Avulsion is a rare and serious traumatic dental injury that needs immediate and complex management. This case report highlights the successful management of an avulsed maxillary central incisor by replantation after a lapse of 120 minutes of being in an extra-oral environment and preserved in milk. A female patient aged 17 years presented with a traumatic dental injury sustained to the anterior maxillary region due to an accidental fall. Clinical examination revealed an avulsed tooth 21 that was replanted according to the International Association of Dental Traumatology (IADT) guidelines and stabilised in place with splinting. Conventional root canal therapy was initiated one week post-replantation. The root canal treatment was completed two weeks post-replantation followed by removal of the splint. Follow up done at regular intervals of one, three, six, and 12 months showed a lack of clinical signs and symptoms and no resorption on radiographic interpretation.  Dento-alveolar trauma results from a sudden blow to the teeth and its associated structures which may lead to varied injuries including complete loss of tooth from its socket. Traumatic injuries involving dentition are seen frequently in the age group of 7-11 years. The majority of these injuries result from accidental falls followed by various sports activities, road traffic accidents, and physical assault ,3.The primary line of treatment for the management of an avulsion injury is replantation. However, in certain circumstances , this option is contraindicated. Albeit a few replanted cases have shown less long-term survival rate, not replanting a tooth is an irreversible decision. Thus, every attempt must be made to save it . Also, aThe periodontal ligament (PDL) cells left on the root surface of an avulsed tooth after trauma must be prevented from dehydration to maintain their function and viability . StorageA 17-year-old female patient presented with an alleged history of fall and injuries sustained to the anterior maxillary region. The patient had no relevant past medical history and was alert as well as responsive during the process of examination. Extra-oral examination revealed mild abrasion and swollen upper lip. On intra-oral examination, the left maxillary central incisor (21) was missing and the marginal gingiva in the associated area was lacerated Figure . On inspThe root surface of the avulsed tooth was treated with 1.23% acidulated phosphate fluoride (APF) gel for a duration of 20 minutes Figure . Local aTwo weeks after replantation, the intracanal medicament was removed. The root canal space of the replanted tooth was obturated with gutta-percha and epoxy-resin sealer  by the cold lateral compaction technique. The access cavity was then sealed with a light-cure composite resin restoration  Figure . The splAt one-month follow-up visit, clinical examination showed normal physiologic mobility and normal probing sulcular depth with the replanted tooth Figure . RadiogrThe optimal treatment option following an avulsion injury is to replant the avulsed tooth at the earliest. However, this is not feasible in all instances. This case report focuses on the replantation of an avulsed maxillary central incisor after an extra-oral time of nearly two hours.Appropriate emergency management, significant treatment plans, and prompt action influence good prognosis in the management of an avulsion injury . The facThe extra-oral period has a direct co-relation with the survival of PDL cells. Studies have found that tooth replanted within five minutes had the best prognosis . WhereasThe rationale behind splinting the replanted tooth is to stabilise it in its appropriate position. In the case discussed above, splinting was done for two weeks with 0.4 mm stainless steel orthodontic wire bonded to the maxillary anterior teeth with a light cure flowable composite resin. This was in accordance with the guidelines prescribed by IADT . HoweverAs per the IADT guidelines, root canal therapy must be initiated within two weeks post-replantation. The replanted tooth needs endodontic therapy because the necrotic pulp and its toxins may gain access to the periodontal ligament through various portals of exit, thus contributing to the process of resorption . In the A replanted tooth must be followed up at regular intervals till 12 months and thereafter annually for a minimum period of five years, with clinical and radiographic examinations at every follow-up visit to rule out any associated complications . EducatiReplantation is the treatment of choice following avulsion. It not only satisfies the patient’s functional and aesthetic concerns but also helps to maintain the surrounding bone for prosthetic rehabilitation, in case of replantation failure. Despite an extended extra-oral time, replantation of an avulsed tooth can have a favourable outcome if all the recommended guidelines and protocols are followed.


Hepatocellular carcinoma (HCC) with a dismal prognosis is the second most deadly malignancy globally. Surgery is believed to be a curative approach. Nevertheless, there is still a considerable probability of postoperative recurrence. Most patients present in advanced stages with a surgically and oncologically unresectable disease. Systemic medicines are increasingly important to downstage the disease and further improve survival.A 67-year-old Chinese man with uncontrolled hepatitis B was discovered to have liver masses with abnormal serum vitamin K absence or antagonist-II (PIVKA-II) level during checkup for upper abdominal discomfort. Abdominal multiphase computerized tomography (CT) and gadoxetate disodium–enhanced magnetic resonance imaging (MRI) showed the bulky bilobar HCCs of Barcelona Clinic Liver Cancer stage B and China Liver Cancer Staging stage IIa. Furthermore, the aberrant right hepatic artery (RHA) originates from the superior mesenteric artery. Due to the location being adjacent to important vasculatures and massive size of the right-sided lesion, curative resection appears to be challenging. To achieve a favorable surgical margin, repeated hepatic arterial infusion chemotherapy (HAIC) was adopted through the variant RHA, while transarterial chemoembolization (TACE) was delivered to the left lobe to arrest tumor growth. Furthermore, sintilimab plus lenvatinib served as the sequential systemic therapy. After 5 months of conversion treatment, the partial response with a decreased serum PIVKA-II level was attained. The R0 hepatectomy was then performed without postoperative complications. The immunohistochemistry and next-generation sequencing results suggested that the two-side HCCs existing tumor heterogeneity were not completely consistent. The patient continues to be without evidence of disease.Our case highlights a favorable outcome in a man with bilobar bulky HCC after undergoing the comprehensive therapeutic schedule that includes personalized intervention and systemic drug therapy. In terms of conversion therapy, our case provides a secure and practical reference for managing unresectable bilobar HCC coexisting with the aberrant hepatic artery. Only 20%–30% of individuals with newly diagnosed early-stage hepatocellular carcinoma (HCC) are amenable to surgical resection, and the recurrence rate at 5 years after surgery is high.We experienced a case of bilobar bulky HCCs with right hepatic artery variation.Due to the location being adjacent to important vasculatures and size of the right-sided lesion, a multidisciplinary team approach helps to coordinate the personalized conversion treatments—repeated hepatic arterial infusion chemotherapy to the right-side lesion, transarterial chemoembolization to the left lobe, and immunotherapy for systematic treatment.Finally, two HCC lesions both achieved partial response and then, a curative hepatectomy was successfully performed.The immunohistochemistry and next-generation sequencing results indicated that two-side lesions may be heterogeneous.Indeed, for surgically and oncologically unresectable HCC, it is a challenging disease requiring a synthetic and personalized treatment scheme that contributes to controlling tumor progression for a better surgery effect and lower recurrence rate.Hepatocellular carcinoma (HCC) accounts for 85%–90% of primary liver cancer cases worldwide and is a prevalent malignant tumor of the digestive system , 2. The The concepts of “neoadjuvant therapy” and “conversion therapy” are important in preoperative adjuvant managements . For theNowadays, the comprehensive management to HCC is mainstream. The diagnosis and treatment model of multidisciplinary collaboration is crucial to addressing specific problems. The targeted countermeasures can be worked out based on tumor heterogeneity, concrete lesion location, anatomic characteristic, liver function, and physical condition to make patients’ benefit maximized.2 . No unremarkable presentations, including ascites and encephalopathy, were detected. A multiphase liver protocol computed tomography (CT) scan demonstrated the bulky bilobar liver masses with a characteristic radiological appearance of HCC —an exophytic left-lobe lesion measuring 7.2 cm × 7.1 cm × 6.4 cm and a right-lobe lesion measuring 5.6 cm × 5.1 cm × 5.0 cm  at 12.5%, and the Eastern Cooperative Oncology Group (ECOG) performance status score was Grade 0. A three-dimensional liver model  infection and alcohol use with 200 ml daily intake for 40 years. He reported no other underlying diseases, including hypertension, diabetes, coronary heart disease, and no family history. On physical examination, his body mass index (BMI) was 22.49 kg/m× 5.0 cm Figure 1To ensure optimal management, a multidisciplinary team approach was warranted. Major diagnosis was defined—HCC . Given the large size and unfavorable anatomical location being adjacent to the important vasculature of the right-side tumor, an aggressive surgery for the first option may be difficult to obtain a favorable incisal margin and be more likely to recur after surgery. Hence, we should take preoperative adjuvant managements into account. Compared with transarterial chemoembolization (TACE), HAIC could be well behaved at the tumor regression to further achieve a more satisfactory surgical margin , 19. In 2, leucovorin 400 mg/m2, fluorouracil bolus 400 mg/m2 on day 1, and fluorouracil infusion 2,400 mg/m2 for 24 h, Q3W) to the right liver lobe and semiquantitative conventional TACE (cTACE) with emulsions of Lipiodol (5 cc) and local chemotherapy of doxorubicin (20 mg), 5-fluorouracil (500 mg) and cis-platinum (50 mg) at the level of left hepatic artery were adopted synchronously. After the second hospitalization, the patient initiated to use sintilimab injection  and oral lenvatinib  and supplemented with anti-HBV administration  and liver protection therapy. After four cycles of conversion treatments, the abdominal contrast-enhanced CT for review showed the partial responses (PRs) of the bilobar tumor based on the modified Response Evaluation Criteria in Solid Tumors criterion  confirmed the variation of the RHA. The sign of additional lesion or arteriovenous fistula was not discovered . Such a therapeutic schedule has a good effect without increasing complications . AnatomiLenvatinib is a representative multikinase inhibitor. As the first-line treatment of advanced unresectable HCC patients, it has emerged as a desirable alternative . MoreoveTERT, TP53, or CTNNB1, are not actionable. Only approximately 25% of HCCs contain actionable mutations . The patients/participants provided their written informed consent to participate in this study. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration. Informed written consent was obtained from the patient for publication of this report and any relevant images.TP and HS designed the report; Y-GW and Y-XJ were involved in the drafting of the manuscript; H-SH, Z-MZ, and X-WL were involved in the collation of clinical data and radiological images. G-ZZ, C-YH, Z-MZ, and X-PY were involved in the manuscript revision. Z-LL contributed to pathological examination. All authors contributed to the article and approved the submitted version.


