Intracranial arachnoid cysts are extra-axial non-enhancing cerebrospinal fluid (CSF) density lesions. These are usually incidental findings on radiological investigations. Usually, the patients with arachnoid cysts are asymptomatic until the cyst grows large while symptomatic patients present with headaches, seizures, and focal neurological deficits. The adjacent calvarial bone may show remodeling and scalloping. Magnetic resonance imaging (MRI) stands superior in soft-tissue contrast and multiplanar imaging in excluding other lesions from the arachnoid cyst. Arachnoid cysts follow CSF signals in all pulse sequences with no gadolinium enhancement. Intraorbital extension of the intracranial arachnoid cyst  is rarely reported in the literature and occurs through the small bony defect. We report a case of a 20-year-old male presenting with proptosis who was detected to have an arachnoid cyst in the middle cranial fossa with intraorbital extension through a small bony defect in the lateral wall of orbit with the resultant orbital cyst. Arachnoid cysts (ACs) are relatively common benign and mostly asymptomatic developmental anomalies occurring in association with the central nervous system, within the intracranial compartment, or the spinal canal. They are thought to arise due to the congenital separation of the arachnoid layer with an accumulation of cerebrospinal fluid (CSF) within the formed potential space. Most of the ACs are detected incidentally when investigated for other complaints. These cause symptoms due to the large size and mass effect on adjoining structures . SeveralA 20-year-old male, a previously asymptomatic patient with normal vision, presented to our outpatient department with diplopia, decreased visual acuity, and gradually increasing painless protrusion of the left eye for the last four months. Conjunctival congestion was present due to incomplete closure of eyelids Figures , 1b.It was associated with left-sided hemicranial headache. It was not associated with vomiting, altered sensorium, seizures, slurred speech, and limb weakness. There was no history of weight loss, appetite loss, cough, seizures, limb weakness, any skin changes, surgery, drug intake, or close contact with pets. There were no co-morbid conditions like diabetes mellitus, hypertension, or tuberculosis. There was no history of orbital trauma. On examination, visual acuity in the left eye was 6/20. There was proptosis in the left eye with a downward and outward deviation of the eye. There was no change of proptosis on straining . No lid lag, retraction, or edema was present. Restricted upward movement of left eye-ball was noted. On palpation pulsation or thrill was absent. Corneal sensitivity was normal with cotton wisp. There was no regional lymphadenopathy. Systemic examination was unremarkable.On orbital ultrasound examination, a well-defined thin-walled anechoic cystic lesion was noted in the left intraorbital region causing proptosis of the left eye. No internal echoes, septations, calcification, or any solid component was noted. Another well-defined thin-walled anechoic cystic lesion was noted in the left middle cranial fossa behind the left orbit. On ultrasound examination, no obvious demonstrable communication was noted between the two cysts Figures , 2b. Magnetic resonance imaging (MRI) of the brain and orbits showed thin-walled large well-defined CSF signal intensity extra-axial cystic lesion measuring approximately 76x43x49 mm  in left middle cranial fossa causing scalloping of the left sphenoid wing and inner table of left squamous temporal bone and floor of the left middle cranial fossa. It was isointense to CSF on T1 weighted image (T1WI), T2 weighted image (T2WI), and fluid-attenuated inversion recovery (FLAIR) image without diffusion restriction on diffusion-weighted imaging (DWI). No hemorrhage was noted on the Susceptibility weighted imaging (SWI) Figures , 5a-5d.It showed few thin septations and was causing mass effect on adjoining left temporal lobe parenchyma which was compressed and displaced medially and superiorly. No abnormal post-contrast enhancement was noted. A small bony defect of size 10x8 mm  was noted in the adjoining left sphenoid bone seen on T1 Volumetric interpolated breath-hold examination (VIBE) sequence Figures , 7a, 7b.A well-defined CSF signal intensity cystic lesion measuring approximately 41x31x34 mm  was noted in left orbit inferior to left orbital roof causing extrinsic compression and inferior displacement of superior rectus and optic nerve. Mass effect was noted on the left eyeball which was compressed and displaced anteriorly and inferiorly with resultant proptosis Figures , 6a, 6b.Non-contrast enhanced computed tomography (CT) scan of orbits was performed to evaluate the bony changes. CT revealed scalloping of the left orbital roof and lamina papyracea, scalloping of the left sphenoid wing and floor of left cranial fossa, and a small defect in the left lateral wall of the orbit Figures , 8b.Intracranial ACs are extra-axial non-enhancing CSF density lesions on CT scans. The adjacent calvarial bone may show remodeling and result in hypoplasia to the adjoining brain parenchyma, usually in the middle cranial fossa . ACs freDiagnostic evaluation includes identification of intracranial ACs, detection of mass effect, and complications if any. Investigations for ACs are neurosonography, plain or contrast CT, MRI . MRI hasDifferential diagnoses of intraorbital cystic mass are lesions arising from orbit, globe, lacrimal system, paranasal sinuses, or meninges. Developmental lesions can be dermoid and epidermoid cysts or coloboma. Acquired pathologies can be orbital abscesses, mucocele, and vascular malformations like arteriovenous malformation . AC of tIntraorbital extension of intracranial AC  has been very rarely reported in the literature . HoweverIntraorbital meningocele can be congenital or post-traumatic constituting 1%-1.5 % of all meningoceles. Congenital meningoceles are usually treated by surgical excision or ligation of the cyst along with the closure of the defect. If the defect is large, it can be closed by titanium plates and microscrews or bone graft .The vast majority of ACs are asymptomatic and conservative management is instituted for most of the patients. Surgical management is fraught with morbidity and avoided in asymptomatic patients not demonstrating signs of increased intracranial pressure or focal neurological signs. These asymptomatic patients need interval follow-up with CT and MRI to monitor growth and early recognition of complications ,11.Symptomatic cysts manifesting with seizures, hydrocephalus, increased intracranial pressure, neurological deficits, and those complicated by intracystic or subdural hemorrhage are usually managed surgically. Few authors believe that all ACs exert a mass effect and should be managed surgically regardless of symptomatology to avoid potential complications such as compression on adjoining brain structures, cyst rupture, and intracystic or subdural bleed. The relationship of the cyst to adjoining brain structure should be carefully explored before endeavoring surgical exploration ,12.Intraorbital extension of the intracranial AC  is one such indication for operative management. Our patient presented with severe proptosis with visual impairment, hence an ideal candidate for surgical intervention. Surgical management of the ACs includes procedures such as surgical excision, cystoperitoneal shunting, endoscopic ventriculo-cystostomy or ventriculo-cystocistenostomy, stereotactic cyst-ventricular shunting, and stereotactic intracavitary irradiation -13. Our ACs are relatively common benign intracranial anomalies while associated intraorbital cystic lesions are not a common occurrence. The concurrent presence of both AC and the intraorbital cystic lesion should raise the suspicion of intraorbital extension of the AC and an active search for the bony defect along the orbital wall should be made to confirm the diagnosis of orbital meningocele. The bony defect can be detected on CT and if large on USG and MRI. Our case highlights the utility of both MRI and CT in the detection of a small bony defect in the lateral wall of orbit with resultant intraorbital meningocele in the case of AC in the left middle cranial fossa.


