histopathologic examination revealed frontal GCIFR and maxillary fungus ball. Treatment with IV azoles provided adequate clinical response.The spectrum of the fungal rhinosinusitis disease is not clear. However, non-invasive fungal rhinosinusitis is not often found concomitantly with invasive types. GCIFR typically manifests with an indolent and gradual progression at early stages. Advanced stages can exhibit orbital and intracranial involvement leading to visual impairment, frequent relapses, and a poor prognosis. A higher incidence of invasive fungal rhinosinusitis has been reported in patients with SARS-CoV-2 infection despite an unremarkable medical history, associated with immune dysregulation.GCIFR is a rare condition with few cases reported in America. Because of its uncommonness, its diagnosis is often delayed leading to increased morbidity and mortality. •Granulomatous chronic invasive fungal rhinosinusitis is a rare entity with scarce cases reported.•Non-invasive fungal rhinosinusitis is not often found concomitantly with invasive types.•A higher incidence of invasive fungal rhinosinusitis is observed in SARS-CoV-2 infection.•Early diagnosis of fungal rhinosinusitis is essential due to possibly fatal outcome.•Physicians should be aware of atypical manifestations for a prompt diagnosis. ChronicAspergillus flavus and the presence of noncaseating granulomas or Langerhans giant cells on histopathologic examination . I,8. IAspe. flavus .Table 1RAlthough non-invasive fungal rhinosinusitis is not often associated with CGIFR our patient presented both concomitant invasive and non-invasive forms of fungal rhinosinusitis. Fungus ball is a form of non-invasive fungal rhinosinusitis with an extramucosal mass of fungi associated with minimal mucosal inflammation localized unilaterally, most commonly in the maxillary sinus. Histopathologically, no granulomatous reaction or tissue invasion is seen .The majority of invasive and non-invasive fungal rhinosinusitis cases are immunocompromised, aside from GCIFR which primarly affects immunocompetent individuals . AlthougEven though proptosis, enlarging mass on facial region, and nasal obstruction are main findings in advanced stages in most cases , our patGCIFR has a high relapse rate; however, it has a good prognosis compared with other types of IFR . Surgica4GCIFR is a rare condition with few cases reported in America. Because of its uncommonness, its diagnosis is often delayed leading to increased morbidity and mortality. Typical clinical manifestations include proptosis, visual changes, and sinonasal symptomatology. Nevertheless, our patient presented with atypical clinical findings including limitation of extraocular movements, palpebral ptosis, and visual impairment, without proptosis. Early diagnosis and management are essential due to its invasive and possibly fatal outcome in advanced stages. A high level of awareness of the clinician is crucial to provide and early diagnosis and management of the disease, mainly in patients with history of recent SARS-CoV-2 infection. Our patient had a delay in adequate treatment, which may have affected her visual and overall prognosis. However, debridement of paranasal sinuses and antifungal therapy with voriconazole and itraconazole provided a satisfactory control of the disease with no relapse at one-year follow-up. Management should be individualized according to the extension of the disease and medication tolerability in every patient.The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Jose Luis Treviño-Gonzalez, substantial contribution to the conception and design, drafting of the work and revision, and final approval of the final manuscript. Karla Marisol Santos-Santillana, substantial contributions to the conception or design of the work, drafting of the work and revision, final approval of the final manuscript. Felix Maldonado-Chapa, substantial contribution to the conception of the work, final approval of the final manuscript. Josefina Alejandra Morales-del Angel, substantial contribution to the conception of the work, final approval of the final manuscript. Rosmal Cortes-Ponce, substantial contribution to the conception of the work, final approval of the final manuscript. Paola Gomez- Castillo, substantial contribution to the conception of the work, final approval of the final manuscript.The research protocol was performed according to the Declaration of Helsinki, being approved by the local Research and Institutional Ethics Committee.Written informed consent was obtained 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.N/a.Not commissioned, externally peer-reviewed.Josefina Alejandra Morales-Del Angel MD MSc.Otolaryngology and Head and Neck Surgery Division, School of Medicine and University Hospital “Dr. Jose E. González”, Universidad Autónoma de Nuevo León, Ave. Madero y Gonzalitos s/n, Mitras Centro, 64460, Monterrey, Nuevo Leon, Mexico.E-mail: jamoralesorl@gmail.com.Fax Number: 8183891111.Authors declare no conflicts of interest.


Familial adenomatous polyposis (FAP) associated with desmoids tumors (DTs) complicated by abscess formation is rare. The management is not easy and the choice of the best treatment may be controversial.A 33-year-old man was admitted to our hospital for abdominal pain, fever, chills, nausea, and vomiting. He had a family history of FAP, and history of abdominal surgery.An abdominal enhanced chest computed tomography (CT) scan revealed a soft tissue mass in the abdominal wall and an irregular mesenteric soft tissue mass with internal fistula and intra-abdominal abscess. A CT-guided biopsy of the abdominal wall mass revealed DTs.The patient was given oral antibiotics for 6 months, and ultimately underwent surgery.The patient had no evidence of recurrence on follow-up at 10 months.This case indicates that for patients with FAP who have a history of abdominal surgery and a progressively enlarging mass and abscess in the abdomen, it is necessary to consider the possibility of DTs. FAP-related DTs are rarely complicated by abscess formation. Antibiotic therapy plus surgical resection of the tumor may be effective and make good prognosis. Among the types of lesions associated with FAP, desmoid tumors (DTs) are potentially life-threatening that require special attention. DTs are rare and easy to miss in diagnosis. Most patients with DTs are asymptomatic and have chronic progression, resulting in a solid abdominal mass which might present with abdominal pain. Complications of DTs result from their locally aggressive nature, causing compression and invasion of the adjacent structures. Although intra-abdominal DTs may cause intestinal obstruction, bleeding, and perforation, it rarely forms an abscess. To our knowledge, there are few reports about of FAP-related DTs complicated with intra-abdominal abscess. Here, we report the first case of FAP-related DTs initially presented with intra-abdominal abscess in China. The patient was successfully treated with antibiotics and ultimately underwent surgery. He was doing well at the last follow-up of 10 months.Familial adenomatous polyposis (FAP) is a cancer syndrome caused by germline mutations in the adenomatous polyposis coli gene.2A 33-year-old male patient was admitted to our hospital in February 2020 due to acute lower abdominal pain, fever, nausea, and vomiting in the absence of diarrhea, hematochezia, cough, and sputum. The patient had a history of FAP for 2 years. He had a surgical history consisting of an appendectomy, cholecystectomy, and colon polypectomy. A laparotomy was performed for intestinal obstruction in 2018, where a cystic mass at the mesentery root was found and resected, but the pathology was unknown. The patient's mother died of colon cancer. His personal history was unremarkable. A physical examination upon admission: Several surgical scars were visible on the abdomen. A hard mass of about 10 cm × 10 cm in the left abdomen was palpable and immovable with pressure pain. Bowel sounds were normal. The lower limbs were not swollen.9/L and the neutrophil count was 7.75 × 109/L. The C-reactive protein level was 235.66 mg/L. Serum albumin was 29.2 g/L. Serum procalcitonin was 0.261 ng/mL. Common serum tumor markers, such as alpha-fetoprotein, carbohydrate antigen 19-9, carcinoembryonic antigen, and carbohydrate antigen 125 were normal. An abdominal enhanced chest computed tomography (CT) scan , also known as aggressive fibromatosis, are a type of fibroproliferative disease caused by the monoclonal proliferation of fibroblasts. These tumors are rare. The incidence of DTs in FAP is 800- to 1000-fold higher than in the general population (0.03%). Most