Temporal percutaneous transhepatic duodenum drainage (PTDD) seems to be effective in the treatment of postoperative afferent loop syndrome (ALS) following transverse loop colostomy for obstructive colorectal cancer.Management of obstructive colorectal cancer still remains a challenge. There are various options with different risks of mortality and mobility for obstructive colorectal cancer. A rare unexpected postoperative ALS following a low anterior resection and transverse loop colostomy for obstructive colorectal cancer is presented in this report. A 64‐year‐old man had the acute ALS had been noted 10 days after transverse loop colostomy. An option was temporal PTDD treatment in the patient with history of Billroth's operation II for upper gastrointestinal bleeding 30 years ago. Acute ALS was treated by temporal PTDD. The drainage tube for PTDD was not removed until closure of the transverse colostomy 2 months later. The patient recovered uneventfully. Acute ALS after transverse loop colostomy for obstructive colorectal cancer is rare and has never been reported in the literature. The mechanism of acute ALS after construction of a loop colostomy and the treatment strategy of PTDD for acute ALS is presented. The management still remains a challenge. The risks of ischemia bowel and perforation of colon may occur if the operation was delayed. There are various options with different risks of mortality and mobility for obstructive rectal cancer, such as stenting, one stage resection anastomosis, total colectomy, resection of obstructive rectal cancer plus a prophylactic loop colostomy, Hartmann's operation or simple colostomy.Afferent loop syndrome (ALS) is usually developed as a complication after gastrectomy with gastrojejunostomy.2A 64‐year‐old man was sent to our emergency room due to abdominal pain, fullness of abdomen and no stool passage for 4 days. He had history of peptic ulcer with bleeding post B‐II operation 30 years ago. The heart rate 94 beats/min, blood pressure 147/100 mmHg, and respiratory rate 20 breaths/min were found. Abdomen was tenderness without rebounding pain and ovoid in shape. An old surgical scar located upper mid‐line of abdomen. Metallic sound was noted. Kidney–ureter‐bladder abdominal radiography (KUB) and computed tomography (CT) of abdomen demonstrated intestinal obstruction with mass lesion over rectum‐sigmoid junction  could participate interchangeably with surgical and percutaneous approaches in unresectable recurrent rectal cancer (URRC). Tumor drug exposure in the pelvis no statistically difference between the percutaneous approach and surgical approach.We reported the rare case of after transverse loop colostomy with ALS, which was successfully managed by following management of the ALS by PTDD.4Routine surgery chosen and less experience for the protective stoma is the transverse colon when we noticed the antecolic reconstruction after gastric surgery. In this case report, we found temporal PTDD seems to be effective in the treatment of benign afferent loop symptoms after T‐loop colostomy. Ileostomy instead of T‐loop colostomy may be suggested for emergent colorectal surgery in patient with previous B‐II surgery.Tung‐Yuan Chen: Conceptualization; data curation; methodology; writing – original draft. Chin‐Wen Hsu: Conceptualization; data curation; methodology. Yee‐Phoung Chang: Conceptualization; data curation; methodology. Min‐Tsung Wang: Conceptualization; data curation; methodology. Yueh‐Jung Wu: Conceptualization; data curation; methodology; writing – original draft. Ching‐Hsien Wang: Resources; visualization. Kuan‐Yu Wang: Resources; visualization. Tian‐Huei Chu: Writing – review and editing. Yung‐Kuo Lee: Funding acquisition; writing – original draft; writing – review and editing.This research was funded by Kaohsiung Armed Forces General Hospital, grant number KAFGH_D_111049; and KAFGH_D_112043.The authors declare that they have no conflicts of interest.Not applicable.Written informed consent was obtained from the patient for publication of this case report and any accompanying images.


A rescued male mixed-breed dog, approximately nine years old, was evaluated due to progressive weight loss and an enlarged abdomen. An ultrasound revealed a large, indeterminate mass with mineral-like margins visible on the radiographs. The animal underwent an exploratory laparotomy, and the mass was excised. Histopathological analysis revealed characteristics consistent with a primary omentum extraskeletal osteosarcoma. This rare neoplasm, originating from mesenchymal cell proliferation and bone matrix production, is highly malignant. It often results in death due to metastasis and local recurrence or necessitates euthanasia post-diagnosis in certain cases. Osteosarcoma is a highly malignant bone neoplasia, characterized by the proliferation of mesenchymal cells and the production of woven bone tissue and osteoid matrix . It can Extraosseous osteosarcoma is typically diagnosed in elderly patients . Unlike Typically, its presentation involves rapid growth formation, characterized by irregular mineralized areas, as well as hemorrhagic and necrotic regions . These fA diagnosis is typically established through the integration of clinical, radiographic, and histological findings . This prDespite the lack of definitive information in most current literature, no specific and effective treatment has been established. When feasible, complete or partial excision of the tumor is recommended, contingent on surgical viability . OutcomeThis study presents a confirmed case of primary omentum extraskeletal osteosarcoma in an elderly male dog. The diagnosis was established through ultrasonography, radiography, and histopathology. The patient was monitored from the initial diagnostic procedure through to euthanasia and necropsy. The case largely aligned with the characteristics outlined in existing literature, with the only deviation being a slightly extended post-surgical survival time than previously reported.A medium-sized, mixed breed male dog, approximately nine years old, was brought in for treatment following a recent rescue. The dog had a history of progressive weight loss and an enlarged abdomen. A physical examination was conducted, revealing stable vital signs: a heart rate of 120 beats per minute, 31 respiratory movements with clear respiratory sounds, and a rectal temperature of 38.2 ºC. Blood tests were performed, indicating leukocytosis with elevated monocytes and neutrophils, as well as hypoalbuminemia. No other significant changes were observed in the remaining test results. During abdominal palpation, a large mass was identified. The patient was subsequently referred for an abdominal ultrasound, which was conducted the following day. The ultrasound revealed a large, irregular formation that was heterogeneous in nature and exhibited mixed echogenicity. The formation had an anechoic center and hyperechoic spots scattered around the margins . The forIn a supplementary assessment, abdominal radiographs were conducted to identify the source of the mass. A uniform mass, characterized by peripheral mineral radiopacity spots, was detected. The primary differential diagnoses included neoplasia, granuloma, or abscess . FurtherAfter two weeks post-diagnosis, the patient underwent an exploratory laparotomy and complete excision of the mass. The mass exhibited moderate adhesion to adjacent tissues, necessitating the removal of a jejunal segment . The excThe patient exhibited signs of recovery post-surgery. However, 27 days later, the patient presented with weight loss. Subsequent ultrasonographic and radiographic examinations were conducted due to clinical suspicion of local recurrence or peritonitis.The ultrasound results indicated local recurrence and metastasis, characterized by multifocal mineral lesions with acoustic shadowing artifacts diffusely spread across the abdomen. These affected the liver, omentum, and mesentery. Additionally, a new mass, measuring 4.50 x 3.66 cm, was identified in the same location as the previously removed one. Abdominal effusion and signs of partial intestinal obstruction were also observed, potentially associated with post-surgical adhesions .The thoracic radiographs revealed no evidence of metastasis . HoweverForty-two days post-surgery, due to clinical deterioration, euthanasia was carried out. The body was subsequently sent for necropsy. The necropsy confirmed the sonographic exam findings, revealing multiple mineral lesions diffusely scattered across the omentum, adhered to the parietal peritoneum, and within the hepatic parenchyma  and 9.The patient discussed in this study was monitored from initial diagnosis through to euthanasia and necropsy. The symptoms presented were consistent with those found in the literature, being nonspecific and primarily associated with the abdominal location of the tumor, which carried a poor prognosis . The epiThe diagnosis was confirmed through an initial ultrasound evaluation, followed by supplementary radiographs and histopathological confirmation, in accordance with the histological features described . The bloThe patient underwent a surgical procedure involving complete resection of the mass, as recommended . HoweverExtraskeletal osteosarcoma is a rare and highly malignant neoplasm in dogs, characterized by its infiltrative and metastatic potential. This condition often carries a poor prognosis, particularly in cases with an abdominal presentation. The literature contains few reports of cases associated with the omentum, as in the case discussed in this study. The efficacy of available treatments remains unproven due to the challenges in diagnosing this rare condition and the lack of statistical and supportive data. Given the nonspecific nature of the symptoms, abdominal ultrasound played a crucial role in the initial diagnosis due to its accessibility. Although it lacks specificity, it is highly sensitive in detecting abdominal masses, thereby aiding in decision-making regarding case management.