The 18F-PSMA-PET/MRI provided evidence of a cystically transformed, diminishing seroma in the left retro-/submandibular region. No 18F-PSMA expressing glandular tissue could be detected in the area of resection, excluding a relapse of a plunging ranula. As a consequence, we opted for a conservative treatment without further surgical intervention. We conclude that a simultaneous 18F-PSMA-PET/MRI is a comprehensive imaging modality, which can help to rule out persistent salivary tissue and recurring plunging ranula. It is a useful tool to facilitate the decision making of surgical interventions.We report the case of a 6-year-old patient with suspected recurrence of a plunging ranula in clinical and ultrasonographic examination. Surgical resection of the left submandibular and sublingual glands had already been performed. Since persistent glandular tissue could not be excluded with certainty via MRI, we expanded diagnostics by performing a PET/MRI using a head and neck imaging protocol and the radiotracer  Ranulas are pseudocysts developing from extravasation of mucous after trauma, infection, or obstruction of the sublingual glands and can be classified into simple ranulas, plunging ranulas, and mixed ranulas ,2.Simple ranulas are located in the sublingual space (SLS), whereas plunging ranulas are found in the submandibular space (SMS), often communicating to the SLS or parapharyngeal space. Most plunging ranulas are directly passing through the mylohyoidal muscle or through a lateral hiatus remaining from embryonal development. Less frequently, plunging ranulas bypass the muscle from posterior .Surgical treatment options include the excision of the ranula itself and the marsupialization or the excision of the submandibular glad with or without the ranula. While sole excision of the ranula and marsupialization of the gland are less traumatic procedures, their recurrence rate is above 50%. In contrast, the reported recurrence rate after excision of the gland is only 1–2%, albeit a higher surgical trauma and risk of infection, bleeding, nerve lesions, and movement restriction by scar tissue . Establi68Ga- or 18F-labeled PSMA is mainly used as primary imaging tool in patients with prostate cancer and biochemical recurrence [Recently, radiolabeled tracers for the visualization of prostate specific membrane antigen (PSMA) by means of positron-emission tomography (PET) have been introduced. PET with currence . Besidescurrence . An off-currence ,10.High physiological uptake of PSMA has been described in healthy salivary, seromucous, and lacrimal glands . The radIn head and neck imaging, PSMA-PET/CT has been shown to be beneficial for the individualization of radiotherapy and quantification of salivary gland tissues . AdditioWe present a case using PSMA-PET/MRI to exclude persistent salivary tissue and a recurrence of a plunging ranula in a 6-year-old child without further surgery.18F-PSMA-1007, simultaneous PET/MR data were acquired on a 3T PET/MR-system , which is able to acquire PET and MRI data simultaneously. The PET acquisition time was 47 min. For the generation of a segmentation-based PET attenuation correction map, a 3D T1-weighted spoiled gradient-echo sequence with Dixon-based fat–water separation was acquired. PET was reconstructed using a 3D ordered-subset expectation–maximization algorithm with 2 iterations, 21 subsets, matrix size 256  ×  256, and Gaussian filtering of 4 mm. The following MRI measurements were performed: T2-weighted transversal and coronal turbo inversion recovery magnitude (TIRM) sequence, T2-weighted sagittal turbo spin echo (TSE) sequence, T1-weighted fast spin echo isotropic 3D sequences, allowing multiplanar reformats, diffusion-weighted imaging (DWI), T1-weighted volumetric interpolated breath–hold examination (VIBE) sequence after intravenous injection of 2 mL gadolinium-based MRI contrast media .Sixty minutes after injection of 45 MBq 18F-PSMA uptake was quantified by measuring the standardized uptake values (SUVs) and calculation of the SUV mean using 40% isocontour volumes of interests (VOIs).Image analysis was performed by two radiologists and a nuclear physician in consensus. The In 2015, a 6-month-old child presented with a swelling in the anterior floor of the mouth in our clinic. The examination revealed a 20 mm painless swelling in the left floor of the mouth without any restrictions of the tongue mobility. The preliminary diagnosis was a simple ranula. Considering the absence of symptoms, the young age, and possible risks of an anesthesia, we recommended clinical observation. However, within the next six months, the size of the lesion increased. Consequently, we performed an extirpation of the tumor exhibiting a granuloma of the mucosa. Two months afterwards, we had to perform a second surgery. The histopathological diagnosis confirmed a ranula at this time. After performing a marsupialization with good results, there was no evidence of recurrence for four years. In November 2019, the patient noticed a painless submandibular swelling on the left side. We performed an ultrasonography showing a 3.5 cm × 2.0 cm × 1.4 cm echo-free cyst and suspected a plunging ranula. This was confirmed by MRI. The patient underwent surgery in June 2020 with extirpation of the ranula and the left sublingual and submandibular glands using a combined intra- and extraoral approach. Shortly after this procedure, we had to drain a postoperative abscess, which showed a normal regression. In December 2020, the patient reported pain around the scar accompanied by a soft swelling in the area of surgery. Ultrasonography  revealedThe subsequently performed external MRI examination  confirme18F-PSMA-1007. Due to the therapeutic consequences for this patient, we expanded diagnostics performing a PET/MRI using a dedicated head and neck imaging protocol and the radiotracer 18F-PSMA-PET/MRI provided evidence of a cystically transformed, size-decreasing seroma in the left retro-/submandibular region (18F-PSMA-expressing glandular tissue could be detected in the resection area, excluding persistent salivary tissue and a relapse. Thus, a conservative treatment was initiated without further surgical intervention. r region . No 18F-18F-PSMA-PET/MRI, we recommended further observation of the swelling. During the last visit, the mother reported varying swelling of the left submandibular region without intraoral changes. The patient was pain free, and the tongue movement was only slightly limited. The US showed a diminishing area of low echo density, conforming to a slowly resorbing seroma. Further appointments for checkups were set.Based on the results of the While simple ranulas are limited to the SLS, plunging ranulas are located in the SMS and are treated by an extraoral surgical approach to reduce the rate of recurrence . In our When the patient exhibited renewed signs of a ranula, the child was almost 6 years old and, thus, much more compliant with imaging techniques. To avoid radiation exposure, we used US and MRI, which supported our decision for second surgery. At time of the next suspicion of recurrence, US and MRI were performed again. This time, however, a clear differentiation between recurrence and seroma was not possible. Residual glandular tissue could not be ruled out by morphological imaging alone.As described by Jain et al., conventional imaging methods sometimes prove to be ambiguous or even wrong . AdditioDue to the young age of the patient, an explorative surgery was not justifiable. The use of PSMA-PET/MRI enabled us to clearly exclude residual glandular tissue that would indicated a relapse of a plunging ranula. 18F-PSMA uptake [This is in concordance to other studies, showing that minor gland locations can be selectively visualized by a physiologically increased A uptake . Saliva-A uptake . AlthougA uptake ,18, PSMAA uptake . The combined acquisition of both morphological information via MRI and metabolic information with PET enables confirmation and differentiation of post-therapeutic anatomical changes in the soft tissue and areas of pathologically increased or decreased function.The effective PET dose calculated from our described applied activity was approximately 2.5 mSV, which is significantly lower compared to the radiation exposure patients normally receive in PET/CT scans ,20,21.Due to the valuable contribution to the diagnosis of ranula, we recommend the use of PSMA-PET/MRI especially for high-risk patients and in case of suspected recurrence.The decision of treatment, especially the indication for a surgical approach, has to be carefully considered in high-risk patients with ranula and suspected relapse.Simultaneous PSMA-PET/MRI is a comprehensive imaging modality to diagnose and clearly exclude persistent salivary tissue in case of recurrence of a plunging ranula. Consequentially, it can prevent unnecessary surgical interventions.


Only 10 cases of cecal epidermoid cyst (CEC) have been reported in the literature. Furthermore, its pathogenesis remains unclear. We report a rare case of congenital CEC in neonate, and discuss its clinicopathological findings.A cystic lesion was incidentally identified in the retroperitoneal area of the abdominal right lower quadrant during a routine prenatal ultrasonography (US), prompting an ileocolectomy 3 days after birth. This congenital cyst was composed of mucosal lining cells and submucosal connective tissues, and the inner lining mucosa was composed of stratified squamous epithelium and focally mucin-producing ciliated epithelium. Based on the macroscopic and microscopic findings, the cystic lesion was diagnosed as a congenital cecal epidermoid cyst.The management of a fetal abdominal mass should be tailored individually, considering that epidermoid cysts can occur in the cecum during the perinatal period. We report the clinicopathological findings in this case, including its possible pathogenesis. In the literature, only 10 case of cecal epidermoid cysts (CECs) have been reported , with itth percentile), height of 49.0 cm (45th percentile), and head circumference of 35.5 cm (55th percentile). Initial physical examination revealed a soft abdomen with no distention.A 28-year-old woman underwent regular follow-ups at an antenatal clinic, without needing any medication. At 24 weeks of gestation, an intra-abdominal cystic mass, approximately 2.0 × 1.5 cm in size, was found during routine prenatal ultrasonography (US). Its size increased to 3.5 × 2.4 cm at 32 weeks of gestation, and thereafter, it ceased to grow until delivery. The amniotic fluid index at 32 weeks of gestation was 1.5 cm, and this was maintained at 1.3 cm by 36 weeks of gestation. Eventually, the male neonate was born at 38 weeks and 2 days of gestation via normal spontaneous vaginal delivery, with Apgar scores of 9 and 10 at 1 and 5 min, respectively. He had a body weight of 3500 g  with echogenic material, fluid, and calcification, which originated from the retroperitoneum and was located in front of the inferior vena cava and descending aorta Fig. a. Due to × 4.2 cmOn macroscopic examination, a cyst was identified without any macroscopic connection to the cecal lumen. The cyst contained a dark brown mucinous fluid, and the mucosal and serosal surfaces of the cecum were unremarkable Fig. b. On micThe present report describes a case of CEC in a newborn. Only 10 CECs have been reported in English literature, with the only one pediatric patient being an 8-year-old girl . EpidermTwo pathogenic mechanisms have been proposed for congenital sequestration. One mechanism suggests that ectodermal implantation occurs at the time of neural groove closure during embryogenesis; however, some researchers have postulated that given the location of the cecum and the neural groove or other epithelial fusion lines, this mechanism would be unusual . AnotherIn conclusion, considering that epidermoid cysts can develop in the cecum during the perinatal period, the management of a fetal abdominal mass should be tailored individually. Moreover, the possibility of CEC should be considered in the differential diagnosis of subserosal cysts in the cecal area, and the cyst should be completely removed to achieve a good prognosis.