patients with FAP develop DTs within 5 years after surgery and 68% to 83% of patients develop DTs after abdominal surgery. It is speculated that iatrogenic trauma of the abdominal wall and abdominal pelvic cavity by surgery results in abnormal monoclonal proliferation of fibroblasts during tissue repair and reconstruction. Our patient underwent 2 abdominal surgeries and DTs developed 24 years after the appendectomy and 4 years after the cholecystectomy. The occurrence of DTs is considered to be related to abdominal surgery.The risks of developing DTs in patients with FAP include the presence of a family history, gene mutations, high estrogen levels, and surgical trauma. Intra-abdominal DTs are mostly located in the mesentery. These tumors grow slowly, generally increasing by 2 to 9 cm per year, and locally without metastasizing distantly. Despite their benign nature, they can be infiltrative and multifocal, causing significant morbidity and mortality. They can invade the intestines and surrounding tissues, causing gastrointestinal bleeding, intestinal obstruction, and perforation. However, the intra-abdominal abscess formation in DTs is rare. There are only 8 case reports about degeneration of intra-abdominal DTs into abscess in literature , abdominal wall 10%–15%), and extra-abdominal (about 5%).0%–15%, a Pathology is the gold standard for the diagnosis of DTs. Histological examination reveals paucicellular proliferation of fibroblasts and myofibroblasts in a dense collagenous background, spindle cells with small and regular nuclei, pale eosinophilic cytoplasm, and acellular central areas with increasing cellularity towards the periphery. Immunohistochemistry shows the cells are β-catenin, vimentin, Ki-67, SMA, CD68, and CD34 positive, which can assist with the diagnosis. The differential diagnosis of FAP associated with DTs includes metastatic tumors, lymphomas, tumors of mesenchymal origin, fibrosarcoma, and neurofibroma. In this case, an abdominal-enhanced CT scan showed a soft tissue mass in the abdominal wall and an irregular mesenteric soft tissue mass with internal fistula and abdominal abscess. FAP-related DTs was suspected and the biopsy confirmed the diagnosis.FAP-associated with DTs was diagnosed based on clinical manifestation, surgical history, and imaging examination. CT and magnetic resonance imaging (MRI) scans can not only help for diagnosis, but also in determining the relationship between tumors and surrounding organs. The density of the lesions on CT imaging is uniform and an enhanced scan can show uniform enhancement. DTs had some specific features on MRI, including a stellar shape and extension into the fascial planes and fat tissue in a sunburst-like form. In addition, they are isointense on T1 and hyperintense on T2. For asymptomatic patients, close observation by serial imaging can be initiated with the interval of 3 to 6 months. For symptomatic patients, surgery and medical management are appropriate options, including non-steroidal anti-inflammatory drugs, estrogen antagonists, and chemotherapy drugs . Occasionally, surgical management becomes the only way in patients with complications, such as in this case where the patient developed abdominal abscess despite antibiotic treatment. In the majority of cases of DTs complicated with abscess reported, the first treatment consisted of antibiotic therapy with or without percutaneous drainage. The surgical resection of the tumor was the second approach due to persistent symptoms related to DTs. In addition, there were three patients successfully treated by antibiotic therapy and percutaneous drainage without surgery. The 4 patients reported with the follow-up time between 6 weeks and 2 years made a good recovery and had no recurrence. Our patient did not undergo percutaneous drainage for the abscess was not so large. However, he still had intermittent abdominal pain and fever after active anti-infective treatment. After 6 months, the blood routine examination was normal, and the abdominal abscess was smaller. He ultimately underwent the surgery. He was doing well on follow-up at 10 months.Intra-abdominal DTs are commonly more difficult to resect compared with extra-abdominal and abdominal wall tumors. Surgery may be technically challenging, and the risk to the patient is high, particularly when these tumors occur in patients with FAP.4In conclusion, we report the first case of FAP-related DTs initially presented with abdominal abscess in China. This case indicates that for patients with FAP who have a history of abdominal surgery and a progressively enlarging mass and abscess in the abdomen, it is necessary to consider the possibility of DTs. Seldom will FAP-related DTs degenerate into intra-abdominal abscess formation. CT and MRI of the abdomen and pelvis are feasible for further examination. Needle biopsy is helpful to confirm the diagnosis. Antibiotic therapy plus surgical resection of the tumor may be effective and make good prognosis.Investigation: Jun Wu.Writing – original draft: Ailing Liu, Hua Liu, Xueli Ding.Writing – review & editing: Zibin Tian, Tao Mao.


In patients with gastric cancer, 6–27% of patients are diagnosed with T4b disease that invades adjacent organs, and curative resection can improve the prognosis of these patients.2). Upper gastrointestinal endoscopy performed after the administration of six courses of the S-1 and oxaliplatin regimen revealed a persistent primary lower gastric wall lesion; however, the diameter of the abdominal wall invasion and metastatic lymph nodes was significantly reduced, in addition to decreased serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels. Subsequently, the patient underwent distal gastrectomy with D2 lymphadenectomy combined with transverse colon and abdominal wall resection. We performed radical en bloc resection and achieved a tumor-free resection margin. Simple abdominal wall closure was performed without mesh or musculocutaneous flap placement. Histopathological examination of the resected tumor specimen showed direct invasion of the mesocolon and rectus abdominis muscle. The patient was postoperatively diagnosed with L Gre-Ant type5 T4b (SI: rectus abdominis muscle) N2 PM0 DM0 Stage IIIA R0 Grade 2a gastric cancer based on histopathological findings and received S-1 as adjuvant chemotherapy, 2 months postoperatively. No recurrence was detected 6 months postoperatively.A 70-year-old Japanese man presented with an abdominal tumor and was diagnosed with advanced gastric cancer  with extensive abdominal wall invasion. We performed open gastrojejunal bypass for gastric obstruction and initiated a chemotherapeutic regimen comprising S-1 (120 mg/day) and oxaliplatin (100 mg/mWe report a case of advanced gastric cancer with extensive abdominal wall invasion that was successfully treated with gastrectomy combined with resection of adjacent organs showing tumor invasion after effective systemic chemotherapy. A therapeutic approach comprising curative surgery combined with perioperative chemotherapy is useful in patients with T4b gastric cancer. Gastric cancer (GC) is the fifth most common malignancy and the third most common cause of cancer mortality worldwide . AlthougWe present a case of advanced GC with extensive abdominal wall invasion that was successfully treated with gastrectomy combined with adjacent organ resection after effective systemic chemotherapy.2, every 21 days). Although neutropenia  occurred as an adverse event associated with SOX therapy, the diameter of the abdominal wall invasion and metastatic lymph nodes was reduced after the administration of four courses of the SOX regimen. Therefore, we administered six courses of the SOX regimen. Upper gastrointestinal endoscopy revealed a persistent primary lesion of the lower gastric wall  presented with an abdominal tumor and suspected advanced GC. He had previously undergone an operation for ileus, and his family history was not significant. A contrast-enhanced computed tomography scan (eCT) revealed extensive abdominal wall invasion by the main gastric tumor in addition to enlarged peritumoral lymph nodes; however, no lung and liver metastases were detected Fig. a. BiopsyCurative resection is the mainstay of treatment for patients with T4b GC –9. HowevIn conclusion, we report a case of advanced GC with extensive abdominal wall invasion that was successfully treated with gastrectomy combined with resection of adjacent organs showing tumor invasion after effective systemic chemotherapy. In our view, a therapeutic approach comprising curative surgery combined with perioperative chemotherapy is useful in patients with T4b GC.