Acute abdominal pain in pregnant women may complicate the diagnostic process of acute abdominal pain because of anatomical and physiological changes and limitations of computed tomography examinations related to radiation exposure. Here, we present the case of a 35-year-old female in her 10th week of pregnancy who was seen in the emergency department with unilateral abdominal pain and gross hematuria. Ultrasound detected only hydronephrosis and failed to identify ureteral stones, but magnetic resonance imaging revealed a diagnosis of idiopathic renal hemorrhage and intraductal ureteral hematoma, not ureteral stones. Although magnetic resonance imaging for pregnant women has the disadvantages of prolonged scan time and difficulty in image interpretation, no harm or complications to the mother or fetus have been reported. Magnetic resonance imaging may be considered in assessing acute abdominal pain in pregnant women, especially when the diagnosis is uncertain, based on shared decision-making with the patient and assessing the clinical situation and availability. The approach to investigating acute abdominal pain during pregnancy is essentially the same as that used for the non-pregnant approach. Although acute abdominal and pelvic pain may be more common during pregnancy, several challenges to diagnosis arise because of pregnancy, such as pregnancy-related anatomical and physiological changes, obstetric complications, and fetus-related conditions Ureteral stones are the most common non-gynecologic cause of abdominal pain among pregnant women Herein, we describe a suspected ureteral stone as the cause of acute right lower abdominal pain in a pregnant woman. Ultrasound examination revealed hydronephrosis. However, because of the difficulty in differentiating between ureteral stone and physiologic causes of hydronephrosis, we proceeded with MRI without contrast, which led to a timely diagnosis of idiopathic renal hemorrhage, a rare condition of occult hematuria. Our case demonstrates the usefulness of MRI for diagnosing acute abdominal pain in pregnant women.The patient was a 35-year-old woman with a history of 2 miscarriages. At the time of consultation, the patient was in her 10th week of pregnancy through artificial insemination. She was taking 100 mg of aspirin per day. She presented to the emergency department at night with a chief complaint of gross hematuria and right lower abdominal pain, which had developed 2 days prior. Physical examination revealed positive tenderness of the right lower abdomen and costovertebral angle (CVA) tenderness on tapping. Abdominal ultrasound showed hydronephrosis in the right kidney but no visible stone lesions in the pyelonephritic transition zone. Information was provided to the patient and family regarding the high possibility of a ureteral calculus, which could not be confirmed via ultrasound. The physician presented the patient and family with recent evidence on the safety of MRI for pregnant women and the usefulness of MRI for abdominal pain disease, including ureteral calculi, without risk of radiation exposure. Through shared decision-making, we proceeded with MRI without contrast, aligning with the patient's desire for a diagnostic examination.MRI showed hydronephrosis of the right kidney and a 4 cm lesion with low signal on T1- and T2-weighted images  and high signal on diffusion-weighted images in the lesion in the renal pelvic-ureteral junction . SymptomFrom MRI images and radiology reports and the patient's clinical symptoms, a diagnosis of idiopathic renal hemorrhage and suspected intra-ureteral hematoma was made by the urologist, and the patient was followed up on an outpatient basis. Aspirin was discontinued at the time of the first follow-up. The patient's symptoms improved, with resolution of the occult urine blood within 4 weeks and negative urine cytology. There was no recurrence of hematuria.In this case, we described our use of MRI for a close abdominal examination of a woman at 10 weeks of pregnancy. MRI was effective for differentiating idiopathic renal hemorrhage, a rare condition, from ureteral stones. Idiopathic renal hemorrhage, also known as "essential hematuria" or "chronic unilateral hematuria," is characterized by intermittent or persistent gross unilateral hematuria from the upper urinary tract The most frequent cause of idiopathic renal hemorrhage is a hemangioma or microvascular rupture ,8. HematIn summary, although the use of MRI in diagnosing acute abdominal pain in pregnant women is still not widespread, our case demonstrates the usefulness of MRI for the timely diagnosis of acute abdominal pain, even for the rare condition of idiopathic renal hemorrhage. Further evidence through case reports and research is warranted to validate this clinical use of MRI. Education regarding the appropriate use of MRI will also need to be considered.Our institution does not require ethics approval for reporting individual cases.Written informed consent was obtained from the patient for the use of her anonymized clinical information in the publication of this case report.


Abdominoscrotal hydrocele (ASH) represents a rare condition characterized by abdominoscrotal cystic enlargement that exhibits hourglass-shaped, fluid-filled accumulation communicating with scrotal and abdominal components on contrast-enhanced computed tomography. We present the case of a 44-year-old patient who presented with swelling in the right scrotal and abdominal regions. Upon examination, a positive cross-fluctuation was observed between the right scrotal swelling and the abdominal swelling, raising suspicions of ASH, which was subsequently confirmed radiologically. The patient underwent a right-sided sac excision and sac ligation at the deep ring performed through a right inguinal approach and subsequently experienced a smooth and uncomplicated recovery during the postoperative period. Surgical repair is the most common management approach rather than conservative management, and the use of an inguinal method over other surgical methods facilitates a lower risk of inadvertent injury to adjacent anatomical structures. Hydroceles are typically characterized by an accumulation of serous fluid within the tunica vaginalis, resulting in painless scrotal swelling . The leaA 44-year-old man presented with unilateral scrotal and lower abdominal swelling, along with dull aching pain and discomfort for the last six months. The patient also reported pain when coughing. There was no history of trauma or prior surgery. Upon examination, right-sided scrotal swelling and right lower abdominal swelling were identified. Both swellings were non-reducible, non-tender, transluminal, and fluctuant. Cross-fluctuation was observed with the swelling, indicating the likelihood of right-sided simple ASH ASH-S1). ASH was not associated with any congenital anomaly or underlying disorder. The CECT of the abdomen revealed an hourglass-shaped, communicating fluid-filled accumulation that extended into the right scrotum and right lower abdomen (Figure . ASH wasDuring surgery, it was found that the swelling originated from the spermatic cord at the deep ring. The swelling had bilobar components: one was the abdominal part, and the other was the scrotal portion. Both components were connected by an isthmus, which was obliterated inside the inguinal canal. Each lobe measured 10 × 10 centimeters in size, containing approximately 280 mL of fluid. The abdominal component was reduced first and excised, followed by the removal of the scrotal component and ligation of the isthmus at the deep ring. The incision was exclusively inguinal, and the scrotal swelling was extracted by pulling it through the inguinal incision (Figure Postoperatively, the patient experienced mild pain at the operated site, which subsided with analgesics. The suture site healed well, and the patient did not have any episodes of fever during the hospital course. The patient was discharged on postoperative day three.ASH was originally described by Dupuytren in 1834, and he referred to it as “hydrocoele en bissac” [A rise in intraluminal pressure inside the proximal processes vaginalis is attributed by Brodman et al. to fluid buildup within the tunica vaginalis. In accordance with Laplace’s law, which stipulates that as the fluid collection’s radius grows, the internal pressure decreases, and this heightened pressure subsequently traverses the internal inguinal ring and enters the abdominal cavity, facilitating further expansion of the ASH . HoweverThe diagnosis of ASH can be achieved through clinical examination, wherein the identification of a lump above the inguinal ring and the observation of fluid movement between the abdomen and scrotum upon compression of the tissues provide clarity regarding the nature of the swelling . ImagingDue to the paucity of standard guidelines, the management of ASH varies across centers. Various techniques have been documented in the literature, including inguinal approaches either with or without scrotal involvement, inguinal methods combined with extraperitoneal or intraperitoneal approaches, or laparoscopic approaches . In our Some studies also report on the conservative management of ASH. However, complications due to ASH are often brought on by pressure effects on nearby structures, such as hydronephrosis or unilateral leg edema brought on by compression of the iliac vein or ureter, respectively. Thus, surgical intervention is preferred over conservative management -10.ASH is a rare type of hydrocele, primarily documented in a limited number of case reports. Currently, there is no established standard guideline for the management of ASH. Typically, a combination of physical examination and ultrasonography suffices for diagnosis, although additional diagnostic tools such as CT scans and MRI may also be employed. Surgical repair is the most common management approach rather than conservative management, and the use of an inguinal method over other surgical methods facilitates a lower risk of inadvertent injury to adjacent anatomical structures.