Case Presentation. Here, we present a case of a 54-year-old man who was examined for chest pain, and computed tomography (CT) incidentally detected a bone tumor at the scapula with destruction of cortical bone and invasion into soft tissue. Magnetic resonance imaging revealed multiple cystic components with fluid-fluid levels. FDG-PET showed uptake at the axillary lymph node. The CT-guided needle biopsy revealed spindle cell sarcoma on histopathology. After neoadjuvant chemotherapy, a scapulectomy was performed. The final postresection histopathological diagnosis was the same as the preoperative diagnosis, and no obvious chemotherapeutic effect was observed. Next-generation sequencing of RNA isolated from paraffin-embedded tumor tissue revealed that these lesions harbored the EWSR1-CREB1 fusion gene, and the tumor was diagnosed as AFH. C-reactive protein level, which was elevated preoperatively, decreased after the operation, and there was no recurrence or metastasis 5 years after the treatment.  Angiomatoid fibrous histiocytoma (AFH) is a rare intermediate malignant tumor that arises mainly in soft tissues, especially in the superficial extremities of patients younger than 30 years. There have been a few reports of AFH arising from sites other than soft tissue, including bone, and unusual site and age make it difficult to diagnose this rare tumor.  The diagnosis of AFH is difficult when the tumor has an atypical presentation. Comprehensive genomic analysis, especially RNA sequencing, is efficient in diagnosing this rare tumor. Moreover, magnetic resonance imaging findings identical to AFH in soft tissue, the presence of paraneoplastic symptoms such as elevated inflammatory markers, and lymph node swelling were clues towards suspecting this tumor. Angiomatoid fibrous histiocytoma (AFH) is a rare tumor of uncertain differentiation and is classified as intermediate (rarely metastasizing) . PatientIn general, diagnosis of some bone and soft tissue tumors is difficult because of the rarity and lack of definite histopathological features. Recent advancements in comprehensive genetic analysis have shown that fusion genes can be used as diagnostic markers for bone and soft tissue tumors . AFH hasImaging features of AFH have been documented in a few studies, and AFH has well-circumscribed polycystic lesions with fluid-fluid levels , 11. HowHerein, we describe a case of AFH arising from the scapula of a 54-year-old man. In this case, we describe the successful use of comprehensive genetic testing with a RNA panel to diagnose this rare tumor. In addition, AFH arising from the bone had imaging features identical to those of AFH in soft tissues.A 54-year-old man was suspected to have a bone tumor of the scapula when a computed tomography (CT) done to analyze the cause of chest pain incidentally revealed a lesion. The Institutional Review Board of the University of Tokyo approved this study, and written informed consent was obtained from the patient.He had no pain around his right shoulder, and a blood test revealed an elevated C-reactive protein level of 7.69 mg/dl. Radiography of his right shoulder revealed a lytic lesion adjacent to the glenoid cavity . CT reveHistopathological examination of the CT-guided needle biopsy resulted in a diagnosis of spindle cell sarcoma . ImmunohEWSR1-CREB1 fusion gene, resulting in the diagnosis of AFH in combination with histological findings.Because of the difficulty of histopathological diagnosis, targeted next-generation sequencing (NGS) was performed after informed consent was obtained. RNA was extracted from the paraffin-embedded tumor tissue. The quality of extracted RNA was checked, and cDNA synthesis and library preparation for junction capture were conducted using a Sureselect RNA capture kit . Custom-made probes for our Todai OncoPanel (TOP) include 464 cancer-related fusion genes . MassiveWe report a case of AFH of the bone in an elderly patient. Unusual location and older age of onset made the diagnosis in this case difficult. However, comprehensive genetic testing, especially RNA-sequencing, was able to detect disease-specific fusion genes. In addition, imaging findings of multiple cystic lesions with fluid-fluid levels and paraneoplastic symptoms of elevated systemic inflammation could suggest this specific diagnosis regardless of the unusual location and age of onset.EWSR1-CREB1 fusion. A previous report has described that AFH can have three fusion genes: more than 90% of cases possess the EWSR1-CREB1 fusion, less common is the EWSR1-ATF1 fusion, and a few cases harbor the FUS-ATF1 fusion [EWSR1-CREB1 in 6% of cases and EWSR1-ATF1 fusion in 94% of cases, as previously reported [EWSR1-CREB1 and help to arrive at the correct diagnosis.Targeted RNA sequencing revealed a characteristic fusion gene of AFH, the 1 fusion , 9. Thesreported . TherefoThe imaging findings of MRI in our case possess similar characteristics to AFH in the soft tissue. A limited case series and case reports have mentioned the characteristics of imaging features of AFH in soft tissue, and AFH is seen to have a combination of solid and multiple cystic lesions filled with blood products, occasionally representing fluid-fluid levels , 11. Marα released by the tumor, and this production is thought to be related to the EWSR1-CREB1 fusion gene as a transcriptional factor. A retrospective review of our case, the existence of regional lymph node swelling, and elevation of C-reactive protein could have helped in the diagnosis of AFH.AFH is known to cause local lymph node swelling. Ulaner et al. reported that seven out of 17 cases of primary AFH of soft tissue had local lymph node swelling . Only onIn conclusion, we presented a case of AFH of bone with an uncommon location and age, and targeted RNA sequencing could support the histopathological diagnosis. Imaging findings were identical to those of AFH in soft tissues, paraneoplastic symptoms of elevated systemic inflammatory markers, and local lymph node swelling might have aided the histopathological diagnosis, which evokes the importance of Jaffe's triangle. Furthermore, in addition to clinical, radiological, and histological information, genetic information can help arrive at a correct diagnosis even for rare and uncommon tumors, such as AFH.


The diagnosis of canine reproductive neoplasia remains challenging as none of the routinely performed diagnostic methods appear to have sufficient sensitivity or specificity. In recent years, advanced imaging techniques have been successfully performed in small animals; however, even though the incidence of reproductive neoplasia is high, no data are available on the performance of these techniques. This review evaluates the applicability of various diagnostic imaging modalities in dogs and describes the findings and specific patterns that may characterise different tumour types. Lamentably, some of the advanced imaging techniques have not yet been adopted as first-line diagnostic tools, although it is clear that in the future they will become important methods for the detection of male and female reproductive neoplasia.Diagnostic imaging plays an essential role in the diagnosis and management of reproductive neoplasia in dogs and cats. The initial diagnosis, staging, and planning of surgical and radiation treatment and the response to therapy all involve imaging to varying degrees. Routine radiographs, ultrasound, nuclear medicine, and cross-sectional imaging in the form of computed tomography (CT) and magnetic resonance imaging (MRI) are routinely used in canine reproductive disorders. The choice of imaging modality depends on many factors, including the level of referral and the pathological information required. The biological behaviour of the tumour also guides the choice of imaging in cancer staging, and imaging may play an important role in guiding serial tumour biopsy during the course of therapy. The sophistication of imaging modalities is increasing exponentially. Each modality has advantages and disadvantages in terms of cost, availability, sensitivity, specificity, and qualities of anatomic versus functional imaging. Several imaging modalities are now available in small animal oncology and in the study of neoplasia involving the female and male reproductive tracts. Each modality has advantages and disadvantages that may relate to cost, availability, sensitivity, and specificity; some provide ‘anatomic imaging’ whilst others provide ‘functional imaging’. Each method may have different roles in diagnosis, staging, treatment selection and follow-up. The use of diagnostic imaging as an aid in canine and feline reproduction has evolved over the past twenty years from its initial role in early pregnancy diagnosis to its current use as an integral component in the management of reproductive cases. Ultrasonography is sensitive for the detection of lesions, but it is not specific for the aetiology of a disease. Therefore, biopsy or fine-needle aspiration of the lesion may be necessary. Ultrasound-guided sampling of tissue can be performed quickly, accurately, and safely. Advances in ultrasound equipment and the development of ultrasonographic contrast agents are increasing the diagnostic specificity of ultrasound. For example, Doppler techniques are used to detect tumour vessels, which are usually seen to be tortuous and at high velocity compared with vessels present within normal tissue.This review describes both standard and innovative approaches to imaging in dogs with suspected reproductive malignancy and highlights the important contribution of imaging to the management of these patients.The ovaries are located immediately caudal to the kidneys and are positioned close to the abdominal wall. The uterus of the bitch is roughly ‘Y’-shaped and has relatively long uterine horns which are positioned proximally, close to the abdominal wall, converging distally in the midline at the uterine body.The ovaries are located in the dorsal abdomen slightly lateral to the caudal poles of the kidneys. Normal-sized or mildly enlarged ovaries are not visible radiographically, limiting the usefulness of this technique and making ultrasound the first-choice in the evaluation of ovarian disorders. Multifrequency curvilinear or linear 5–11 MHz transducers are the standard equipment for ovarian examination. High-resolution probes  are currently available and may maximise the ability to visualise subtle changes in the ovary. The caudal pole of the kidneys and the adjacent area are examined in sagittal and transverse planes to localise the ovaries. Their identification may be facilitated by the appearance of marginal artefacts dorsal to each ovary. The changes seen in the bitch ovary during the reproductive cycle have been described [Survey radiography was the first technique described for imaging canine ovarian tumours; however, radiography provides little information regarding ovarian mass architecture. When the ovary is significantly enlarged, it results in a ventrally located mass that causes medial, but not ventral displacement of adjacent organs on radiographs. Right ovarian masses displace the descending duodenum and ascending colon medially, whereas left ovarian masses displace the descending colon medially ,11,12,13Confirmation that a mass is ovarian in origin is based on its appropriate location, being caudal to the kidneys, and ideally having an association with an adjacent uterine horn. The adjacent uterus can be confirmed by imaging the ovarian veins with Colour Doppler. Ultrasonographically, ovaries in bitches with ovarian tumours may appear unilaterally enlarged, with regional or focal lesions that may be solid or cystic. Frequently there is a significant disruption of the normal appearance with an inhomogeneous echotexture. Tumours may be small or large and may be solid, contain small cysts, or be primarily cystic in appearance. A literature search of ultrasound imaging of ovarian masses identified only two case series ,13 and nAn attempt to classify ovarian masses based on ultrasonographic appearance has been proposed  and inclWhen imaged with computed tomography (CT), ovarian tumours in dogs appear as large soft-tissue attenuated masses located in the mid-ventral abdomen, with moderate or severe contrast enhancement . CT may With CT, the origin of the tumour may be confirmed, and the assessment of surgical options may be significantly