Three-dimensional reconstruction imaging provides useful information in addition to conventional imaging, allowing a more accurate preoperative planning, and being used as a navigation instrument during liver resection.•The use of three-dimensional reconstruction imaging allows to predict the precise location and direction of anatomical structures with high approximation, allowing to reach a high degree of precision surgery. The use of three-dimensional image reconstruction in liver surgery is well-known and has got many applications: It was first developed for vein reconstruction in liver transplantation and for liver volumetry to prevent post hepatectomy liver failure (PHLF) after major resections. There are many other advantages described in the literature provided by three-dimensional reconstruction, however its diffusion is currently limited.We present the case of a woman with a single colon cancer metastasis in segment 5 of the liver. Using CT scan images we created a three dimensional reconstruction of the patient’s liver and its inners structures. The rendering was used to hypothesize the plan of dissection and to predict the pedicles that needed to be dissected during the procedure.We try to demonstrate that, thanks to three dimensional image reconstruction, all the structures that need to be dissected could be effectively located prior to the the surgery with a high grade of approximation. Furthermore the 3D reconstruction could be used as a step by step guide during the whole surgical procedure, showing all the pedicles To be encountered and dissected at every stage.3d reconstruction of the liver is a valid aid in the interpretation of preoperative imaging and intraoperative ultrasound, both for the surgeon and for the entire equipe, facilitating comprehension of patient’s liver anatomical features. It allows to predict the location and direction of the pedicles that need to be dissected and resected with high approximation, in order to achieve a more precise and tailored surgery. In almost all cases, treatment options and surgical strategy are assessed from the evaluation of two-dimensional imaging. The first application of 3D reconstruction imaging reported in literature aimed to assess the extent of disease in intrahepatic cholangiocarcinoma . Imaging1.1We describe the case of a 53 Y/o woman with no previous clinical and drug history, hospitalized for occlusive left sided colon cancer with synchronous single 4.7 cm liver metastasis in segment 5, and treated with urgent left hemicolectomy and subsequent colostomy for anastomosis leakage. In consequence of the long postoperative period, in order to reassess the burden of the disease the patient underwent a new abdominal CT scan, which showed an unexpected reduction in size of the liver metastasis. A multidisciplinary discussion was conducted, resulting in the indication for liver resection. An anathomycal segmentectomy 5 was planned.2Portal phase Dicom data were uploaded in INvesalius® software. Separate layers for liver, portal branches, hepatic veins and liver metastasis were created. In this software each layer has got the capability of transparency regulation to better visualize every single structure. Once the three-dimensional reconstruction had been done, we used the model to precisely locate the tumor and estimate their relations with the portal and hepatic branches. We then planned the procedure by hypothesizing the liver's dissection plan, and predicting all the vascular structures crossing it .Fig. 1PrDuring the planning of the intervention, we recognized four main pedicles crossing the plan between segments 5 and 8 and two portal pedicles for segment 5 originating from the right anterolateral branch. Along the plan of the right hepatic vein, we identified four veins arising from it and a small portal pedicle from the branch for segment 6.3Both 3D reconstruction and laparoscopic surgical procedure were lead in November 2020 by the first author, an experienced laparoscopic and liver surgeon, assisted by two more operators.The intervention was conducted with patient in left lateral decubitus position. Trocars were placed at the margin of the right upper quadrant in a semicircular arrangement.During the laparoscopic intervention, intraoperative ultrasound was performed, confirming the location and depth of the metastasis and guiding the marking of the dissection plan on the liver surface.We started the dissection from the pericholecystic plan, at the apex of segment 4. Three-dimensional images were made available on screen inside the operating theatre; as the dissection proceded these images could be consulted in real time, guiding the step by step search for all the pedicles that had already been identified in the preoperative planning phase.In the separation plan between segments 8 and 5, we found four principal pedicles that were recognized, clipped, and sectioned. Once we had opened this plan, the dissection continued with the search for the right anterior portal branch, where we found two main pedicles for segment 5, as predicted .Fig. 2PeThe following dissection started from the apex of segment 6 using the right hepatic vein as a marker. As already predicted during the three-dimensional reconstruction, on this plane we found four veins tributaries of the right hepatic vein and one portal pedicle originating from the branch for segment 6 . All theWe achieved a precise anathomycal resection of segment 5.Post-operative recovery course was uneventful, except for mild fever, which was treated with empirical antibiotic therapy  and was discharged on postoperative day 8. At present, the patient is under adjuvant FOLFOX chemotherapy, in good general conditions.4The use of three-dimensional reconstruction in liver surgery is well-known. Its applications range from vein reconstruction in liver transplantation  to organThe availability of dedicated rendering softwares have added further advantages, enabling intra-organ visualization and precise reconstruction of the patient’s liver different features and vascular structures. Many authors ,6 have pAs demonstrated in our clinical case, and as previously reported by other authors , this hyUsing this methodology, instead of opening the dissection plan and finding vascular structures, we were able to direct the dissection process towards the way determined by the preliminary search for vascular pedicles.5Three-dimensional reconstruction imaging can be considered a powerful tool in liver resection, allowing to visualize the organ and its inner structures from every possible angle, which is impossible to achieve with standard 2d imaging. This technique is a valid aid in the interpretation of intraoperative ultrasound both for the surgeon and the entire equipe, facilitating anatomical comprehension. It allows to predict with high approximation the pedicles that need to be dissected and resected, in order to achieve a more precise and tailored surgery.The case report follows both the SCARE and PROCESS Guidelines .The authors report no declarations of interest.No found sources.No ethical approval is require, because it is a single case report and the patient signed consent form for publication.Written informed consent was obtained from the patient for publication of this case report and accompanying images. All reported images and discussion protect anonymity.Banchini Filippo: Conceptualization, Methodology, Software, Resources, Writing - Original Draft, Writing - Review & Editing, Visualization, Supervision, Project administration.Luzietti Enrico: Writing - Review & Editing.Cecconi Sara: Writing - Review & Editing.Ribolla Marta: Writing - Review & Editing.Palmieri Gerardo: Writing - Review & Editing.Capelli Patrizio: Writing - Review & Editing.Not applicable.Filippo Banchini.Not commissioned, externally peer-reviewed.


Lymphomas are malignant tumors arising from lymphoid tissues and can spread to other organs. Primary extra-nodal locations such as the spinal epidural space are less common. Primary spinal epidural lymphoma (PSEL), which can be either Hodgkin’s or non-Hodgkin’s type, is rare. There are different cell types of Non-Hodgkin’s PSEL, among which mantle cell lymphoma (MCL) is extremely rare. MCL can have an aggressive or indolent course. Indolent MCL in the epidural space is not yet reported. We report a case of 20-year-old male who presented with radiating low back pain for six weeks followed by a progressive neurological deficit in both lower limbs for nine days. Magnetic resonance imaging (MRI) revealed spinal epidural tumor extending from L2 to L3. Decompression and subtotal excision biopsy were performed. Histopathology and immunohistochemistry identified indolent MCL. His neurological status improved to normal postoperatively, and he was referred to an oncologist. He is under observation and planned for radiotherapy. At one-year follow-up, he is asymptomatic and doing his regular job abroad. SOXII and TP53 [Lymphoma, a neoplastic disorder of lymphoid tissue, can involve the vertebral body, epidural compartment, spinal cord, and cauda equina . Primaryand TP53 . Mantle and TP53 .Primary MCL in the spine and epidural space is extremely rare. To date, there are only three reported cases of primary spinal epidural MCL ,9. To thA 20-year-old immunocompetent male arrived to our emergency department with a chief complaint of low back pain for six weeks followed by radicular pain and difficulty in bearing weight in both lower limbs for nine days. He also complained of decreased sensation over bilateral lower limbs and had normal bowel and bladder habits. He had a road traffic accident six weeks back while riding a motorcycle with minor injuries. There was no history of fever, headache, or night sweats.On examination, no obvious spinal deformity was appreciated. Localized tenderness was present over the L3/L4 vertebra. Motor power varied across muscle groups: hip flexors , knee extensors , ankle dorsiflexors , long toe extensors , and ankle plantar flexors . Sensations of both lower limbs were reduced from L4 downwards. Deep tendon reflexes of the knee and the ankle joints were absent. Plantar reflex was down-going bilaterally.A provisional diagnosis of traumatic prolapsed intervertebral disc  was made, and an X-ray of the lumbosacral spine was performed, which showed loss of lumbar lordosis and no bony lesion. Magnetic resonance imaging (MRI) of the spine revealed posterior cortical erosion accompanied by epidural lesion, which was iso-intense on T1 and iso- to hyper-intense on T2, with severe spinal stenosis at L2-L3 vertebrae level , liver and renal function tests, peripheral blood smear, lactate dehydrogenase (LDH), uric acid, and urinalysis were normal. However, erythrocytic sedimentation rate (ESR) was 60 mm/hr  and CRP was 205.5 mg/L .Decompression (laminectomy) and subtotal excision biopsy of the lesion were performed through the posterior midline approach. Intraoperative findings revealed a grey-colored, circumferential lesion that was soft to firm in consistency and was loosely adhered to the dura. A 4 × 4 cm of the mass  was sent for histopathology, which showed IMCL Figure .