Teaching Point: Spontaneous rupture of the anterior tibial tendon at the ankle joint may mimic a tumor. A 75-year-old man presented with spontaneous soft tissue swelling at the left ankle joint anteriorly. Longitudinal sonogram of the tibialis anterior tendon (TAT) of the left ankle joint showed a retracted, irregular, hypoechoic, and swollen proximal part of TAT and pre-existing tendinopathy. There was focal discontinuity of the TAT between superior and inferior retinaculum .Magnetic resonance imaging (MRI) confirmed a full-thickness tear of the TAT with slight retraction of the tendon on sagittal fat-suppressed (FS) T2-weighted Image (WI) . Axial FTAT courses at the medial compartments of the superior and inferior retinacula. It inserts at the medial cuneiform bone and the base of the first metatarsal bone. Dorsiflexion of the foot is its primary function. Diagnosis of TAT rupture should be suspected clinically if a triad of a ‘pseudotumour’ of a ruptured tendon, loss of tendon contour, and reduced dorsiflexion is present .Spontaneous rupture occurs predominantly in the elderly with pre-existing tendinopathy. The tear can go clinically unrecognized because of preserved active dorsiflexion of the foot – although significantly weakened – due to residual integrity of the digitorum longus and hallucis longus tendons.Patients may present with a focal soft tissue swelling above the anterior aspect of the ankle joint, because of tendon retraction. Although careful comparative clinical examination may suggest the diagnosis, by revealing a tendon gap, imaging is often required to confirm the diagnosis of tendon rupture and to exclude the diagnosis of a soft tissue tumor.Ultrasound shows focal tendon thickening and heterogeneity, with loss of the normal fibrillar pattern above the level of the tendon tear and absence of the tendon between the superior and inferior extensor retinaculum. Power doppler may show hypervascularity. Proximal tendon thickening with increased signal intensity on T2-WI, and tendon discontinuity at the level of the tibiotalar joint are the diagnostic imaging features on MRI.Treatment is usually conservative in elderly patients with extensive comorbidities. The use of an ankle-foot orthosis, bracing, and shoe adaptations are recommended.In conclusion, although diagnosis of TAT rupture depends on the clinical triad, elderly patients with spontaneous TAT tears may only present with a soft tissue swelling at the ankle joint, which may be misinterpreted as a soft tissue tumor. Imaging is pivotal to define the pseudotumoral nature of this lesion.


Neoadjuvant treatment followed by highly complex surgical procedures has been studied over the last decade with promising short- and long-term results in patients with locally advanced pancreatic ductal adenocarcinoma (LAPC). In recent years, a wide variety of complex surgical techniques that involve extended pancreatectomies, including portomesenteric venous resection, arterial resection, or multi-organ resection, have emerged to optimize local control of the disease and improve postoperative outcomes. We aim to describe the preoperative surgical planning as well different surgical resections strategies in LAPC after neoadjuvant treatment in an integrated way for selected patients with no other potentially curative option other than surgery. Pancreatic ductal adenocarcinoma remains a global health challenge and is predicted to soon become the second leading cause of cancer death in developed countries. Currently, surgical resection in combination with systemic chemotherapy offers the only chance of cure or long-term survival. However, only 20% of cases are diagnosed with anatomically resectable disease. Neoadjuvant treatment followed by highly complex surgical procedures has been studied over the last decade with promising short- and long-term results in patients with locally advanced pancreatic ductal adenocarcinoma (LAPC). In recent years, a wide variety of complex surgical techniques that involve extended pancreatectomies, including portomesenteric venous resection, arterial resection, or multi-organ resection, have emerged to optimize local control of the disease and improve postoperative outcomes. Although there are multiple surgical techniques described in the literature to improve outcomes in LAPC, the comprehensive view of these strategies remains underdeveloped. We aim to describe the preoperative surgical planning as well different surgical resections strategies in LAPC after neoadjuvant treatment in an integrated way for selected patients with no other potentially curative option other than surgery.  Pancreatic ductal adenocarcinoma (PDAC) remains a global health challenge and is predicted to soon become the second leading cause of cancer death in developed countries . CurrentIn recent years, a wide variety of complex surgical techniques that involve extended pancreatectomies, including portomesenteric venous resection (PVR), arterial resection (AR), or multi-organ resection, have emerged to optimize local control of the disease and improve postoperative outcomes. Microscopic tumor involvement in the resection margin and lymph node metastases are common in this scenario, and, therefore, local recurrence is frequent and conditions patient survival. One of the main challenges in LAPC is achieving tumor-free resection margins (R0 = tumor-free margin > 1 mm)  and lympMultidetector computed tomography (MDCT), using specific pancreatic contrast protocols, represents the most widespread method for establishing a suspected diagnosis of PDAC. It allows precise staging of the disease, determining tumor resectability and surgical planning according to vascular variations and/or adjacent organ invasion. Historically, localized pancreatic disease has been classified as resectable (without vascular involvement by imaging methods) or locally advanced . According to the consensus statement of the International Study Group of Pancreatic Surgery (ISGPS) , which iHowever, considerable disparities in multidisciplinary team evaluations of patients with pancreatic cancer exist, including substantial variation in resectability assessments . A recenp ≤ 0.0001) and the percent increase from minimum value to final restaging CA19-9  were predictive of tumor progression in patients with advanced pancreas cancer.Another important aspect during patient work-up is the decreased levels of tumor marker serum carbohydrate antigen (CA) 19-9 after neoadjuvant therapy, because this may predict a better prognosis, with low incidence of hepatic recurrence after surgery . Rose etTanaka et al.  recentlyA recent classification proposed a four-stage Whipple procedure categorization based on the extent of surgery and surgical outcomes. Multivisceral pancreatoduodenectomy (type 3) or pancreatoduodenectomy with arterial resection (type 4) had increased probability of surgical complications, relaparotomy, and 90 day mortality . Type 3 The early steps of the operation are similar as in conventional pancreatic resection and some technical aspects have been described previously . HoweverThrough an extensive Kocher maneuver in combination with the Cattell–Braasch mobilizations of the cecum, right colon, right colonic flexure, and the root of the small bowel. together with the Treitz ligament. an adequate exposure of the entire infrahepatic vena cava (IVC), aorta, the left renal vein (LRV), and the right origin of the SMA, which is situated just above the LRV, can be achieved and offer adequate tractability of the mesenteric root in case segmental vein resection and reconstruction should become necessary  Figure . The oriIn the situation that MDCT shows tumor extension close to the jejunal branches of the SMV or distal aspects of the SMA, the identification of the superior mesenteric vessels is performed at the root of the mesentery below the transverse mesocolon to the origin from the aorta. The middle colic artery is detached at its origin from the SMA in this manner, and the tumor-infiltrated section of the transverse mesocolon is resected to remain with the specimen . The firA recent systematic review and meta-analysis showed that patients undergoing an artery-first approach to pancreatoduodenectomy may be associated with improved perioperative outcomes and survival in comparison with those having standard pancreatoduodenectomy . The strStandard distal pancreatectomy and splenectomy for PDAC in the body or tail have been associated with high positive margin rates and poor overall survival in relation to tumor infiltration of the anterior renal fascia and the left adrenal gland . For thiIt has been theorized that one of the explanations for the poor long-term survival is that tumor-infiltrated autonomous nerve spreads frequently in the preaortic region and this spread can lead to positive resection margins or sites of tumor-infiltrated lymphatic tissue.The TRIANGLE operation  is a proExtended resection of neural and lymphatic tissue carries a risk of increased surgical morbidity, including adverse effects such as postoperative bleeding, uncontrolled diarrhea, and ascites.As mentioned above, the LAPC clinical scenario can be associated with unconventional resections of organs adjacent to the pancreas that involve multivisceral resections. The ISGPS published a list of structures and organs additionally to the ones resected in a standard pancreatoduodenectomy, pancreatic left resection, or a total pancreatectomy because of the many different classifications that existed to that point . Some puPancreatic surgery in combination with PV and/or SMV resection represent a frequent and more complex surgical scenario in patients with LAPC compared with standard pancreatic resection. Although several studies suggest that pancreatic resections with PVR are associated with acceptable perioperative risk, performing venous resection undoubtedly adds a technical challenge to an already complex surgical procedure . The benThe extent of en bloc venous