improved compared with other imaging modalities. Similar to radiography, CT may identify mineralised areas in some ovarian masses and tooth-like structures in teratomas. The CT appearance of an ovarian papillary adenocarcinoma has been described, showing an obvious internal structure, areas of contrast enhancement. and connection with the ovarian vein . An ovarThe function of the canine uterine tube, also called the oviduct , is to carry the ova from the ovary to the uterine horn. Each Fallopian tube is a narrow structure that lies near the ovary and passes over it into the uterine horn. They are not visible with modern imaging techniques unless they enlarge due to fluid accumulation or neoplasia. Tumours are extremely rare and are unlikely to become symptomatic until they reach a large size. At that stage, uterine tube masses may be seen on radiographs as a generic soft tissue mass. Ultrasound is a more sensitive technique than radiography, and it is possible to speculate that mass lesions adjacent to the ovary may originate from the uterine tube. Leiomyoma of the mesosalpinx has been described as a solid mass . Large aMethods of uterine imaging include survey radiography, ultrasound, CT, and MRI. As described under ovarian mass lesions, the main limitations of survey radiography are subject density and size. The uterus has the same subject density as adjacent soft tissue structures, and, therefore, it cannot be identified radiographically. Ultrasound imaging of the uterus is best performed with the bitch in a standing position after clipping the hair of the ventral abdomen. Partial filling of the bladder helps identify the body of the uterus and the larger diameter of the cervix. The uterine bifurcation can be detected in about 40% of cases. The uterus is surprisingly tortuous and may coil and position itself in unexpected directions, but the proximal portions of the two uterine horns can be imaged and traced laterally to the abdominal wall. They often lie along the length of the body wall. The uterine body and horns are composed of two distinct layers: a central homogeneous, relatively hypoechoic region surrounded by a peripheral hyperechoic layer. The ability to differentiate these layers depends upon the stage of the cycle. During oestrus, the uterus becomes increasingly hypoechoic and is much larger in diameter. The lumen is generally not seen but may be visible as a bright echogenic central line, which represents the mucosal–luminal interfaces. During proestrus and oestrus, there may be minimal anechoic content (fluid) 1 mm wide in the lumen [Uterine neoplasia is rare in the bitch, and since imaging techniques cannot readily distinguish neoplastic from granulomatous diseases, fine-needle aspiration is often required to make a definitive diagnosis. Diagnostic imaging is an important step in identifying uterine abdominal masses and subsequent treatment planning. However, the size and nature of large uterine masses can make interpretation of abdominal radiographs and ultrasound challenging. Two retrospective studies ,19 and mUltrasonography has been described as a useful method to demonstrate the uterine origin of an abdominal mass by tracing the abnormal area to a region of normal appearing uterine horn or body. However, when a large mass is present, identification of the affected organ can be very challenging. Ultrasonographically, uterine neoplasia may appear as endoluminal or intramural, homogeneous or heterogeneous, mass lesions with a possible amount of uterine fluid. Leiomyoma, fibroleiomyoma, and leiomyosarcoma have been described as solid masses, but anechoic ischemic cavities are often observed in the mass, giving a mixed to cystic pattern ,21 Figu. OccasioUnderstanding the appearance of the uterus in CT and magnetic resonance (MR) images may be important as the use of advanced imaging becomes more common in the examination of the canine abdomen. Cross-sectional imaging may also help to assess more complex uterine anatomic abnormalities and mass lesions that cannot be clearly confirmed as uterine by other imaging modalities. CT was undertaken to determine the uterine nature of a cystic mass occupying most of the abdomen and was subsequently diagnosed as a lipoleiomyoma and also to reveal another solid uterine leiomyoma . The firThe vagina has mainly a pelvic position. Survey radiographs and ultrasound are useful as screening tools but have limited diagnostic value. Vaginoscopy is very useful for visualisation of deep proliferative luminal lesions, although some large and obstructive masses cannot be easily evaluated. On abdominal radiographs, leiomyomas may be seen as ill-defined soft tissue masses in the ventral pelvic canal, causing dorsal displacement of the rectum . VaginalUltrasonographically, it is extremely difficult to image the pelvic canal via a transabdominal approach. Some proximal vaginal masses may be detected by pointing the ultrasound probe caudally to visualise the region immediately caudal to the cervix. It is also feasible to infuse saline into the vagina, thus providing anechoic contrast that can be used to image some proximal vaginal wall lesions. It is also difficult to image the vagina with a perineal transcutaneous approach. Although not usually performed in small animals, transrectal ultrasound has been used to image a vaginal mass . LeiomyoCT and MR are important imaging modalities for the evaluation of vaginal abnormalities. CT allows localisation of the anatomic site of origin due to its multiplanar imaging capabilities and improved contrast resolution. A CT of the caudal abdomen and perineum allowed assessment of the size and location of vaginal leiomyoma and fibroma ,29. SuchThe prostate is an ovoid-shaped bilobed gland located at the bladder neck, surrounding the proximal urethra. The normal prostate is located within or immediately cranial to the pelvis and is bordered dorsally by the rectum. The gland is smoothly marginated, and ultrasonographically the parenchyma has a moderate homogenous echogenicity in entire dogs, with a fine to medium echotexture.Prostate size is often easily assessed by measuring the maximum total prostate width from images in the transverse plane, but is better assessed by calculating prostate volume using the formula for the volume of an ellipse:Prostatic size varies for dogs of different breeds.Diagnosis of malignant prostate disease is challenging because benign and malignant lesions may have similar clinical presentations and imaging appearance at the initial stages. The search for improved diagnostic techniques continues, and a variety of other imaging modalities have been reported in human medicine, including CT, MRI, positron emission tomography, and single-photon emission computed tomography . In dogsUltrasonography is the technique of choice for the evaluation of the canine prostate gland, considering that the plethora of imaging modalities commonly performed in human medicine are not frequently used in dogs. Unfortunately, despite providing excellent images, it may be difficult to differentiate between benign and malignant canine prostatic diseases with ultrasound due to their similar appearance when using this technique . ProstatRecently, CEUS has been performed in dogs, demonstrating this to be an innovative technique capable of quantifying vascular perfusion, essentially by measuring peak flow and transit time within tissues using video-densitometric analysis of real-time images. This technique offers significant advantages over simply measuring flow within organ-supplying vessels and enables targeted specific measurement in suspected lesions. The use of CEUS has been described in both normal dogs and those with a variety of prostatic diseases ,37. ProsElastography is a diagnostic tool that may be used to obtain highly detailed images attributable to changes in tissue stiffness. Elastography has been used to evaluate both the normal prostate gland and testicular disease, but there are no studies about the application of elastography to diagnose prostate tumours in dogs.In general, CT imaging of abdominal organs has several advantages: organs can be imaged without superimposition; small structures can be identified due to high-resolution; organ size and shape can be assessed in multiple planes with image reconstruction. CT examination is considered a helpful tool for the evaluation of the canine prostate gland . HoweverThe use of MR to evaluate the prostate is still limited and only one short communication describes the use of MR in canine prostatic tumours . The autRadiographs are rarely performed in the evaluation of intra-scrotal testicular diseases. Enlarged testicles or testicular masses may appear as an enlarged scrotal silhouette, but this cannot be distinguished from intra-scrotal fluid or thickening of the scrotal soft tissue contents. Ultrasound examination is a sensitive method for evaluating testicular parenchymal diseases, allowing differentiation of testicular from extra-testicular causes of scrotal enlargement . ImproveTesticular tumours are the most common tumours of the canine male genitalia and account for approximately 90% of all cancers of the male reproductive tract. Testicular tumours are the second most common tumour affecting male dogs. They may be benign or malignant and may or may not be endocrinologically active. While B-mode ultrasound is extremely useful for detecting testicular tumours, the ultrasonographic appearance of lesions varies and is not specific for the type of tumour . TesticuInterstitial cell tumours may appear as well-defined focal hypoechoic lesions. However, areas of haemorrhage and necrosis may occur in all tumour types and may be seen ultrasonographically as disorganised hyperechoic and hypoechoic regions. Other findings that may be associated with testicular neoplasia include areas of calcification within the testicular parenchyma that appear as hyperechoic foci producing acoustic shadowing. There are few descriptions of testicular blood flow in abnormal testes. Colour Doppler ultrasonography shows an increase in blood flow within and around most tumours . While tCEUS is a feasible diagnostic tool in the evaluation and detection of testicular lesions, with hyper-enhancement being an important feature in the diagnosis of malignancy. The study published by Volta et al.  reportedThe penis is composed of three principal divisions: the root, the body, and the glans. The root of the penis is composed of the two crura and the bulb of the penis. The body is primarily comprised of the two adjacent corpora cavernosa. The glans is subdivided into a bulbus glandis and a pars longa glandis. The os penis, or baculum, is a feature always present in the male dog. It forms from a paired ossification centre in the corpora cavernosa. On X-ray, the penis is best studied on the lateral view when the os penis is visualised, while the root, body, and glands appear as a uniform soft tissue opacity, ventral to the abdominal wall. The penile anatomy is easily demonstrated by conventional B-mode ultrasonography and can be a useful alternative method for penile assessment whenever its exposition becomes impossible.Penile tumours are relatively rare in domestic animals. The most frequently reported canine penile tumours are transmissible venereal tumour, fibropapilloma, and epithelial tumours, such as squamous papilloma and squamous cell carcinoma . The lit