+, CD5+, CD10-, CD20+, CD23+, CD30-, CD99+, BCL-2+, cyclin D1+, Ki-67 (<10% positive), and PAX-5+.Immunohistochemistry reported it as CD3The postoperative period was uneventful. His radicular pain in both lower limbs improved immediately following surgery. No other lesion was identified on staging evaluation. Contrast-enhanced computed tomography scan (CECT) of the chest, abdomen, and pelvis excluded any accompanying abnormalities. Bone marrow aspiration and biopsy were negative for malignancy. His weakness improved gradually with physiotherapy to 5/5 in all muscle groups in both lower limbs by the time of discharge. Postoperative MRI showed some residual mass at the L2-L3 level. He was comfortably walking when we referred him on the 22nd postoperative day to a cancer center for further treatment (chemotherapy and/or radiotherapy).At three months follow-up, he was asymptomatic with complete neurological recovery. He is a migrant worker in India. On video-conferencing for a one-year follow-up, he was doing his routine job. He was under follow-up with an oncologist and planned for radiotherapy in a tertiary care center . The oncologist has followed the watch-and-wait policy as acceptable management since it was an indolent-type MCL.MCL is a variant of intermediate lymphocytic lymphoma, a distinctive type of NHL with unique clinical, pathological, and biological features . It can Primary spinal epidural lymphoma is rare and accounts for 0.1%-6.5% of all lymphomas and 9% of all spinal epidural tumors . Mantle TP53 and SOXII [Aggressiveness of MCL is determined by over- or under-expression of many genes such as nd SOXII , which cnd SOXII . Ki67 isnd SOXII .In the past years, MCL had a poor prognosis, with a five-year OS rate of only 27%. However, introduction of novel drugs and therapeutic options have shown significant improvements in treatment outcome, with a current five-year survival rate of 50%-75% .primum non nocere . Nonetheless, nonaggressive, indolent lymphomas can transform over time into aggressive lymphomas [Clinicians treating MCL have recognized a subset of patients with MCL who have a slow (indolent) disease course with significantly longer survival (>7-10 years). Indolent lymphoma is a slow-growing tumor compared to other aggressive lymphomas. Indolent lymphomas are less dangerous if left untreated; however, they are more difficult to cure because the lower proliferation of cells makes it less susceptible to chemotherapy. For indolent lymphomas, where cure is not an option, the most important treatment may be to avoid overtreatment, ymphomas ,17.Our case presented with typical symptoms  of back Unlike Schwechheimer et al.'s and Barnard et al.'s reported cases of spinal epidural MCL, in which the patients were over 70 years of age and had other co-morbidities, our patient was a young, healthy adult with no co-morbidity ,9. Both Our case had an excellent neurological improvement in the lower limbs immediately after the surgery. At three months’ follow-up, he had full neurological recovery. The patient was asymptomatic and has resumed his job in India. Since it was an indolent type of MCL, the oncologist has followed the watch-and-wait policy. It is an acceptable management strategy in selected clinically well patients. The treatment was deferred since the time to treatment did not predict OS, and the median OS of the observation group was statistically longer than that of the early treatment group .We agree with Tsukada et al. that functional recovery of spinal cord compression due to primary spinal epidural lymphoma is relatively better than metastatic carcinoma , and earPrimary spinal epidural IMCL is an extremely rare tumor due to which its diagnosis is challenging. A high degree of suspicion along with a team approach  is vital for its diagnosis and management. The young age of the patient without co-morbidity, early diagnosis, and treatment are the keys to a favorable outcome.


Spermatic cord cancer is a rare entity. Among malignant tumors of the spermatic cord, liposarcomas are the most common type, often presenting as painless slow-growing masses usually in the fifth and sixth decades of life; they can be misdiagnosed as inguinal hernia or hydrocele. Radical orchiectomy with wide local soft tissue resection is an accepted standard of care for spermatic cord liposarcoma and has been curative in some cases. There is no definitive role for other treatment modalities such as chemotherapy, retroperitoneal lymph node dissection (RPLND), and radiotherapy. We present a case of liposarcoma of the spermatic cord managed with radical orchiectomy, wide local excision, and was followed up without disease recurrence. We also engage in a review of the literature on the role of systemic chemotherapy and radiotherapy in preventing locoregional recurrence after primary surgery.A combination of surgery and postoperative radiotherapy is effective in preventing locoregional spread. Data from case reports support this strategy in certain histologic subtypes or when margins are positive after primary surgery. A follow-up period of up to a decade after surgery is recommended. Spermatic cord cancer is a rare entity. Primary paratesticular tumors account for 7-10% of all intrascrotal tumors [Radical orchiectomy with wide local soft tissue resection is an accepted standard of care for spermatic cord liposarcoma and has been curative in some cases . The proWe present a case of liposarcoma of the spermatic cord managed with radical orchiectomy, wide local excision, and was followed up without disease recurrence. We also review the literature on the role of systemic chemotherapy and radiotherapy in preventing the locoregional recurrence of this rare entity.Our patient was a 65-year-old male who presented with complaints of progressive painless scrotal swelling for the last five years. Three years prior, he had the scrotal swelling aspirated and a diagnosis of right hydrocoele had been made. Surgery had been recommended as the swelling had persisted. He presented because the swelling, though painless, had slowly increased in size. He had no other urogenital complaints such as dysuria, frequency, or hematuria. Physical exam was consistent with a hydrocoele and urology was consulted. A scrotal ultrasound with Doppler made an impression of a large right-sided hydrocele with an estimated volume of 79 cc. Scrotal ultrasound findings suggestive of hydrocoele are shown in Figure A right hydrocelectomy was scheduled. Intraoperative findings included a small right hydrocele, thickening, and nodularity of tunica albuginea and spermatic cord. Spermatic cord changes were concerning for malignancy and the nodules were biopsied. Biopsy results revealed scattered atypical cells characterized by multilobate, hyperchromatic nuclei within smooth muscle cells of the spermatic cord. These features were strongly suggestive of well-differentiated liposarcoma with smooth muscle differentiation. Fluorescence in situ hybridization (FISH) performed on the atypical cells showed amplification of MDM2, confirming the histologic impression of liposarcoma. The patient subsequently underwent radical orchiectomy and en bloc scrotal wall excision for liposarcoma. The only postoperative complication was a scrotal abscess and mild wound dehiscence, which was managed with debridement and a course of antibiotics.Histopathology report was notable for dedifferentiated liposarcoma with heterologous smooth muscle differentiation, tumor dimensions of 11 x 9.5 x 7.5 cm, histologic grade 2 (of 3), and margins narrowly negative for sarcoma. The definitive diagnosis was well-differentiated liposarcoma with heterologous smooth muscle differentiation. Imaging workup after scrotal resection was only remarkable for bilateral sub-centimeter pulmonary nodules, which were indeterminate; otherwise, there was no radiological sign of distant metastasis.Medical oncology service was consulted, and it was determined that the patient was not a candidate for chemotherapy. Radiation oncology was also consulted as adjuvant radiotherapy was being considered but the recommendation of the radiation oncology team was to withhold radiation and monitor for locoregional recurrence. By means of shared decision-making by the patient and the primary managing team, it was decided that the course of management would be six-monthly follow-ups with imaging surveillance. The patient had no local recurrence during three years of follow-up. Unfortunately, he died due to complications from coronavirus disease 2019 (COVID-19) after three years of follow-up.Primary malignant spermatic cord tumors can be classified based on their histology and include liposarcoma, rhabdomyosarcoma, leiomyosarcoma, fibrosarcoma, and malignant fibrous histiocytoma. Liposarcoma in turn has five histologic subtypes, which include well-differentiated, myxoid, round cell, pleomorphic, and dedifferentiated. The first two subtypes have a high propensity for locoregional recurrence, and the latter subtypes are more likely to metastasize . Nodal aRole of radiotherapyA review of the literature revealed six studies -7 that pTable Some authors have recommended a combination of surgery and radiotherapy to achieve locoregional control, especially for pleomorphic or round cell histologic subtypes and in situations where the margin status is uncertain due to incomplete tumor removal ,6. AmongWhen comparing pre- versus post-surgical radiation, Chowdhry et al  demonstrIn a study by Fagundes et al. , the indRegarding radiation dosing, the current recommended dose is 60-65 Gy over the course of six weeks  The mostOur patient had wide scrotal excision. Though he had components of dedifferentiation on histology, the margins were negative (distance from sarcoma to closest margin was 0.1 cm) with no evidence of locoregional spread or metastasis, and hence adjuvant radiotherapy was not given.Role of chemotherapyAdjuvant chemotherapy has no definitive role in the management of spermatic cord liposarcoma. In the literature, chemotherapy use was only reported in cases with recurrences , and itsFollow-upFollow-up is mandatory given the high propensity for locoregional recurrence. A minimum follow-up period of 36 months to 10 years has been reported in the literature  but recuSpermatic cord liposarcoma is a rare high-grade tumor with a high propensity for locoregional recurrence often misdiagnosed as hydrocele. We presented a case that was managed with wide excision and follow-up without disease recurrence. We also reviewed the literature on the role of chemotherapy, radiotherapy, and follow-up. A combination of surgery and postoperative radiotherapy is effective in preventing locoregional spread. Data from case reports support this strategy in certain histologic subtypes or when margins are positive after primary surgery. A follow-up period of up to a decade after surgery is recommended.