resection is related to the possibility of venous reconstruction, while the technique of vascular reconstruction differs drastically based on anatomical vascular variations and surgeon preferences. The ISGPS suggests a specific categorization of the types of venous reconstruction to be incorporated in analyses for more detailed and evidence-based evaluation in patients with venous involvement . Small vA lateral patch into the venous defect can be safely used for some defects (type 2). Autologous substitute for venous reconstruction, such as parietal peritoneum, can be harvested from the diaphragm, the right or left hypochondrium, or the falciform ligament  Figure A. The meSegmental defects can frequently be reconstructed with primary end-to-end anastomosis (type 3) . With thThe use of a vascular graft interposition (type 4) is contemplated for the reconstruction of large vascular segment defects . SuitablCavernous transformation of the PV represents a challenging surgical scenario in LAPC. This situation may be associated with complete tumor occlusion of the PV/SMV or in relation to a paraneoplastic procoagulant disorder. The technique of “venous bypass graft first” approach was recently described to avoid major bleeding complications, intestine congestion, or liver perfusion disorders ,34. The Although recent meta-analyses concluded that pancreatectomy with AR were associated with increased morbidity and mortality in comparison to non-AR pancreatectomies ,37, the From the anatomical and technical point of view, there is a great difference between AR of the SMA, with respect to the CT and the hepatic artery. For example, after resection of the CT, the blood supply to the liver and pancreas head via the common hepatic artery relies on retrograde arterial perfusion of the pancreatoduodenal arcades and the gastroduodenal artery with the blood flow coming from the SMA. To improve collateral flow tributaries and reduce postoperative liver ischemia, we applied preoperative common hepatic artery embolization . We had Recently, the technique of “arterial divestment” opens a great possibility for a periarterial neurolymphatic tissues dissection without the need of AR and respective reconstruction, with the risks that this implies. Arterial clearance is achieved by placing it in a plane between the uninvolved arterial wall and the tumor tissue of the affected arterial segment . The disIn this review, recent surgical and technical aspects in LAPC were discussed, including extended pancreatic resections, PMV resections and their respective forms of vascular reconstruction, arterial resection, or alternatively arterial divestment. Furthermore, through multimodal treatment systems and appropriate surgical resection techniques, the long-term outcome after extended pancreatectomies can be similar to standard resections and considerably better than palliative care, despite the fact that we do not have the sufficient level of scientific evidence.


We report on a 67-year-old woman who experienced drowsy mental status, facial numbness, and hearing loss on the right side; the symptom gradually worsened over the last 4 years. Brain magnetic resonance imaging revealed a 4.8 × 1.8 × 2.6 cm lesion located in the right cerebellopontine angle.She underwent surgery with the retrosigmoid suboccipital approach and support from the digital robotic exoscope Synaptive Modus V system. To the best of our knowledge, this is the first reported case that used the robotic exoscope system in Vietnam, and also in Asia.We performed radical resection of the tumor, the surgery position and the pathology result concluded the diagnosis was trigeminal schwannoma.After 30 months of follow-up, she fully recovered and the magnetic resonance imaging showed radical resection of the tumor.The aim of this study is to share our experience with the robotic exoscope system, which can improve optical field and image resolution, hence creating an opportunity for surgery that otherwise is impossible. The application of this robotic exoscope system is a breakthrough in neurosurgery in developing countries, such as Vietnam. The most frequent type of tumors are vestibular schwannomas, followed by meningiomas and epidermoid tumors; much more rare tumor of CPA are schwannomas of other cranial nerves. The treatment options for tumors of CPA include observation, radiation therapy, and surgery.,2 Surgery can offer a definitive solution, however, due to the critical anatomical position of CPA, the surgery option was often put into hesitation.The cerebellopontine angle (CPA) is a triangular space in the posterior cranial fossa. It is an important landmark of anatomy and clinical, which is occupied by the CPA cistern, including the cranial nerves V, VI, VII, and VIII along with the cerebellar artery. Tumors of the CPA account for around 5% of intracranial neoplasm. Thus, the robotic exoscope system can resolve the surgical microscope problems, and bring better outcomes for the patient. Here, we report an immensely challenging case of tumor in the right cerebellopontine angle, which was successfully treated by surgery with support of the digital robotic exoscope Synaptive Modus V systemThe introduction of the surgical microscope greatly impacted the neurosurgery field. The current surgical microscopes have gone through major updates, but still, it has some limitations. Firstly, the binocular lenses are attached to the microscope, which requires handling thus affecting the comfort of surgeons and prolonging the surgery duration. Secondly, illumination during surgery in-depth has some limitations that can affect the surgical outcome. The Synaptive Modus V system is fully automated, it provides a hands-free robotic movement of the camera and optical focal depth control via a tracked surgical instrument, with an enhanced LED light sources surrounding the camera.The Modus V  is a fully automated 2-dimensional exoscope, with tracked surgical instrument that provides hands-free robotic movement of the camera and optical focal depth control. The main surgeon had an experience of more than 20 hours of practising with the system in the lab setting before the surgery. For case series data, we searched PubMed using the keywords “Trigeminal Schwannoma” and “Microsurgery”; In total, 355 reported cases were reviewed, we extracted relevant data and created Table We report on a 67-year-old woman who experienced vertigo, headache, facial numbness, and hearing loss on the right side. Over the last 4 years, she went to many hospitals in Vietnam, with the diagnosis of tumor in the right CPA, however, due to the critical position of tumor, the microsurgery option was postponed, and the patient was put on observation. She was treated only to reduce her symptom. We performed radical resection of the tumor in a 4-hour operation, with minimal bleeding and all of the important structures were preserved. The pathology result of the tumor sample was schwannoma, and both the MRI images and the surgery position is on cranial nerve V, which concludes the diagnosis of trigeminal schwannoma. The patient’s condition improved at 24 hours after the operation (Day 4), and was discharged at 96 hours, which is Day 7 after hospital admission. After 30 months of follow-up, she fully recovered. In detail, the patient feels very slight numbness in the right half of the face according to the V2-dominant region and still improving, she can hear whispers and snapping fingers, with Weber test combined with Rinne test results showing equal hearing in both ears, thus a manifestation of full recovery of hearing ability. The cranial nerves VII, IX, X, XI, XII have no abnormal signs. The MRI at 3 and 24 months of follow up showed complete removal of the tumor without any recurrence .On the physical examination, the blood pressure, pulse, temperature, and respiration rate were 120/70 mm Hg, 76/min, 36°C, and 20/minutes, respectively, the patient’s condition overall is poor. Neurological examination revealed Glasgow Coma Scale score of 15 points, drowsy mental status, with peripheral cranial nerves V, VII, and VIII palsy on the right side. In detail, the examination of the cranial nerve V showed decreased sensation in the right half of the face according to the dominant region of V2. The patient had moderate hearing loss, with Weber test combined with Rinne test results showing sensorineural hearing loss on the right side. The cranial nerve VII on the right has mild paralysis. The cranial nerves IX, X, XI, XII have no abnormal signs. Brain magnetic resonance imaging (MRI) revealed a 4.8 × 1.8 × 2.6 cm uniform density lesion located in the right cerebellopontine angle, in association with severe compression of the brainstem and fourth ventricle  is a rare tumor that accounts for less than 0.1% of all intracranial tumor.,2; similar to previous reports, in this case, the tumor continued to grow, and the patient’s symptoms gradually worsened over the last 4 years. She was admitted to our hospital with poor overall condition, drowsy mental status, and cranial nerves palsy. With the tumor that have a maximal diameter of 4.8 cm, thus the stereotactic radiosurgery is not recommended, and the surgery approach was chosen, with the ultimate goal is not only a removal of the big tumor at CPA but also functional preservation of all cranial nerves and recovery of quality of life.,10,11Four years ago, our patient initially presented with vertigo and headache. She went to many hospitals in Vietnam and was diagnosed with a tumor in the right CPA. Nevertheless, because of the critical anatomical position, the observation approach is chosen with the assumption that the tumor will stop growing or undergo spontaneous regression. However, other studies reported that the majority of the CPA tumors exhibit further growth,13,14 In this case, we chose the retrosigmoid sub-occipital approach and the supprot from Modus V system, which can offer a good visual of the whole CPA and increase safety during tumor