Elastofibroma dorsi (ED) is known as a particular clinical and biological entity. We report a case of a bilateral elastofibroma dorsi (ED) in a 65-year-old female who presented to the Department of General and Oncologic Surgery of Emergency Clinical Municipal Hospital Timisoara, Romania. The patient was symptomatic on the right side, presenting pain in the interscapulothoracic region associated with a variable tumoral mass, dependent on the position of the right arm. Imaging studies revealed a well-defined, bilateral tumoral mass with alternation of the muscular and fatty tissue. The initial diagnosis of lipoma was taken into consideration based on the CT scan and clinical findings. Surgical excision of the right subscapular tumor was performed without any postoperative complications. Microscopic examination of hematoxylin and eosin, Masson’s trichrome, and orcein stained slides revealed the diagnosis of ED. Considering the high rate of reported postoperative complications and the asymptomatic presentation of the contralateral subscapular mass, the patient underwent clinical and imagistic monitoring for the contralateral tumor. Due to its rare nature, ED is a difficult preoperative diagnosis that can, however, be suggested by its specific location and may require an accurate histopathological examination for a final diagnosis. Elastofibroma dorsi (ED) is known as a particular clinical and biological entity. ED usually develops between the inferior angle of the scapula and the thoracic wall. It is considered to appear secondary to mechanical lesions due to scapulothoracic biomechanics during abduction, being suggested at the same time to occur as a result of tissue aging . ImmunolDue to its rare appearance, the optimal therapeutical algorithm for ED is not standardized at this moment. A conservative approach is usually attempted for all the asymptomatic cases, marginal excision with proper management of the dead spaces and postoperative immobilization is required for symptomatic patients, taking care all the time to exclude the suspicion of soft tissue malignancy. The high rate of postoperative complications  is seen mainly due to the localization of the lesion and the impossibility of complete immobilization of the excisional site ,7.A 65-year-old female patient presented with persistent right paravertebral pain. The symptoms started 3–4 months before presentation, and there were no correlations with other associated comorbidities or preexistent treatments. A palpable tumoral mass appeared after 2 months at the level of the inferior pole of the scapula with dimensions that were dependable on the position and movement of the right thoracic limb. Among the preexistent comorbidities we mention: Cardio-vascular disease , psychiatric pathology (bipolar disorder), orthopedic conditions , and neurosurgical pathologies . The preexistent treatment included NSAID’s  and myorelaxant drugs for pain control of all orthopedic conditions together with the cardiac medication. There were no changes in evolution regarding the general or local clinical findings during follow-up, regardless of posture or therapeutic choice.Clinically, at the right subscapular level, a firm, relatively well-defined tumoral mass could be palpated, with deep, submuscular localization, measuring approximately 7–8 cm in diameter, variable with the position of the right arm . The amount of pain increased with the previously described movements, with partial functional impairment of the right shoulder.Soft tissue ultrasound revealed the presence of a hyperechoic tumoral mass, relatively well-defined in the observable area, with weak vascularization at color Doppler sequence, protruding under the scapular plane and under the latissimus dorsi.Computed tomography  revealed a bilateral tumoral mass with muscular and fatty density alternation, posterior to the serratus muscles and anterior to the latissimus dorsi muscles and the scapular plane .According to the clinical and imaging findings, the diagnosis of subscapular lipoma was suspected, and surgical treatment consisting of marginal excision of the tumor was proposed.After proper preoperative evaluation and preparation, the patient was placed in left lateral decubitus with forward flexion of the arm. A parallel incision with the inferior margin of the scapula was performed. Following the dissection of the latissimus dorsi muscle fibers, a tumoral mass of 9/8/6 cm was found with the following macroscopic aspect: Polylobate surface, of firm consistency with rough areas, partially encapsulated (excepting the area of insertion at the level of the anterior scapular periosteum), with brownish color and yellowish, lipoma-like areas and white areas that comprised the whole tumoral mass, 6/6/5 cm in size, with a single vascular supply emerging from an artery located in the subscapular region. Intraoperative macroscopic characteristics of the tumor directed the previous clinical and imagistic diagnosis of lipoma towards a low-grade soft tissue sarcoma, and an extemporaneous microscopic exam of the tumoral tissue was performed.The extemporaneous Papanicolau-stained smears examination did not reveal cellular or nuclear atypia, thus following surgical excision, drainage of the remaining cavity and closure of the anatomic planes was performed.The tumoral tissue sample that was harvested during the surgical procedure was fixed in 10% neutral formalin solution and was included in histological paraffin, according to the histopathological protocol. There were performed 4-μm serial sections stained with Hematoxylin–Eosin (H&E); also, Masson’s trichrome and orcein stains were obtained. Microscopic H&E exam revealed a benign tumoral proliferation, with pale eosinophilic thick bands of collagen fibers, admixed with coarse, thick or globular groups, medium-size fusiform cells, with fibrillar eosinophilic cytoplasm, oval nuclei, some of them with irregular contour, others with sharp heads, fine chromatin pattern, equally distributed; small hyperemic blood vessels were also observed a. MassonThere were no postoperative complications, drainage was maintained for 72 h, without the occurrence of postresection seroma or hematoma, and no signs of local inflammation. The postoperative functional score at 3 months was good according to OSS (Oxford Shoulder score) .ED is known to represent 2% of all primary tumors localized on the chest wall in adults ,9, partiThese lesions are characterized by an asymptomatic evolution and tend to grow slowly in more than 50% of cases ,14,15. EThe diagnosis cannot be sustained by clinical and anamnestic findings, the only possible indicator of an ED  being the symmetrical disposition of the periscapular lesions. In general, from the clinical point of view, in most cases, the tumoral mass is discovered randomly by the patient. In 10% of cases, the mass produces interscapulothoracic pain , as in tSoft tissue ultrasound, as well as CT or magnetic resonance imaging (MRI) do not reveal specific elements that would suggest the diagnosis of ED, except the location, the symmetrical aspect of the lesions, and, respectively, the density pattern. Positron emission tomography-computed tomography (PET-CT) with fluorodeoxyglucose 18F-FDG) examination has shown its utility in identifying ED lesions, in case of patients undergoing screening studies for cancer, with a reported frequency of 1.66% [F-FDG exaA fine-needle or core biopsy can be done under local anesthesia confirming the lesion benignity, procedure recommended by several authors ,19. HoweIn these conditions, the therapeutical algorithm varies between surgical excision for symptomatic patients and surveillance for asymptomatic cases . In geneThere is still a debate even these days whether ED’s are authentic neoplasms or pseudotumors developing from an abnormal soft tissue ,19, seenThis article presents a rare case of bilateral elastofibroma dorsi with different asymmetrical comparative evolution of both sides. The asymptomatic variant with no influence on the scapulothoracic motion can be observed on one side in contrast with the symptomatic type with significant influence on the shoulder mobility on the other side.ED is a rare tumoral entity that can be diagnosed based on the clinical and imagistic findings, especially through its specific location, but possibly requiring histochemical staining for a final diagnosis.Surgical marginal resection should be reserved only for symptomatic cases with significant discomfort for the patient during daily activities because of the increased rate of local complications. Although related problems, residual seroma or hematoma in the post excisional space and the prolonged postoperative rehabilitation interval following this latissimus-split procedure are among the most commonly reported complications.


Sclerosing thymoma (ST) is quite a rare disease, as denoted in previous literature. Less than 20 cases of ST have been reported to date. However, the combined thymoma, composed of both type AB thymoma and ST, has never been described before.The subject, a 49-year-old woman, came in with the chief complaint of cough for 10 days.Both the contrast-enhanced computed tomography scan and the ultrasonography showed a huge mass located in the right thoracic cavity with inhomogeneous contrast accompanied by the invasion of the pericardium and pleura. Subsequently, computed tomography-guided core-needle biopsy revealed type B2 thymoma, and type AB thymoma could not be excluded. Based on postsurgical histopathology and immunohistochemical finding, this tumor was given the final diagnosis of ST and type AB thymoma.After 6 months of adjuvant chemotherapy and local radiotherapy, total thymectomy was performed.The patient has been duly followed up for 1 year without any tumor recurrence.ST is a very rare mediastinal neoplasm. Moreover, ST in combination with AB thymoma and affecting a large area, is unprecedented. Whether radiotherapy and chemotherapy have a certain effect on ST requires further investigation. In addition, due to the unclear recurrence rate of ST, long-term follow-up evaluation seems necessary. Sclerosing thymoma (ST) is a rare anterior mediastinal neoplasm, originating within the epithelial cells of the thymus and accounts for an estimated 0.02% of all thymoma. and <20 cases have been reported since then. The clinical manifestation for ST is myasthenia gravis, but approximately 75% of ST patients have no obvious symptoms. The imaging of ST exhibits features of conventional thymoma lacking any special signs; therefore, the final diagnosis mainly depends on the pathology and immunohistochemistry results.ST is an extremely rare thymoma with exuberant collagen-rich stroma. It was reported first in 1994 by Kuo,The following is a case of a 49-year-old female patient with ST with a large mass in the right thoracic cavity. This case presentation of the rare neoplasm is for educational purposes, for discussing the relevant pathologic and imaging features, and establishing the diagnosis for future clinical practice.29 cells/L), with normal hematocrit and platelet count. Conventional tumor markers, including CEA, CA199, and NSE, were reported in the normal range.A patient is a 49-year-old woman who was admitted with a chief complaint of cough for 10 days without myasthenia gravis, vomiting, nausea, or any other symptoms. The patient was admitted for cough for 10 days. No other conditions were recorded at the time of admission. No significant history of past illnesses was identified. The patient had no previous or family history of a similar illness. During the physical examination, she was found to have a distended abdomen with no palpable masses. Laboratory tests revealed mild leukocytosis  chemotherapy regimen. Six months later, tumor size significantly decreased with dimensions 3.6 × 2.5 cm  was significantly larger than any previously reported tumors, and a considerable region of type AB thymoma could be found in the tumor. Thus far, no such case has been reported in the literature.In previous cases, most of the ST tumors were reportedly <10 cm in length and diameter and could be combined with all subtypes of thymoma , whereas the sclerosing type is mainly composed of abundant collagen fibers and a very small number of lymphocytes.At present, the optimal treatment of the most sclerosing thymomas is complete surgical removal. The reported patients had a good prognosis after the resection of the mass. No evidence of recurrence or metastasis was reported.4In conclusion, we have reported a case of thymoma composed of sclerosing component and a large region of the AB types, wherein the patient received a series of chemotherapy and radiotherapy before surgery. This is the first documented case of ST with an extensive type AB component. However, whether chemoradiotherapy could induce the formation of ST still needs further investigation.Conceptualization: Rui Li.Data curation: Yu-ting Jiang.Writing – original draft: Yu-ting Jiang, Tian-yue Zhang.Writing – review & editing: Dan-dan Guo, Rui LiConceptualization: Yu-ting Jiang.Data curation: Yu-ting Jiang.Formal analysis: Yu-ting Jiang, Rui Li.Funding acquisition: Rui Li.Investigation: Dan-dan Guo, Rui Li.Software: Dan-dan Guo.Supervision: Rui Li.Validation: Rui Li.Writing – original draft: Yu-ting Jiang, Tian-yue Zhan.Writing – review & editing: Rui Li.