Osteochondroma of the coronoid process also known as Jacob’s disease, has rarely been reported in the literature and it posses a challenge as diagnosis may be overlooked in favour of other causes of limited mouth opening.This is a case report of an adult male patient who presented with restricted mouth opening in whom radiological imaging, especially 3D computed tomography, played a role in establishing the diagnosis of Jacob’s disease.An osteochondroma of the coronoid process of the mandible (Jacob’s disease) is a rare cause of restricted mouth opening and its diagnosis can be overlooked in favour of TMJ ankylosis. The CT scan plays an important role in diagnosis and in planning for surgery. Osteochondroma, or osteocartilaginous exostosis as it may be called, is a cartilage-capped mass arising from the cortex of a bone and constitutes around 10–15% of all bone tumours . Jacob wA 32-year-old man presented to our outpatient department with complaints of progressive restricted mouth opening and painless swelling in the right zygomatic region since the past 6 months. On physical examination there was facial asymmetry with protruding right zygoma. The swelling was diffuse with osseous consistency and non-tender with normal overlying skin. The inter-incisal opening was only 8 mm . RadiogrComputed tomography imaging of the face revealed an elongated coronoid process of the mandible forming a pseudojoint with the inner surface of the zygoma; there was also thinning of the zygomatic arch  and 2b. A fibrous pseudocapsule was found around the mass and was released. Coronoidectomy was performed with around 1 cm of healthy bone below the tumour margins. Grossly, the resected mass measured 2.5 cm and consisted of bone covered by a cap of cartilage . HistopaOn the seventh postoperative day the measured inter- incisal opening was 38 mm , and sweOsteochondromas being the most common benign tumours of bones are relatively uncommon in the jaw, affecting the condyle or tip of the coronoid process. In the literature only 38 cases of histologically proven osteochondroma of the coronoid process have been documented , and alsAlthough the exact causative factors are not known, several theories have been proposed to explain its aetiology. According to Weinmann and Sicher there is hyperplastic development of embryonic cells with chondrogenic potential because of continuous activity of tendons inserted in the coronoids . LitchteMost of the patients with coronoid process hyperplasia are first diagnosed as having a TMJ disorder and managed as such. Magnetic Resonance Imaging of the TMJ does not evaluate the coronoid processes because they are not included in the field of view . AlthougThe primary goal of treatment is to recover acceptable mouth opening. The surgical approaches described can either be intraoral, external, or a combination of both . Until 1In this case the external approach using modified hockey stick incision was adopted as the patient presented with markedly restricted mouth opening, there was thinning of the zygoma, and the mass was felt superficially. Post- operatively, the patient had near-normal mouth opening and acceptable facial scar without any other complication.An osteochondroma of the coronoid process of the mandible (Jacob’s disease) is a rare cause of restricted mouth opening and its diagnosis can be overlooked in favour of TMJ ankylosis. The CT scan plays an important role in diagnosis and in planning for surgery. The intraoral approach is most favoured because of minimal or no complications, but in some cases the size and bulbous nature of the tumour may prevent delivery of the mass through the space between the zygomatic arch and the temporal bone, and in such cases an external approach is indicated.


Pilomatrixoma is a benign skin tumor that originates from the hair matrix. It usually appears in children and young adults and is preferably in the head and neck region. It clinically presents as an asymptomatic firm, solitary subcutaneous mass of less than 3 cm. When located in the preauricular area, it is often misdiagnosed as benign or malignant parotids, skin tumors, or sebaceous cysts. Its treatment of choice is surgery, and recurrence is due to incomplete excision. We present a case of a male referred to our hospital with a diagnosis of recurrent pilomatrixoma in its giant form. The lesion was fully excised with no signs of recurrence and no functional impairment. Pilomatrixoma is a benign skin tumor that originates from the hair follicle matrix -10. It fDue to its unspecific presentation, clinical diagnosis is difficult and often misleading. Differential diagnoses include benign and malignant skin tumors, sebaceous cysts, folliculitis, pyogenic granuloma, arteriovenous malformation, lymphoma, and dermatofibroma ,3-6. WheTo assess the lesion extension and contour, imaging tests such as computerized tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI), and ultrasound may be solicited. Most findings are of a well-defined soft tissue mass with calcifications and no invasion of neighboring tissues. Although these are shared characteristics of other pathologies, in the preauricular area it is of utmost importance to differentiate cutaneous, vascular, and parotid tumors ,5,6,8,10Pilomatrixoma does not spontaneously regress, therefore its definite treatment is complete surgical excision ,5,6,8,10After removal, the prognosis is very good with recurrency as a very rare event which is owed to incomplete excision ,5,6,9,10A healthy 38-year-old male was referred to our hospital with the diagnosis of a recurrent right preauricular lesion that had been excised one month prior, and histopathology revealed "pilomatrixoma." In our observation, a nodule with 4.5 cm and an ulcerated surface was noticed Figure .It had a firm consistency, adherent to superficial skin, but moved freely in deeper planes. Surrounding the ulcer, there was a reddish halo that was painful on palpation. The facial nerve was unaffected and no lymph nodes were clinically detected. Because of its rapid growth, to help with the definite diagnosis and to ensure the nodule’s relationship with the parotid gland, several exams were requested, namely: histological revision of the previously excised lesion, fine needle aspiration, and parotid ultrasound. A histological revision revealed that the "pilomatrixoma was not completely excised." Fine-needle aspiration reported "epithelial neoplasm with trichilemmal keratinization." The ultrasound revealed a "homogenous oval mass with cutaneous fistula with no relationship to the parotid gland nor facial or cervical lymph nodes detected. The lesion is suspected of being a local recurrence of the previously excised tumor" Figure .In conclusion, all the exams coincided with the diagnosis of "recurrent pilomatrixoma." The patient was submitted for complete excision of the lesion, confirmed by histological evaluation of the surgical specimen, with no need for superficial parotidectomy. A macroscopic description of the lesion reported a mass of 4.5 cm x 3.5 cm. The surgical defect was reconstructed with primary closure (Figure On three-month post-op evaluation, the patient remains asymptomatic, with no signs of recurrence, no functional impairment, and a good aesthetic result Figure .He remains under periodic evaluation with clinical and image control.Pilomatrixoma is a benign adnexal tumor derived from follicular matrix cells with multiple clinicopathological variants -11. AlthClinically, the rapid growth following a first excision attempt and the ulcerated reddish skin, depicted in Figure For imagiological characterization, we selected ultrasound since this method is quick, affordable, does not rely on ionizing radiation, and is suitable for palpable superficial masses. Radiology reported a preauricular homogenous oval mass with a few millimetric cystic areas located in the subcutaneous layer with a cutaneous fistula. According to the literature, common ultrasonographic features of pilomatrixoma comprise a well-defined, oval, hyperechoic nodule-cystic mass located at the subcutaneous level, which is in accordance with our findings . A hypoeOf all the methods available, the most reliable for pilomatrixoma diagnosis is histopathological characterization . PreviouPilomatrixoma is a benign entity easily mistaken for malignant tumors. Correct identification of the lesion relies on clinical, imagiological, and histopathological findings and allows a much less aggressive surgical approach. Recurrence is rare, but possible if excision is incomplete. Here, we reported a case of a pilomatrixoma of the preauricular area recurring as a giant form.