dissection from brainstem and lower cranial nerves. According to Li et al, reported on 43 cases with trigeminal schwannoma received conventional surgical treatment, the postoperative rate of facial numbness remain at 82.8% of patients, other publications also reported similar data with associated morbidity was high at around 57% to 85%–10 (Table  The aim of this study is to share our positive initial experiences with the Modus V system, and we plan on reporting our clinical trial with the system.The strengths of exoscopes are the wide view and deep focus with good illumination that can reduce the need for repositioning and refocusing during the surgery, hence better visual which is critical for surgery. Published data on the VITOM-3D, ORBEYE, and Modus V exoscope systems reported comparable results with the conventional surgical microscope with better image quality and illumination in surgeries.In conclusion, the digital robotic exoscope Synaptive Modus V system is a safe and helpful tool to perform intracranial tumor resection. Especially, the artificial intelligence in the system provides hands-free movement, which gives a time-saving factor and comfortable for surgeons. The optical field and the image resolution are better than that of a surgical microscope. These factors help to reduce the length of the operation, minimize the risk of complications, hence creating an opportunity for surgery that otherwise is impossible, and bringing better outcomes for the patient. The application of this robotic exoscope system is a breakthrough in neurosurgery in developing countries, such as Vietnam.We would like to say our special thanks to Quynh Nguyen Xuan Thuy, Department of Infectious Diseases, Children’s Hospital no.2, Ho Chi Minh City, Vietnam; and Tan-Son Chu, Department of Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam; for their contribution to English correction, and literature review. We would like to say our special thanks to the faculty of People’s Hospital 115, Ho Chi Minh City, Vietnam; and the Department of Neurosurgery, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam; for their contribution to medical support.Conceptualization: Tan-Si Chu.Data curation: Tan-Si Chu, Tri-Dung Huynh, Van-Dinh Phan, Bao Ngoc Dang, Quoc Dat Tran.Funding acquisition: Tan-Si Chu.Investigation: Tan-Si Chu, Van-Dinh Phan, Bao Ngoc Dang, Quoc Dat Tran.Methodology: Tan-Si Chu, Tri-Dung Huynh.Project administration: Tan-Si Chu.Supervision: Tan-Huy Chu.Validation: Tan-Huy Chu.Visualization: Tan-Huy Chu.Writing – original draft: Tan-Huy Chu.Writing – review & editing: Tan-Huy Chu.


A 58-year-old man was diagnosed 4 years ago with a 9-cm gastrointestinal stromal tumor (GIST) of the gastric fundus. Under neoadjuvant treatment with imatinib, the GIST was substantially reduced in size and subsequently removed via laparoscopic fundus resection. Despite adjuvant treatment, a recurrence appeared 3 years later at the surgical site on the staple line . Owing Therefore, we performed submucosal tunneling endoscopic resection (STER). The tumor was located extraluminally and could not be identified during endoscopy . Via enVideo 1 Submucosal tunneling endoscopic resection for a recurrent gastrointestinal stromal tumor at the surgical anastomosis.Endoscopic resection has been suggested as an alternative to surgical excision for GISTs, provided that complete removal is technically possibleTo our knowledge, this is the first case of complete endoscopic removal of GIST recurrence at the surgical site on the gastroesophageal junction in a patient under treatment with a tyrosine kinase inhibitor.Endoscopy_UCTN_Code_TTT_1AQ_2AD


Supratentorial cortical ependymoma is an extremely rare malignancy in the pediatric population, especially in very young age groups. Most of the reported cases present with dramatic neurological symptoms like seizures and sudden onset hemiplegia. We hereby report a case of anaplastic supra-cortical ependymoma in a 13-month-old male child, with subtle seizures for four weeks. The child, who was brought for non-neurological complaints to the outpatient clinic, was found to have abnormal staring episodes. An electroencephalogram showed focal epilepsy and an MRI brain showed a large intra-axial lesion in the left frontal area. The child underwent gross total resection of the lesion and histopathology revealed WHO grade 3 cortical ependymoma.  Ependymomas are rare neuroectodermal tumors originating from the ventricular system. These are the third most common pediatric intracranial tumors, even though they account for only 1.2-7.8% of the total. About 90% of ependymomas are intracranial and among them, around one-third occur in the supratentorial compartment. Survival rates of posterior fossa tumors are inferior to supratentorial tumors. Surgical resection followed by radiotherapy has been the standard treatment recommendation, but recently chemotherapy has been suggested in very young children to avoid the detrimental effects of radiation on the developing brain [A 13-month-old boy, third born from a non-consanguineous marriage, was brought to the pediatric clinic for a general checkup and minor upper respiratory complaints. During history taking, the mother mentioned some abnormal behavior in the child which was noted four weeks earlier. The child had brief staring episodes lasting for around one minute, with a lack of response to sound or touch. According to the mother, multiple episodes were noted over the last four weeks. There was no loss of consciousness or tonic-clonic convulsions. The child did not have a fever and was active and interacting well. Since the parents did not consider it significant, they had not sought any medical attention. There was no family history of seizures, developmental disorders, or unexplained death.On examination the child had normal vital signs, no neurocutaneous markers, and systemic examination was normal. There were no focal neurological signs, no facial deviation, and gait was normal.Suspecting epilepsy, the child was referred to a pediatric neurologist. The electroencephalogram (EEG) showed four episodes of electrographic seizures starting from the left frontal lobe and spreading to the left hemisphere, which suggested focal epilepsy. The child was started on oral valproic acid and further assessed by MRI brain. MRI brain showed a large intra-axial lesion in the left frontal lobe measuring 5.8x4.6x4.4 cm with peripheral contrast enhancement. MR spectroscopy showed high choline and low N-acetyl aspartic acid (NAA) peaks. There was perilesional edema with compression of the left frontal horn of the lateral ventricle and a midline shift of 8 mm to right. A differential diagnosis of supratentorial ependymoma or pilocytic astrocytoma was suggested Figures -4.The child underwent surgery in the form of gross total excision of the tumor without any residual neurological sequelae Figures , 6. The The child is currently under the treatment of a pediatric oncologist for chemotherapy using cyclophosphamide, carboplatin, and etoposide. He is tolerating treatment well and has no neurological deficits.  Ependymomas are rare tumors of neuroectodermal origin. They arise from the ependymal lining of ventricles, choroid plexus, filum terminale, or central canal of the spinal canal. They account for 1.2-7.8% of all brain tumors . CorticaThe clinical presentation depends on the age of the patient, tumor size, and location. The diagnosis is often made by neuroimaging, especially MRI. The MRI may show iso or hypointense lesions on T1 weighted images and hyperintense lesions on T2 weighted images. The lesion could be solid tumors with calcification necrosis or cystic changes. The lesions are usually well-circumscribed mass lesions. Calcification may be better appreciated in CT. MR spectroscopy may show elevated choline and low N-acetyl aspartate levels .The ependymomas are classified according to the WHO grading system (updated in 2021). The WHO grading of ependymomas is based on features like pleomorphism, mitotic count, cellularity, vascularity, necrosis, and molecular and genetic features. Grade 1 is slow-growing myxopapillary and subependymal ependymoma, grade 2 is conventional ependymoma which is the most common form in the pediatric age group, and grade 3 is anaplastic ependymoma with aggressive tumor growth. The ependymoma cells have a positive reaction to glial fibrillary acid protein and protein S100 .The treatment of ependymomas in children is based on surgical resection and radiation. The extent of the complete resection is an important prognosis factor. In the pediatric population, the majority of cases are infratentorial and may be complicated by incomplete resection whereas supratentorial lesions are more amenable to complete resection. The role of chemotherapy in children is still under debate but may be beneficial in very young children at risk of extensive radiation damage .A recently published study by Cuoco et al. based on a systematic review of published cases of supratentorial ependymomas showed the mean age of presentation as 21.2 years in a reported number of 153 cases. Out of the total, 47 cases were of pediatric age groups, and only nine cases involved very young children less than three years [Comparison of casesWe have done a comparison of cases involving very young patients of less than three years Table . There wSupratentorial cortical ependymomas are rare in very young children. Large supratentorial tumors can present with minimal signs and symptoms. Gross complete resection with or without radiation is the cornerstone of treatment. Cortical ependymomas have a slightly more favorable prognosis than other supratentorial ependymomas. A high index of suspicion is recommended in evaluating very young children with abnormal behavior or movements noted by parents. The present case is an example of a large lesion with a midline shift presenting with a history suggestive of subtle seizures in an otherwise normal infant.