Split cord malformation (SCM), a subtype of spinal dysraphism, represents a rare entity of congenital malformation in the spine that occurs rarely in adults. SCM commonly presents with back pain. MRI is the gold standard for diagnosis. We report a case of a previously healthy 25-year-old woman who presented with lower back pain for a duration of 6 months. MRI confirmed a diagnosis of type I SCM. This case highlights the neuroimaging characteristics of SCM, although it might remain asymptomatic for many years. Surgical intervention might not be indicated in case of absent clinical complications. Split cord malformation (SCM) is a rare dysraphic lesion of the spinal cord. It consists of dividing the spinal cord into two symmetrical or asymmetrical hemicords , produceThe condition was first reported in 1837 ,6. It caSCM might occur isolated, which confers a better prognosis  or it miThe literature shows numerous cases of SCM diagnosed in the prenatal period by means of ultrasound and confirmed by MRI ,8,9. MajWe report a case of a 25-year-old lady who presented for a lower back pain of 6 months duration. Physical exam was unremarkable except for the lower back pain. There were no signs of radiculopathy, lower extremity weakness, or bowel/bladder dysfunction. Neurologic exam was normal at presentation.MRI of the lumbar spine was performed on a 3T Ingenia unit  in the following planes and sequences: 1) sagittal T1 turbo spin-echo (TSE), T2 TSE, short tau inversion recovery fat suppression (STIR), 2) axial T1 TSE, T1 fat-saturated, T2 TSE, 3) coronal T2 TSE. There was evidence of SCM (type I) at L1-L2 level (Figures This patient had an isolated SCM without any other associated spinal cord dysraphisms or vertebral column malformation.The classification of SCMs was simplified by Pang in 1992 by dividing it into type I and type II. The factors used to differentiate between those two types of SCMs are the presence of one or two dural tubes and whether the dividing median septum is rigid or non-rigid. Type I SCM consists of two hemicords, each contained in a distinct dural tube divided by a rigid osseocartilagenous median septum. Type II SCM implies housing of two hemicords in a single dural tube separated by a non-rigid fibrous median septum. Owing to the rarity of this condition, inconsistencies arose in the literature mainly in three recurrent areas: the nomenclature; embryological origin; and clinical significance. As a result, terms like diastematomyelia, diplomyelia, and dimyelia were used interchangeably and are currently substituted by the term SCM. Concerning the origin, the wide accepted theory proposes that the origin of all SCMs originated from one basic ontogenic error occurring around the time of closure of the primitive neurenteric canal. A formation of an accessory neurenteric canal which is considered as an abnormal fistula causes regional splitting of the notochord and the overlying neural plate -10. The Split cord malformations represent a rare entity of spinal dysraphisms. The condition can be prenatally diagnosed, which offer early recognition thus better treatment outcome. Type 1 and type 2 SCMs are differentiated by the presence of two dural sacs surrounding each hemicord in type 1, compared to one dural sac in type 2. This case report represents an additional example of type I SCM presenting in adulthood, and as far as our knowledge, it is the first case to be reported in Lebanon.


Ferumoxytol is an ultra-small superparamagnetic iron oxide (USPIO) agent that is taken up by splenic tissue. This study describes our initial institutional experience of ferumoxytol-enhanced MRI (feMRI) for differentiating intrapancreatic splenules (IPS) from other pancreatic lesions.In this retrospective study, patients with computed tomographic imaging that identified small enhancing lesions in the tail of the pancreas subsequently underwent feMRI for further characterization. The feMRI protocol included T2-weighted (T2w) imaging with and without fat suppression (FS), R2* mapping, diffusion-weighted imaging (DWI), and T1-weighted (T1w) imaging with FS, prior to contrast injection. Immediately after slow intravenous infusion with 3 mg/kg body weight ferumoxytol, T1w was repeated. Delayed imaging with all sequences were obtained 24–72 h after ferumoxytol administration.Seven patients underwent feMRI. In two patients, the pancreatic lesions were presumed as pancreatic neuroendocrine tumor (PNET) from feMRI and in the remaining 5 IPS. One of the two patients with PNET was symptomatic for NET. In another symptomatic patient with pathologically proven duodenal NET and suspected PNET, the pancreatic lesion was proven to be an IPS on feMRI. IPS demonstrated strong negative enhancement in feMRI on T2w and increased R2* values consistent with splenic tissue, while the presumed PNETs did not enhance. T2w FS was helpful on the pre-contrast images to identify IPS, while R2* did on post-contrast images. Neither DWI nor T1w contributed to differentiating PNETs from IPS.This study demonstrates the potential utility of feMRI as a helpful adjunct diagnostic tool for differentiating IPS from other pancreatic lesions. Further studies in larger patient cohorts are needed. Splenules  are ectopic splenic tissue , 2. TheySplenules are frequently found as incidental findings during imaging and may be difficult to differentiate from other lesions . In part.When a splenule is suspected, the current imaging method of choice is 99mTc labeled heat-damaged red blood cell scintigraphy (99mTc-HDRBC) , 18, 30.An alternative approach of using ultra-small superparamagnetic iron oxide particles (USPIO) for imaging the mononuclear phagocyte system  has been proposed and investigated , 31–36. In 2009, the US Food and Drug Administration (FDA) approved ferumoxytol  to treat iron deficiency anemia in adults with chronic kidney disease (CKD) , 43. ImpThe purpose of this retrospective study was to describe our institution’s experience with ferumoxytol-enhanced MRI (feMRI) for differentiating IPS from other types of pancreatic lesions.Our institution began formally offering feMRI in October 2014 after implementing a routine clinical protocol. This IRB-approved, retrospective study reviewed all feMRI studies performed for characterization of enhancing lesions in the tail of the pancreas. Patient demographics and relevant clinical information were retrieved from the electronic medical record.MRI was performed on various 1.5 and 3.0 T clinical MRI systems using 8–32 channel phased array torso coils  (Table b = 50 and 500 s/mm2). The number of slices for each of the above acquisitions were adjusted to cover the relevant anatomy of interest, based on prior imaging. All acquisitions were performed in a breath-hold (20 s or less), except T2w-FSE FS and DWI, which were performed using respiratory triggering.The feMRI was performed as follows: Pre-contrast MR #1 axial and coronal 2D T2w single shot fast spin echo , 2D axial T2-weighted fast spin echo with fat suppression (FS) , axial 3D T1w spoiled gradient echo with FS , 3D axial multi-echo chemical shift encoded MRI (CSE-MRI)  for fat-corrected complex R2* mapping, and 2D diffusion-weighted imaging , and fat (SIfat) both in the MR #1 as well MR #2 using McKesson PACS . Circular ROIs were drawn as large as possible while conforming to anatomic boundaries and avoiding large vessels, bile ducts, etc.Regions of interest (ROIs) were measured in corresponding areas of axial T2w-SSFSE in the liver, spleen, pancreas, intrapancreatic lesion  underwent feMRI as part of their clinical workup for an enhancing intrapancreatic tail lesion observed on prior imaging. No side effects due to the ferumoxytol administration were experienced by any patients in this study.n = 1); chest CT for thoracic outlet syndrome (n = 1); and abdominal CT (n = 4) for cystic liver lesions, left rib pain, and a right inguinal hernia. In one patient (pt. 6) clinical symptoms had raised suspicion of an insulinoma for which imaging was obtained. In another patient (pt. 7) a CT was obtained due to epigastric pain and a complex clinical picture concerning for glucagonoma.The clinical presentation of the 7 patients are summarized in Table Of the 5 asymptomatic patients, three patients  had no notable laboratory derangements, and imaging findings of the ferumoxytol MRI supported the diagnosis of IPS.One patient (pt.2) had a mildly elevated chromogranin A (CgA) level of 111 ng/mL , but also suffered from asthma and took a serotonin specific reuptake inhibitor, which are both factors that can lead to an elevation of CgA , 48. An A second asymptomatic patient (pt. 4) had a notably elevated CgA level of 1576 ng/ml demonstrated during the workup of an incidental lesion. The feMRI supported the diagnosis of a PNET. Due of the relatively small lesion size of 12 mm as well its stability in size in comparison to a CT obtained one year prior, a watchful waiting strategy was chosen. A follow-up CT 7 months after our feMRI did not demonstrate any lesion growth or any metastatic disease. Continued surveillance is planned.One symptomatic patient (pt. 6) was admitted to our institution for altered mental status found to be the result of severe hypoglycemia. His workup included fasting insulin check during which he became symptomatically hypoglycemic within 6 h of fasting and was found to have an insulin level of 24 µIU/mL , and a proinsulin level of 10.6 µIU/mL . His clinical history revealed up to 15 recurrent hypoglycemic episodes over the prior year with visual changes, including blurry vision/diplopia and later dizziness, confusion, and aphasia. His labs revealed normal CgA (52 mg/ml) and cancer antigen (CA) 19–9  levels. Abdominal CT showed a well-delineated, contrast-enhancing, hyperdense, 13 mm lesion in the portal-venous phase. Based on this clinical presentation and the CT imaging findings, a functional PNET (insulinoma) was suspected . The feMIn another patient (pt. 7), an abdominal CT demonstrated a 17 mm enhancing lesion in the pancreatic tail, which was noted to be stable in size from previous imaging in 2013, and a newly detected enhancing 15 mm duodenal lesion. The patient’s family history was notable for a pulmonary neuroendocrine tumor. The patient had brittle diabetes and was found to have an elevated glucagon level of 359 ng/L , which was concerning for the presence of a glucagonoma. The CgA level was also elevated to 915 ng/mL, although the patient was taking a daily proton pump inhibitor, which is known to elevate CgA levels. EUS-FNA of the duodenal lesion was performed, and pathology demonstrated a low- grade neuroendocrine tumor (KI-67 < 3%). Given the presence of the duodenal lesion the pancreatic tail lesion was suspicious of NET. 68 Ga-DOTA-TATE PET/CT showed intense focal uptake for both the