Mobile Schwannoma is a rare soft tissue tumor that commonly involves the elderly population. It has no cellular material and grows as solitary, firm, oval, encapsulated benign tumors from the sensory  nerve root. If multiple, they are usually associated with Neurofibromatosis type 2 (NF-2). The initial sign and symptoms include segmental pain and paresthesia. It may lead to myelopathy if the tumor expands.We present a twenty-year-old female with chronic lower backache radiating to the ipsilateral thigh with no urinary or fecal incontinence. On physical examination, the ankle reflex was hypoactive on the left side, and the straight leg raise test was positive. A large 32 × 15 × 14 mm heterogeneous enhancing focal lesion was found on the posterior side of L5 and S1 vertebrae with severe central canal stenosis. A diagnosis of nerve sheath tumor was made based on contrast MRI pre-operatively. The underlying cause was a nerve sheath tumor. A total bilateral laminectomy at the L1-S5 level and mass excision was performed, preserving nerve roots. The postoperative period was uneventful, and no tumor re-growth was noticed.Schwannoma is a slow-growing tumor; benign; usually, less than 8 cm in diameter tumor, commonly found in the head and neck region. It is the 3rd most common soft tissue tumor and the 2nd most common intradural extramedullary tumor. In our report, a young, non-Caucasian female patient is diagnosed with schwannoma, which is quite rare. In our case, a larger tumor of size 32 × 15 × 14 mm was noted, affecting the posterior body of L5 and S1 vertebrae in the left lateral recess with impingement of the left S1 traversing nerve root. Around 29% of spinal root nerve tumors are schwannomas. As the tumor grows slowly, the diagnosis may be delayed.Schwannoma is a slow-growing solitary, firm, oval, encapsulated benign tumor arising from the sensory  nerve root. Histopathology plays a vital role in diagnosis, and overall, the disease has a favorable prognosis. Therefore, an appropriate approach is necessary to rule out the disease. •Schwannomas are benign, solitary, firm tumors. Primarily occur in the fourth and sixth decades of life.•It is most commonly associated with neurofibromatosis type 2 (NF-2) in children.•WHO defines spinal schwannoma as a benign grade 1 nerve sheath tumor that arises from Schwan cell.•Histopathology plays a vital role in diagnosis, and overall, the disease has a favorable prognosis. They contain no cellular material and grow as solitary, firm, oval, encapsulated benign tumors from the sensory  nerve root . SchwannThis case report has been reported in line with the SCARE Criteria .2A 20-year-old previously well female presented with progressive, severe lower backache for four years, with recent radiation to the left lower limb. The pain was relieved by rest and analgesics, aggravated on exertion, and standing long. She did not have urinary or fecal incontinence. The patient's family history was unremarkable.On physical examination, the ankle reflex was hypoactive on the left side, and the straight leg raise test was positive. The patient had hyperalgesia in S1 dermatomal distribution. The anal tone was normal, with no perianal numbness. The rest of her examination was unremarkable. Her routine laboratory investigations were normal, including complete blood count, inflammatory markers, electrolytes, renal function, and liver function tests.A provisional diagnosis of spinal nerve compression was made. An urgent contrast-enhanced lumbosacral magnetic resonance imaging (MRI) was ordered. The MRI report revealed diffuse disc bulge at the L5-S1 level, causing indentation on the thecal sac. A large 32 × 15 × 14 mm heterogeneous enhancing focal lesion was found on the posterior side of L5 and S1 vertebrae in the left lateral recess with impingement of the left S1 traversing nerve root a with seA multi-disciplinary team meeting was done, and surgery was planned to preserve nerve root and sympathectomy as a permanent relief solution. The surgery was done under general anesthesia. The patient was placed in the prone position; after prepping and draping with povidone-iodine, an 8 cm skin incision was made in the Lumbosacral area a. We reaWe achieved total resection of the nerve sheath tumor without any postoperative neurological deficit. After surgery, the patient was hospitalized for a week. The backache resolved completely. The patient is following up in the neurosurgery clinic. Postoperative histopathology of the mass revealed schwannoma. 6-week follow-up showed no radiologic evidence of disease recurrence.3Schwannoma is the 3rd most common soft tissue tumor and the 2nd most common intradural extramedullary tumor, followed by spinal meningioma . It is aWorld Health Organization (WHO) defines spinal schwannoma as a benign grade 1 nerve sheath tumor that arises from Schwan cell ; 29% of Hagiwara et al. reported 20 × 15 × 12 cm tumor in the buttock . In our Local bony changes caused by the schwannoma growth are usually visible in X-ray, CT, and MRI examinations ,11. Thes4Schwannoma is a slow-growing solitary, firm, oval, encapsulated benign tumor arising from the sensory  nerve root. It is most commonly associated with neurofibromatosis type 2 (NF-2) in children. Schwannoma of the lumbosacral area is a rare but distinct entity of benign tumor of intra-dural/soft tissue tumors and can lead to chronic back pain. Solitary schwannomas without neurofibromatosis are rare. Histopathology plays a vital role in diagnosis, and overall, the disease has a favorable prognosis.The patient did not present his point of view.The authors declare that they have no funding.Not commissioned, externally peer-reviewed.This is a case report that does not require formal ethical committee approval.NA.None.None.Name of the registry: NA.Unique Identifying number or registration ID: NA.Hyperlink to your specific registration (must be publicly accessible and will be checked): NA.Irfan Ullah.Irfanullahecp2@gmail.com.Kabir Medical College, Gandhara University, Peshawar, Pakistan. +923340968239.Yes.The authors declare that there is no conflict of interest.