Salivary gland tumors account for approximately 3% of all tumors, most of which are benign, with pleomorphic adenomas being the most common, occurring mostly in middle-aged women, mostly originating from the major salivary glands and, to a lesser extent, from the minor salivary glands, with the tongue being a very rare site of occurrence. To date, case reports of pleomorphic adenoma at the root of the tongue are also rare.A 56-year-old male patient with no obvious cause of foreign body sensation in the pharynx, sputum, no pain, no blood in the sputum, no dysphagia, and no difficulty in swallowing and breathing, which was significantly aggravated in the past 2 weeks, with difficulty in swallowing, breath-holding on lying down.computed tomography and magnetic resonance imaging revealed a soft tissue mass at the root of the left tongue, which involved the tongue body in the forward direction. Electronic laryngopharyngoscopy showed a left-sided tongue root mass with a poorly smooth mucosa, covered with a mucous white pseudomembrane and a localized brownish-black crust without active bleeding. The final pathological findings showed a pleomorphic adenoma.Postoperative symptomatic treatment was given, and the patient recovered well. Eight days after surgery, the patient was discharged from the hospital, and the pharyngeal pain basically subsided at the time of discharge, with no fever and no pharyngeal discomfort. Postoperative laryngoscopy showed smooth mucosa of the pharyngeal cavity, good pseudomembrane formation in the operated area, no active bleeding, no purulent secretions, and normal blood routine on recheck. The medical advice after discharge was firstly, full rest for 1 week, secondly, continue the oral anti-inflammatory treatment, 1 week after the operation need to review the outpatient clinic, finally, if there are any uncomfortable symptoms, seek medical attention in time.At present, the patient has been followed up for half a year and has recovered well from the operation without any discomfort.It is very rare to find a pleomorphic adenoma of the tongue, and it occurs mostly in middle-aged women. In clinical diagnosis, it is sometimes difficult to distinguish it from malignant tumor of the tongue. Pleomorphic adenomas are neoplastic lesions containing tumorigenic epithelial tissue and mucous-like or cartilage-like tissue, with a pleomorphic and mixed histology, hence the name pleomorphic adenoma. Most of them originate from the major salivary glands and a few from the minor salivary glands, but lingual pleomorphic adenomas are very rare and the number of reported cases is limited. We report a rare case of pleomorphic adenoma of the tongue presenting as a tongue mass in a 56-year-old male patient and discuss its clinical features, imaging diagnosis and differential diagnosis and treatment.Pleomorphic adenomas were first described by Minssen in 1874 in Ahlbom monograph.T1-weighted image, mixed high signal in T2-weighted image, linear low signal at the edges, extending towards the tongue body, and inhomogeneous high signal in diffusion weighted imaging , the effect is not good, in the last 2 weeks the foreign body sensation in the throat significantly aggravated, with difficulty in swallowing, lying down to hold the breath, no pain and fever. past 35 years of smoking history and hypertension history for more than 1-month, irregular medication, blood pressure control is poor, had oral aspirin, now stopped, no special family genetic history. The result of physical examination showed chronic congestion of the mucosa of the pharyngeal cavity, narrowing of the pharyngeal cavity, and a spherical bulge at the left tongue root with an egg-sized swelling that blocked the pharyngeal cavity and moved with the tongue body. Electronic laryngopharyngoscopy (Fig.  pleomorphic adenomas are neoplastic lesions containing tumorigenic epithelial tissue and mucus-like or cartilage-like tissue, generally with an intact envelope, when no envelope or incomplete envelope is seen, it means that the tumor is aggressive and has a malignant tendency, with pleomorphic and mixed histology, so it is also called mixed Most tumors occur in middle-aged women, most of them originate from the major salivary glands, and a few from the minor salivary glands, and the minor salivary glands mostly involve the palate, followed by the lips, while the tongue is a very rare site of occurrence. Chaudhry et al found in a study of 1320 tumors that only 1% of salivary gland tumors originated in the tongue, and when lesions occurred in the tongue, the root of the tongue was the most common site, with a progressive decrease in incidence from posterior to anterior. To date, case reports of pleomorphic adenoma of the tongue root are also very rare, and according to previous case reports, dysphagia is the first symptom, which was confirmed by the study of Yoshihara T, and the present case presented with progressive foreign body sensation in the pharynx with dysphagia, and the clinical symptoms were consistent with the literature.Salivary gland tumors account for about 3% of all tumors, and most of them are benign, among which pleomorphic adenomas are the most common,T2-weighted image sequence, but the T2-weighted image signal is not uniform due to the uneven distribution of epithelial tissue and mucus-like tissue. The tumor margins are clear and low signal foci are seen in each sequence, which is also consistent with old hemorrhage around the pathology and is a more characteristic manifestation of pleomorphic adenoma. CT enhancement scans are mildly heterogeneous with progressive enhancement, and this enhancement is due to the fact that pleomorphic adenoma is composed of glandular epithelial cells and myoepithelial cells, sometimes in the form of adenoid structures, which are sparsely vascularized and rich in mucus-like and cartilage-like mesenchyme, and the arteries on enhancement scans the contrast agent that enters the tumor at the early stage is less, but due to the slow elimination of contrast agent, the contrast agent stays in the tumor for a longer time. Differential diagnosis of tongue occupancy imaging: squamous cell carcinoma of the tongue: often occurs in middle-aged and elderly people, preferably at the edge of the tongue, with unclear borders, strong aggressiveness, and deep infiltration, obvious inhomogeneous enhancement, most early lymph node metastasis can be detected; lymphoma: MRI signal is uniform, with mild to moderate uniform enhancement, multiple enlarged lymph nodes can be seen in other areas; adenoid cystic carcinoma: more pieces in middle-aged and elderly people, preferably at the root of the tongue, imaging Soft tissue mass, equal or slightly hypointense, multiple cystic hypointense foci forming sieve-like changes, without pseudo-envelope, and uneven enhancement. The final diagnosis depends on the pathological findings.The most commonly used imaging methods for tongue pleomorphic adenoma are CT and MRI. CT can detect the adjacent bony changes and surrounding enlarged lymph nodes in time, while MRI can better define the scope of the tumor and the internal components of the lesion. Most pleomorphic adenomas have abundant mucus stroma and high signal in Currently, the most common treatment for pleomorphic adenoma of the tongue is surgical excision, but the manner and extent of excision depends on individual circumstances, such as age, lesion size, location, and general condition of the patient. Surgical approaches include transoral, transcervical, midline transglottic, transpharyngeal, and lateral pharyngeal dissection, with care needed to protect the hypoglossal and lingual nerves, and complete transoral endoscopic excision of the mass in the patient in this article. Recurrence of this disease is uncommon and may be due to partial resection or multifocal origin of the tumorWe report a rare case of pleomorphic adenoma of the tongue. Although pleomorphic adenomas can occur in minor salivary glands, tongue pleomorphic adenoma is quite rare and the number of reported cases is limited. When imaging reveals an encapsulated soft tissue density occupancy in the tongue, especially at the tongue root, with limited nuclear magnetic diffusion, and uneven progressive enhancement without surrounding enlarged lymph nodes, the possibility of a pleomorphic adenoma of the tongue needs to be considered. Adequate excision of the diseased tissue under direct microscopic surgery is curable in most cases.Investigation: Yuanzi Liang, Dong Bai, Wenting Liu.Supervision: Yuanzi Liang, Dong Bai.Writing – original draft: Yuanzi Liang, Dong Bai.Writing – review & editing: Zhiqun Wang.