duodenal and pancreatic tail lesion. There was uncertainty in a PNET diagnosis of the pancreatic tail lesion because of the negative follow-up. On feMRI, the imaging findings of the pancreatic tail lesion were most consistent with IPS.In the five cases with a presumed diagnosis of IPS  feMRI showed consistent imaging patterns. For all sequences and phase of contrast, all IPS followed identical imaging characteristics as the spleen. Specific behavior is described below.On T2w-SSFSE in the pre-contrast MRI, all IPS were isointense or slightly hyperintense to the pancreas and isointense to the spleen Fig. . In the All IPS behaved similarly to the spleen in pre-contrast T2w-FSE FS and DWI. On the pre-contrast T2w-FSE FS, the IPS were easily recognized as a well-delineated lesion that were homogeneously hyperintense compared to the pancreas. All IPS showed restricted diffusion in DWI similar to the spleen Fig. . In the On pre-contrast T1w-SGRE FS, the IPS appeared isointense or moderately hypointense to the pancreas. Immediately after the administration of ferumoxytol, the IPS appeared hyperintense, while in the delayed MRI (MR#2), they appeared isointense to the spleen. Of note, one patient (pt. 1) received gadobenate dimeglumine and was subsequently administered ferumoxytol 24 h prior to obtaining delayed imaging. This case was not included into the qualitative post-contrast T1 analysis.The enhancement pattern of all five presumed IPS were consistent with a diagnosis of an intrapancreatic splenule as described in the literature , 38, 39.In the two cases of presumed pt. 4) or confirmed (pt. 6) diagnosis of a PNET, the contrast characteristics of these pancreatic lesions differed substantially from the IPS cases. With T2w-SSFSE on the pre-contrast MRI the PNETs were hypointense to the pancreas and spleen  the PNET showed a similar restricted diffusion as the spleen; in the other (pt. 6) the PNET did not.In the pre-contrast T1w-SGRE FS the lesions appeared isointense to the pancreas, and after ferumoxytol administration, no enhancement of either lesion was observed immediately after the administration of ferumoxytol.The ferumoxytol contrast enhancement of the two PNETs differed significantly from the contrast behavior for IPS described in the literature , 38, 39.In this work we have described our experience with feMRI for characterizing small pancreatic tail lesions, which was found to be helpful in distinguishing IPS from PNETs. All IPS cases demonstrated a consistent imaging pattern on feMRI that corresponded to the expected pharmacokinetics of ferumoxytol in the MPS, unlike lesions suspected to be PNETs.The characterization of intrapancreatic tail lesions either IPS or PNET is essential for treatment planning. The primary goal is to identify all PNETs and avoid unnecessary surgical resection of IPS . ClinicaThe current most specific imaging modality to differentiate IPS from PNETs, 99mTc-HDRBC, offers limited spatial resolution for lesions smaller than 20 mm and requires exposure to ionizing radiation , 18, 52.As expected physiologically, all IPS demonstrated negative enhancement on delayed T2-weighted imaging after ferumoxytol administration in a manner consistent with splenic tissue. In contrast, the PNET cases did not demonstrate negative enhancement or follow the behavior of the spleen. Additionally, the liver and spleen demonstrated increasing R2* values after the administration of ferumoxytol, indicating the presence of iron uptake in the MPS. This corresponds with the known pharmacokinetics of USPIO by the MPS , 39, 58.Additionally, dynamic T1w imaging following ferumoxytol administration demonstrated strong positive enhancement for IPS, while PNETs did not show similar positive enhancement. Factors that may contribute to this phenomenon include varying microvascular density of the tumors, the long blood half-life of ferumoxytol (14–21 h), and the specific T1w sequence used , 64, 65.In clinical scenarios where there is a need to characterize a pancreatic lesion suspicious for PNET vs IPS, we recommend a feMRI protocol comprising T2w without and with FS, R2* mapping before and 72 h after the administration of ferumoxytol.T2w-SSFSE without FS is helpful to confirm negative contrast enhancement of the lesion as well as give valuable anatomical information. The T2w-FSE with FS can help find all accessory spleens on the pre-contrast images. The use of delayed phase T2w imaging only, may prove inadequate because PNETs can appear hypointense on T2-weighted imaging prior to the administration of ferumoxytol, as observed in our experience and in previous work . We founFerumoxytol also has a very good safety profile for both adults and pediatric patients with side effects demonstrated in 10–15%  and severe side effects in up to 1%, similar to known rates with use of ionic iodinated contrast agents , 70, 71.Ferumoxytol is generally more costly than gadolinium agents, but the price for the MRI scan at all is more expensive .Our study had several limitations. First, it is retrospective in nature. Although this study is, to the best of our knowledge, the largest series reported in the literature, it includes a relatively small number of patients. Our study included all patients in our clinical experience over 5 years, reflecting the overall rarity of this clinical situation. Additionally, we do not have pathological correlation for all cases, which is due to our protocol being implemented clinically. Biopsies of small pancreatic tail lesions are known to be unreliable and are, therefore, infrequently obtained, and surgery was appropriately not performed for those cases with presumed IPS. While one PNET was removed surgically, the clinical team elected to follow a watchful waiting strategy for the second small PNET based on the small size, patient preference, and the fact that many PNETs never undergo malignant transformation. Lastly, we did not have direct comparison of feMRI with 99mTC HDRBC, since the lesions included in this study were considered too small for 99mTC-HDRBC.In conclusion, we have demonstrated the feasibility of feMRI for the characterization of small pancreatic tail lesions in a clinical case series. With high spatial resolution and no ionizing radiation, ferumoxytol-enhanced MRI can be a valuable adjunct to, or a substitute for, scintigraphy and somatostatin analogs PET/CT and may satisfy an important unmet clinical need. Further evaluation of feMRI in larger cohorts of patients is needed to confirm our initial experience.


Amyloidosis is a condition identified by the accumulation of abnormal proteins in various tissues and organs that eventually lead to impaired function. Systemic amyloidosis with gastrointestinal (GI) tract involvement is more common than localized GI amyloidosis, whereas predominant jejunal involvement is even more uncommon. We report a rare case of systemic amyloidosis with predominant jejunal involvement in a 76-year-old female who presented with lower abdominal bloating and lethargy. Amyloidosis is a rare disorder defined by the extracellular deposition of abnormal, insoluble and fibrillar proteins in various tissues and organs, which eventually cause distortion of tissue architecture and function. It can be broadly classified into systemic or localized amyloidosis . SystemiA 76-year-old lady presented to the outpatient clinic with a history of lower abdominal bloating and lethargy for 1 week. The patient denied abdominal pain, nausea, altered bowel habits or GI bleeding. Her past medical history included gastroesophageal reflux disease, ulcerative colitis and a previous hysterectomy. Physical examination exhibited pallor of the conjunctiva, distended abdomen with visible peristalsis on inspection but soft, non-tender on palpation and absence of ascites. Laboratory testing found normocytic normochromic anaemia, thrombocytosis and a positive myeloma screen with elevated kappa to lambda free light chain ratio despite normal renal and liver function. An ultrasound of the abdomen was unremarkable. Computed tomography (CT) with IV contrast of the abdomen revealed diffuse thickening of the small and large bowel with the small bowel dilated throughout. Magnetic resonance imaging of the small bowel showed multiple abnormally thickened loops of the jejunum and proximal ileum with a maximal wall thickness of 0.9 cm  and 2. GAmyloidosis is a disease that affects multiple tissues and organs by causing accumulation of abnormal and misfolded extracellular proteins . ImmunogPrimary amyloidosis is associated with multiple myeloma in 15–20% of cases, whereas primary amyloidosis of the GI tract on the other hand is rare with only 1% having had biopsy-proven symptomatic gastric amyloidosis based on a case series of 769 patients with primary systemic amyloidosis .The pathogenesis of GI involvement in amyloidosis can be broadly divided into mucosal or neuromuscular infiltration. The layers involved in mucosal infiltration depends on the type of amyloid deposition as AL amyloidosis can involve muscularis mucosa, submucosa and muscularis propria forming protrusions that lead to symptoms of bowel obstruction, whereas AA amyloidosis mainly affects the mucosa which leads to erosions and manifest as diarrhoea and malabsorption . The depThe investigation for AL amyloidosis should include testing of serum and urine for monoclonal light chains by immunoelectrophoresis and immunofixation followed by a bone marrow aspirate for quantification of the number of plasma cells as well as to establish presence of monoclonal chains. Endoscopic examinations and biopsy is beneficial; however, some patients may require push enteroscopy or capsule endoscopy to detect lesions that are limited to the jejunum . The golThe management of amyloidosis depends on the amyloid subtype and the extent of involvement. AL amyloidosis commonly requires chemotherapy and in certain cases haematopoietic stem cell transplantation to remove plasma cell clones. The treatment of AA amyloidosis depends on managing the underlying inflammatory condition to diminish disease progression such as the use of anti-tumour necrosis factor in Crohn’s disease . The amy