Fibromatosis Colli also known as congenital torticollis is a rare cause of benign cervical pseudotumor in neonates, consisting of benign fibrous tissue proliferation within the sternocleidomastoid muscle, resulting in a fusiform enlargement. The cause of fibrosis is unknown; however it could be linked to trauma during pregnancy or at the time of birth, resulting in hemorrhage and, subsequently, fibrosis. Ultrasound plays a necessary role in confirming this diagnosis and follow-up. We Report a case of Fibromatosis colli in a four-week old newborn who was diagnosed using ultrasonography and treated with physiotherapy. Fibromatosis Colli is a rare condition of benign cervical masse seen in newborns. It is a focal or diffuse enlargement of the sternocleidomastoid muscle giving an aspect of a cervical pseudotumor. Though the exact etiology is still unknown, it has been reported that birth trauma or muscle injury in utero could be incriminated in the appearance of this pseudotumor. The diagnosis is mainly clinical, the unilateral cervical enlargement could be associated with facial asymmetry and limited movement of the neck, called congenital torticollis. However, the ultrasound is able to confirm the diagnosis, eliminate the differentials and ensure the follow-up. This pseudotumor natural evolution is usually spontaneous in 4 to 8 months requiring only physiotherapy as treatment. We present a case report of congenital torticollis in a four-week-old newborn who had a right cervical swelling that the mother had noticed a few days before.A four-week-old newborn , was admitted with right cervical swelling and restricted neck movement. The obstetrical history of the mother revealed that the pregnancy reached full term, but was poorly monitored, and the newborn was delivered by a natural assisted birth, with dystocia due to breech presentation. The clinical examination revealed a swelling of firm consistency without any inflammatory sings A cervical ultrasound revealed a fusiform thickening of the right sternocleidomastoid muscle, which was homogeneous in echo-structure, with a preserved muscle's fibrillar structure. No significant change in internal vascularity was seen. This pseudotumor measured 9.3 mm compared to 4.9 mm on the left side, without mass effect on the vascular axis or the adjacent structures The newborn benefited from motor physiotherapy, the physician advised his parents to gently rotate the head of the child toward the side of the lesion, five -to six times daily and hold it for a few seconds.Fibromatosis Colli is a rare condition, with a prevalence estimated at 0.4%. It is categorized as a benign fibroblastic proliferation of the sternocleidomastoid muscle Fibromatosis Colli is, first of all, a clinical diagnosis and is suspected in cases of unilateral cervical swelling and history of birth trauma. However, ultrasound is the key imaging modality to confirm the diagnosis, with a sensitivity of 100%, it is also able to eliminate adenopathies or invasion and mass effect on the adjacent structures and ensures the follow-up. It is a gold standard in case of Fibromatosis Colli, due to its availability, low cost and absence of irradiation. It typically shows a fusiform or an ellipsoid shaped thickening of the sternocleidomastoid muscle In case the ultrasound is inconclusive, we can further assess the pseudotumor using CT, although this exposes the newborn to ionizing radiation, and it shows an iso-attenuated enlargement of the sternocleidomastoid muscle with normal surrounding structures Fibromatosis Colli is a rare benign pseudotumor in neonates. The diagnosis is mainly clinical and can be confirmed using ultrasonography that is an ideal, easily available, low- cost imaging modality that also ensures the follow-up. MRI can be useful in doubtful cases. The evolution is usually gradual and spontaneous and can be accelerated using simple physiotherapy techniques.An informed consent was obtained from the patient.


Purpose: To investigate the clinical characteristics, diagnosis, differential diagnosis, therapy options, and outcomes of retroperitoneal ganglioneuroma.Methods: In this retrospective study, we collected and analyzed the clinical data of 32 patients diagnosed with retroperitoneal ganglioneuroma and admitted to Peking Union Medical College Hospital from October 2012 to August 2019.Results: Among our 32 cases with retroperitoneal ganglioneuroma, the male-to-female ratio was 1:3 and the mean age was 35. Only 25% of the cases presented with abdominal pain while more than 65% had no specific symptoms. The masses could be found through physical examination in only five patients. Most of the tumors are located near the renal area. They were usually single and displayed an embedded growth pattern with diameters <10 cm, clear borders, and soft texture. For radiological imaging, the majority of tumors demonstrated soft tissue density with mild-to-moderate enhancement on CT imaging and showed hypoecho with moderate blood flow signals in ultrasound. No significantly abnormal laboratory examinations were found in most patients. Of all the 32 patients, 2 chose surveillance after biopsy due to difficulties in operation, while others chose surgical resection. The mean follow-up time was 15.8 months among 26 patients. The tumor remained stable in the surveillance cases. Residual tumors were found in four cases receiving operations with no progress and discomfort. No recurrence was seen in all patients.Conclusions: The retroperitoneal ganglioneuroma is a benign tumor without specific clinical manifestations or significant laboratory findings. Typically, it is shown as low density with a clear border and an embedded growth pattern in radiological imaging. The overall prognosis is good. Surgery is an effective approach with possible severe complications. Incomplete resection or surveillance can be considered for some cases where complete resection is difficult to achieve. Ganglioneuroma (GN) is a rare benign tumor of neural crest origin arising from the sympathetic nervous system. It is a mature and well-differentiated subtype of peripheral neuroblastic tumors (pNTs) that are classified into four categories: neuroblastoma (NB), ganglioneuroblastoma-nodular (GNB-N), ganglioneuroblastoma-intermixed (GNB-I), and GN in International Neuroblastoma Pathology Classification (INPC) . HistoloThe majority of GNs arise as primary lesions, but secondary GNs can be found differentiated from NB spontaneously or induced by treatment . TheoretPrevious reports of retroperitoneal GN are mainly single cases and only a few studies summarized some characteristics of the masses. As their clinical behaviors and features are still poorly understood, we retrospectively analyzed the clinical data of 32 patients with retroperitoneal GNs including several hard cases and summarized their features, diagnosis, treatment strategies, and outcomes to provide more experience for diagnosis and therapy of retroperitoneal GNs.In this retrospective study, we collected and analyzed the medical records of 32 cases diagnosed with retroperitoneal GN in Peking Union Medical College Hospital (PUMCH) from October 2012 to August 2019. Patient data included sex, age, manifestations, physical examination, laboratory and radiological findings, treatments, outcomes, and follow-up. Laboratory examination mainly included endocrine tests , tumor antigens such as CEA, CA125, CA19-9, CA724, NSE, and AFP, as well as metabolic indexes. Radiological findings included the location, size, number, shape, border, density, neighboring structures, the blood flow information, as well as enhancement performances. For pathological reports, the sizes of tumors, gross macroscopic findings, immunohistochemical staining, and pathological diagnosis were collected. Clinical diagnoses of retroperitoneal GN were mostly based on radiological findings, and the definite diagnoses relied on histopathological examinations.For surgical procedure of laparotomy, incision position was dependent on the tumor location, mostly through the rectus abdominis. Firstly, the surgeons cut into the abdominal cavity layer by layer and explored the tumor. Then, they opened the peritoneum, protected and separated the neighboring structures, and exposed the mass. Next, fibrous connective tissue involved by the mass was removed and the tumor was freed along the tumor capsule until it was resected. Last, the surgeon stopped the bleeding, placed a drainage tube on the wound, led it out of the abdomen with another opening, and closed the abdomen layer by layer. For laparoscopic operation, normally three ports were placed. Similarly, the tumor was exposed from the adjacent organs and vessels, and then it was freed along the capsule and finally removed. Besides, one of the laparoscopic cases was achieved through robotic technique.This study did not directly involve patient subjects and is exempt from ethical committee approval. Informed consent was waived considering it is a retrospective study. Descriptive data were summarized by frequencies and percentages.This study collected the clinical data of 32 patients with retroperitoneal GN admitted to PUMCH from October 2012 to August 2019 . The sexBased on tumor gross observations and radiological findings, these 36 retroperitoneal GNs exhibited some characteristic features . Most ofn = 30), ultrasound (n = 22), magnetic resonance imaging , PET/CT (n = 3), somatostatin receptor (SSR) imaging (n = 14), and MIBG adrenal medulla imaging (n = 7).So far, screening and clinical diagnosis of GN mainly depends on radiography. With the development of imaging methods and techniques, it would be easier for us to distinguish benign from malignant tumors as well as identify the possible origin site. However, as the tumors can exhibit untypical features, sometimes the radiological examination can be inaccurate and even misleading. The radiological methods and the findings are shown in Among them, CT imaging was the most common method, followed by ultrasound. In plain CT, the density of GNs were low with CT values ranging