BRAF p.V600E hotspot mutation) with co-occurring homozygous deletion of CDKN2A encoding the p16 cell cycle regulator protein in most PXA [BRAF and RAF1 have previously been reported by our group [CDKN2A/B homozygous deletion and NACC2–NTRK2 or PPP1CB–ALK fusion, along with DNA methylation signatures aligning to PXA. In both, the main differential diagnostic consideration was infant-type hemispheric glioma (IHG).Pleomorphic xanthoastrocytoma (PXA) is a circumscribed glioma arising in the cerebral hemispheres of children and young adults. Recent molecular studies demonstrate an activating mitogen-activated protein (MAP) kinase mutation . Post-operatively, the patient was treated with focal proton radiation to 55.8 Gy and concurrent temozolomide followed by 24 months of adjuvant daily oral larotrectinib (NTRK inhibitor) therapy. The patient is alive without evidence of disease 33 months following diagnosis.Patient #1: This 3-year-old boy presented with a 3-month history of progressive headaches, emesis, sound sensitivity and altered gait. Magnetic resonance imaging (MRI) demonstrated a 9.4 cm avidly enhancing, solid and cystic right temporal horn mass, extending into adjacent parenchyma and middle/posterior cranial fossa. He underwent gross total resection. Intraoperatively, the tumor appeared tan-yellow and vascular with extensive tentorial involvement. Histology revealed a mostly solid appearing spindled and epithelioid glial neoplasm arranged in fascicles, sheets, and papillae . Post-operatively, the patient (now age 3) was treated with focal proton radiation to 55.8 Gy and concurrent temozolomide followed by adjuvant daily oral lorlatinib (ALK inhibitor) therapy. The patient is alive without evidence of disease 6 months following diagnosis.Patient #2: This almost 3-year-old girl with longstanding mild gross motor and speech delays presented with a six-month history of episodic uncontrollable right arm shaking. MRI demonstrated a rounded 2.5 cm, partially cystic, enhancing left frontoparietal mass between the motor and sensory cortices. A gross total resection was achieved after two surgeries. The tumor was tan-red and well demarcated from adjacent brain parenchyma. Sections revealed a predominantly solid glial neoplasm with cells containing enlarged, irregular hyperchromatic nuclei, including scattered multinucleated forms Fig. g. Areas NACC2 . No other structural variants, focal chromosomal amplifications or deletions were noted. For both, DNA methylation profiling was performed as previously described [UCSF500 targeted next-generation sequencing (NGS) was performed as previously described . Tumor #escribed  and demoth edition of the CNS WHO [NTRK1/2/3, ROS1, ALK or MET [PPP1CB–ALK fusion identified here has been described in two IHGs [CDKN2A/B homozygous deletion. NTRK family fusions have also been reported in rare pilocytic astrocytomas [ETV6–NTRK3 fusion along with CDKN2A homozygous deletion [NACC2–NTRK2 fusion with CKDN2A homozygous deletion identified here has recently been described in a pediatric cerebellar high-grade glioma [Given the young patient ages, the diagnosis of IHG was considered initially. This new entity in the 5 CNS WHO  presentsK or MET , 5, 8. Ttwo IHGs . Howeverocytomas . Of notedeletion . The samCDKN2A/B homozygous deletion with accompanying RTK fusions rather than MAP kinase alterations. A small subset of PXA do not harbor BRAF or RAF1 alterations, and these may contain RTK fusions that are only inconsistently detected using conventional NGS methods. Additional molecular studies could be informative to more accurately categorize these challenging pediatric lesions which may otherwise be classified as IHG or diffuse pediatric-type high-grade glioma, H3-wildtype, and IDH-wildtype according to contemporary criteria [Given the non-canonical molecular profiles in our two cases, the integrated diagnosis was heavily weighted on the DNA methylation profiling results. These cases extend the molecular spectrum of anaplastic PXA to include tumors harboring In summary, the fusions identified here illustrate that a subset of PXA can harbor RTK fusions rather than MAP kinase alterations, which extends the molecular spectrum of this tumor type beyond what is currently recognized . In addiSupplementary file1 (PDF 910 kb)Below is the link to the electronic supplementary material.


A 50-year-old man without medical history, complained about effort dyspnea with enlargement of the abdomen. Physical examination showed an enlarged liver reaching the right and the left iliac fossa with a collateral venous circulation. Biological exams were within normal ranges. Hepatitis B and C serologies were negative. Abdominal computed tomography and magnetic resonance imaging demonstrated an enlarged liver of 36 cm in diameter. Multiple heterogenous bilateral liver masses with enhancement after contrast intravenous injection were shown.The largest one with 26 cm in diameter was located in the left liver. A dense collateral venous circulation existed. A diagnostic percutaneous biopsy was made. Histopathological exam concluded to giant cavernous cavernoma. Since the surgery was risky especially hemorrhage, a percutaneous embolization for the largest mass was indicated.


Only 14 cases of leiomyoma with ureteral origin have been reported previously. Such primary leiomyomas often present as hydronephrosis, making the diagnosis difficult. Radical nephroureterectomy is often performed because of the possible diagnosis of a malignant tumor. We report the 15th case of primary leiomyoma with a ureteral origin.A 51-year-old Japanese man presented with a chief complaint of asymptomatic gross hematuria with a history of hypertension. Enhanced computed tomography showed a tumor at the upper part of the right ureter that appeared to be the cause of hydronephrosis and contracted kidney; no retroperitoneal lymphadenopathy and distal metastasis were observed. A well-defined 20-mm (diameter) defect was identified at the upper of the right ureter on retrograde pyelogram with no bladder cancer on cystoscopy. Urine cytology and right divided renal urine cytology findings were negative. Laparoscopic nephroureterectomy was performed, and the extracted tumor measured 20 × 13 mm. Histopathological examination revealed primary leiomyoma with no recurrence 16 months after the operation.Preoperative examination with the latest available ureteroscopic technology can help preserve renal function in the case of benign tumors by enabling preoperative ureteroscopic biopsy or intraoperative rapid resection. Moreover, nephroureterectomy is recommended in the case of preoperative suspicion of ureteral malignant tumors. Primary leiomyoma rarely develops in the urogenital organs. There have been even fewer reports of leiomyoma of ureteral origin. Ureteral leiomyomas often cause hydronephrosis, which make their detection and diagnosis. Therefore, radical nephroureterectomy is often performed owing to the possibility of malignancy.Our patient also underwent laparoscopic nephroureterectomy for right ureteral cancer. The present report describes this case and includes a review of the relevant reports in literature. To the best of our knowledge, this is the 15th case of primary leiomyoma with a ureteral origin.A 51-year-old Japanese man visited our department with a chief complaint of asymptomatic gross hematuria in November 2019 with a history of hypertension. Family history was unremarkable.At the first visit, height and weight of the patient were 179 cm and 93 kg, respectively. Blood pressure was 128/78 mmHg, pulse was regular with 62 beats/minute. and body temperature was 36.4 °C. The patient had no history of smoking or drinking.There were no specific abnormalities or neurological findings at the initial physical examination. Blood biochemistry revealed no abnormal findings, and urinalysis revealed microscopic hematuria with red blood cells (RBC) 20–29/high-power field (hpf) and white blood cells (WBC) 1–4/hpf.Abdominal computed tomography (CT) revealed hydronephrosis and contracted right kidney, in addition to fatty liver. Enhanced CT showed a tumor in the upper part of the right ureter, with a density similar to the ureteral wall, which appeared to be the cause of hydronephrosis and no retroperitoneal lymphadenopathy Fig. A, B. DisBased on the above findings, the patient was diagnosed with contracted kidney with right ureteral cancer  and right hydronephrosis, and the condition was close to that of a nonfunctional kidney; laparoscopic nephroureterectomy was performed.The extracted specimen was a nonpapillary, broad-based, solid tumor measuring 20 × 13 mm with a yellowish-white cut surface , ureteral polyps, and papilloma, but no characteristic diagnostic imaging method has been established.Surgical treatment was performed in 14 of the 15 patients. Partial ureterectomy preserving the kidney was performed in only seven patients. Of patients who underwent partial ureterectomy, five were diagnosed by intraoperative rapid section and only two by ureteroscopic biopsy. In the other seven patients, nephroureterectomy was performed without differential diagnosis of benign or malignant tumors before surgery. As our patient was suspected of having cancer in the right ureter with contracted kidney and right hydronephrosis, and the condition was close to that of a nonfunctional kidney, laparoscopic nephroureterectomy was performed.It has become possible to diagnose benign tumors by preoperative examination as a result of advancements in ureteroscopic technology in recent years. Therefore, if renal function is good and benign tumors are suspected in young people, ureteroscopic biopsy or rapid intraoperative pathology should be performed to make an active histopathological diagnosis, and it is important to pay careful consideration to the preservation of renal function.Primary leiomyoma of the genitourinary tract is rare and difficult to diagnose before surgery. Preoperative examination can help preserve renal function in the case of benign tumors by efficient diagnosis and appropriate treatment. Nephroureterectomy in the case of suspicion of ureteral malignant tumor is a logical option.


Tarlov cysts are fluid-filled dilatations of the nerve root sheaths that are present in up to 4.18% of the population . We presA 69-year-old woman with no significant past medical history presented with sudden onset lower back pain, perineal numbness and urinary retention. Six days earlier, she was commenced on Rivaroxaban, a direct oral anticoagulant agent for acute unprovoked bilateral pulmonary emboli. Her observations were stable and examination revealed reduced anal tone and decreased sensation in the right S2, 3 and 4 dermatomal distributions.Magnetic resonance imaging of the lumbosacral spine revealed a 3.4 × 2.0 × 4.7-cm right-sided haemorrhagic multiloculated Tarlov cyst . As per Patients with symptomatic Tarlov cysts may present with back pain, sensory and/or motor radiculopathy, bladder, bowel and/or sexual dysfunction . CT-guidThis case highlights a rare complication of anticoagulation, which required prompt recognition and multidisciplinary management. Anticoagulation rationalisation and timely intervention should be initiated in the event of neurological deterioration.The authors confirm that they have no conflict of interests.None.No ethical approval was needed.Written consent for publication has been obtained from the patient.Wai Cheong Soon.