from 21 to 45 (mean: 31.78). The masses were mostly solid and uniform, while eight tumors had cystic components and four had calcification. Most of the tumors showed mild-to-moderate enhancement . HoweverUltrasound is a cheap, convenient, and common way to detect abdominal and pelvic mass. GNs usually presented as hypoecho (95.45%) and some could have mixed hyperechogenic components. Half of our cases showed blood flow signals, mainly in the shape of dots or bands.MRI was only performed in 10 patients, but in one case, it showed no obvious abnormity because of partially heavy artifact. The tumors were of hypo- to iso-intensity in T1WI, iso- to hyper-intensity in T2WI, and hyperintensity in DWI, and the ones going through enhanced MRI all reported enhancement.n = 7) were found increased in radioactive uptake. As for PET/CT, the SUV values of the tumor were 1.4, 1.9, and 2.2, respectively, for the three patients, and only the last one indicated malignancy from the renal cortex.On SSR imaging, no expression of the receptor was found in the tumor cells 13 out of 14 cases. However, one patient was reported to mildly express SSR in the tumor margins, which led to the clinical suspicion of pheochromocytoma before surgery even without the corresponding manifestations. In addition, the patients whose tumors were found in the adrenal area may perform MIBG adrenal medulla imaging to exclude paraganglioma, and none of them (n = 15) were suspected as retroperitoneal GNs as the first diagnosis, while six cases were suspected to be malignant. Others were suspected as benign tumors of other origins including lymph vessel, adrenal gland, and mesenchymal tissues.In conclusion, two out of three of our cases reported the possibility of neurogenic benign tumors based on radiologic findings; 46.9% of the cases  level and decreased plasma renin activity (PRA), and his ALD level was not suppressed by captopril. These findings supported primary hyperaldosteronism, and thus the tumor was suspected as adrenal aldosterone adenoma. However, the tumor was found not originate from adrenal tissue and was identified as GN instead by surgical pathology, and the final diagnosis was actually idiopathic hyperaldosteronism. Moreover, three more patients were found low PRA with no abnormality or symptoms, so the abnormal PRA was not enough to support other disease. However, it should also be confirmed by pathology. Another patient was found moderately high in urinate norepinephrine, and the SSR imaging showed that the receptor was mildly expressed in the tumor margins, which suggested that the tumor might be pheochromocytoma. This diagnosis was denied through biopsy and the pathology confirmed it as GN. In addition to the misdiagnosis, laboratory test could also discover complications that may be related to GN. One 19-year-old female patient had experienced menstrual disorder and body hair increase for several years, and her blood androgen, progesterone, LH, FSH, ACTH, as well as urinary free cortisol (UFC) were found increased. She was finally diagnosed as congenital adrenal hyperplasia (CAH) with non-functional GN by surgical pathology.As for tumor markers, NSE was elevated in one patient whose CT implied irregular mix density and heterogeneously enhancement with lipid components, so there was a relatively high possibility of liposarcoma. Last, laparoscopic biopsy showed that the tumor was GN instead. The tumor was not excised because it was surrounded by vessels and hard to separate, leaving the risk of malignancy neglected by biopsy. Besides, CA724 was elevated in two patients and CA125 was found high in another patient, but they had no other evidence to support malignancy.n = 6) to 66.7% . The comparison of tumor features and surgical outcomes is summarized in Of all the 32 patients, 2 patients underwent biopsy and chose surveillance, while the other 30 patients underwent surgery . The twon = 2), pancreas (n = 2), uterus (n = 2), or liver (n = 2). Kidney was also resected at the same time in two cases because the renal vessels were embedded in the tumors, and gall bladder was removed in another case with complicated chronic cholecystitis. Organ involvement was seen in 13 cases, including adrenal gland, renal vessels, inferior vena cava, abdominal wall muscles, iliac vessels, abdominal aorta, and spine, while there was usually fat space between the tumors and adjacent kidney, pancreas, or uterus. R0 resection was achieved in 76.67% of the surgical cases, while R2 resection was seen in six cases and R1 was seen in one case.Among the 30 surgical cases, most of the tumors (63.3%) were located near the kidney, especially in the adrenal area and near renal hilum, and especially in the right adrenal area. They can also be located near aorta abdominalis (With the concept of enhanced recovery after surgery (ERAS) widely accepted, the patients who received surgery all passed flatus and fed within 5 days, mostly in 2 days (72.4%). More than half of the drainage tubes (55.17%) were removed in 3 days. The patient whose GN was around 15 cm and close to abdominal aorta and renal vessels had stayed in the ICU for 1 day after the surgery, and then fed and got rid of the drainage tube the next day. Another patient had acute cholecystitis in the 6th day after the operation and recovered in the next 2 days. The case with hand numbness and neck pain was relieved from the tumor-mass effects once the tumor was excised. No postoperative hemorrhage, limb numbness, Horner's syndrome, or intestinal obstruction was observed in our cases.In our study, 26 patients (81.25%) was followed up. The follow-up time ranged from 6 months to 36 months, and the average time was 15.8 months. Among the 24 followed up patients with GNs excised, 18 cases had the tumors completely removed, while CT examination showed residual tumors in the other six patients. Although the operations did not achieve R0 resection, the residual tumors did not progress and two of them even shrank in subsequent examinations. No recurrence and complications were observed in all of the surgical cases. For the two cases undergoing surveillance, the tumors were evaluated by CT scanning every year. There was no discomfort, and the masses were stable during the last several years.Retroperitoneal GN is a mature pNT, characterized by extremely low incidence, lack of symptom, rare recurrence, and good prognosis . The incMost retroperitoneal GNs are asymptomatic and nonfunctional, so they are mainly found incidentally by health examination or other disease complications , which aAs retroperitoneal GNs lack specific symptoms and laboratory findings, clinical diagnosis mainly depends on radiological examination. Typically, the mass is well-circumscribed, oval, or oval lobulated with diameters ranging from 3 to 10 cm and tends to surround major blood vessels without compression or occlusion , 24. MasPrevious studies revealed that most of the cases with retroperitoneal masses were actually malignant and 90% of the malignancies were sarcoma, while the common benign tumors included neurogenic tumors, paragangliomas, fibromas, angiomyolipomas, and lipomas . We founn = 22) suffered from surgery-related complications, and among them, two were fatal and seven were severe , six cases were incompletely resected due to either artery or spine involvement or the large size of the fused masses. No tumor progression and malignant transformation was seen in spite of incomplete excision in the six cases, and two of them even shrank in the following examinations. Kidney was removed in two cases for complete resection of the tumor, and gall bladder was resected in a patient with chronic cholecystitis and tumor was located near the gall bladder. Major vascular resection with prosthetic replacement was also seen for a recurrent retroperitoneal GN , but it In conclusion, although complete resection is an adequate therapy, the surgery may result in severe complications when the mass is adjacent to major vessels, nerves, or important organs. Therefore, incomplete resection is suitable for the tumors hard to separate, and surgical pathology can be then used for definite diagnosis, which is more convincing than percutaneous biopsy. Besides, preoperative percutaneous biopsy can help to diagnose retroperitoneal GN with relatively high sensitivity, especially when radiological imaging is untypical. However, it should be noted that there is still a low possibility of false negatives and even long-term malignant transformation. Surveillance can be considered for the cases with high risks of postoperative complication who are diagnosed as GN by biopsy, especially for the patients without distinct symptoms. All the patients should receive regular re-examinations and follow-up to avoid tumor progression or recurrent.As for other therapy options, due to the benign natures of GN, adjuvant systemic chemotherapy or local radiotherapy are not considered in clinical practice . ActuallRetroperitoneal GN is a rare benign tumor with excellent prognosis, mainly seen in children and young adults. Most of the tumors are asymptomatic without specific laboratory findings, while nonspecific tumor-mass effects and functional mass can be seen in some cases. The clinical preoperative diagnosis mainly depends on radiological imaging, which shows low density <10 cm with a clear border and an embedded growth pattern. Differential diagnosis can be hard for the ones with untypical performance and features, and pathology is the gold standard for GN diagnosis. Surgery is widely accepted as an effective therapy with possible complications, and rare tumor progression is seen in less radical surgery or surveillance. More investigations are needed to further explore the rationale and outcomes of resection for retroperitoneal GN.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individuals, and minors' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.JX and ZZ designed the study. ZZ collected and analyzed the data and wrote the paper. JX revised the paper. 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.