Adrenal ganglioneuromas are mostly asymptomatic, although they may manifest with compressive local effects. We present a 27-year-old man with no medical history who was referred to the surgical oncology clinic due to the incidental finding of a left adrenal mass. The initial computed tomography (CT) abdomen revealed a large mass causing displacement of adjacent organs. A CT-guided biopsy was inconclusive, and further evaluation with an NM endo-adrenal (MIBG) medullary scan pointed to a possible diagnosis of pheochromocytoma. Laboratory tests showed normal levels of urinary metanephrine and normetanephrine. The patient's history revealed chronic abdominal pain, with no symptoms of hypertension, headache, palpitations, or sweating. Subsequently, the patient underwent a left adrenalectomy without complications. This case underscores the importance of a comprehensive approach in managing adrenal masses, particularly when dealing with non-specific symptoms, emphasizing the importance of timely diagnosis and appropriate treatment. Adrenal ganglioneuroma (AGN), a benign tumor originating from the autonomous sympathetic nervous system, can be found at various sites in proximity to autonomic ganglia, including the adrenals, retroperitoneum, mediastinum/thorax, and cervical area , 2. It iHistory and clinical examinationA 27-year-old male with no known medical history was referred to the surgical oncology clinic for a left adrenal mass. He weighed 76 kg and measured 176 cm (body mass index = 21.63). The general examination, including assessments of blood pressure, respiratory rate, pulse, and temperature, yielded normal results. Furthermore, the blood parameters and the blood composition exhibited normal values. A computed tomography (CT) abdomen performed in a primary hospital revealed the presence of a left adrenal mass. A CT-guided biopsy was subsequently performed, and the results showed a spindle cell neoplasm versus gastrointestinal stromal tumor (GIST)  and normetanephrine (1.3 Umol/day. Mcg/24h) within normal limits. The abdominal CT abdomen on 9/4/2018 revealed a large mass in the left upper abdominal quadrant, causing an anterior and superior displacement of the spleen, an anterior displacement of the pancreas and stomach, and an inferior displacement of the left kidney. The mass measures approximately 15.9 x 11.8 x 13.5 cm. The left adrenal gland was not visible, and the mass appeared to be separate from the spleen, pancreas, and left kidney. Internal vascular structures were evident in the arterial phase, with an average density of 44 HU in the Porto venous phase. An incidental note revealed a double inferior vena cava (IVC) with the left renal vein draining into the left IVC. There was a suspicion of a small thrombus within the left renal vein (4/56).On April 25, 2018, an NM endo-adrenal (MIBG) medullary scan was performed, involving the injection of approximately 60 MBq of 131I-MIBG and iodine overload using Lugol 5%® solution for seven days. Whole body planar images and spot views of the chest were obtained 24 hours after injection, along with SPECT/CT of the abdomen. The scan revealed a focal area of increased tracer uptake in the left upper abdomen, corresponding to a large hypodense lesion in the left upper quadrant with elevated tracer activity. Physiological activity was observed in various regions and no other abnormal focal tracer activity was observed. The findings were consistent with an MIBG-avid lesion, indicative of an adrenergic neuroectodermal tumor, likely pheochromocytoma  and later moved to the ward. Following a smooth recovery, the patient was discharged in good condition, with no complaints, and scheduled for regular follow-up appointments. The histopathology report revealed a diagnosis of GN Figure .PrognosisSubsequent CT scans of the abdomen and pelvis conducted on February 12, 2023 showed no evidence of local recurrence or distant metastasis, providing a positive outlook for the patient's health Figure .Adrenal gangliogliomas generally exhibit a slow growth pattern and often remain asymptomatic. However, our case stands out as it involves a massive AGN in a male patient who presented nonspecific flank pain. Interestingly, the initial CT did not diagnose the adrenal mass. This highlights the importance of a thorough evaluation in patients with persistent flank pain. Our case presented a relatively large tumor, measuring 15.9 cm in diameter. It should be noted that the largest reported ganglioneuroma to date measured 19 cm in size [The differential diagnosis for the observed adrenal mass includes several possibilities: pheochromocytoma, adrenocortical carcinoma, and metastatic adrenal mass are potential considerations. In addition, other potential diagnoses include adrenal myelolipoma, ganglioneuroma, and neuroblastoma. AGN and neuroblastoma are also part of this category. The distinguishing ganglioneuroma from these two tumor types can be achieved by the presence of mature sympathetic ganglion cells. Generally, AGNs are nonfunctioning tumors, but in some cases, they may be associated with pheochromocytoma and secrete catecholamines and their metabolites. There have been rare suggestions in the literature that AGNs can also secrete cortisol and androgen . In our It has been suggested that adrenal masses smaller than 3 cm have a very low probability of being functional, while those larger than 3 cm are more likely to be functional. Therefore, the endocrine evaluation should be considered for large adrenal masses. Additionally, when an adrenal mass is discovered, 75% of cases are due to metastases from other organs . The priThe MRI and CT views of AGNs can resemble those of other adrenal tumors. Consequently, based solely on imaging techniques, distinguishing ganglioneuroma from adrenocortical carcinoma and pheochromocytoma is challenging. In cases of adrenal incidentalomas, the urine should be monitored for catecholamines and fractionated metanephrine for 24 hours prior to surgery. Elevated levels of metanephrine and/or catecholamine indicate the presence of pheochromocytoma with a sensitivity and specificity of 91% and 98%, respectively . The finThe differentiation of AGNs from other adrenal tumors through imaging techniques, such as MRI and CT, can be challenging. AGNs are distinct from neuroblastomas and are characterized by the presence of mature sympathetic ganglion cells. When dealing with adrenal masses, an endocrine evaluation is essential for masses larger than 3 x 3 x 3 cm, which are more likely to be functional.


It consists of an ectopic pregnancy in which the fetus dies but cannot be reabsorbed by the mother's body, which then coats it in a calcium-rich substance. We present the case of a 77-year-old woman with an incidental diagnosis of a lithopedion, which had been retained in her left pelvis for presumably 40 years.Lithopedion ( Abdominal ectopic pregnancy, defined as implantation of the fertilized ovum in the peritoneal cavity, excluding tubal, ovarian or intraligamentary implantations, is an uncommon type of extrauterine pregnancy. It has an estimated incidence of 1 per 10,000 to 25,000 live births and leads to high maternal and fetal mortality.An extrauterine pregnancy that has calcified over time is known as lithopedion.The Lithopaedion of Sens, which describes a female lithopedion retained for 28 years, discovered during the necropsy of a 68-year-old woman.In the medical literature, there are ∼ 300 reported cases of lithopedion.KuchenmeisterThe duration of lithopedion retention has been described to be between 4 and 60 years. For lithopedion development, the fetus has to remain alive for more than 12 weeks. Additionally, the ectopic pregnancy has to escape medical detection, and the fetus has to remain in aseptic conditions and in a favorable environment for calcification.Computed tomography (CT), magnetic resonance imaging and barium enema have been described to be performed based on the patient's symptoms and are useful to plan the surgical approach. The treatment of these patients should be individualized, considering maternal age, presentation and symptoms. Main complications include intestinal obstruction, pelvic abscess, cephalopelvic disproportion in future pregnancies, extrusion of fetal parts through the abdominal wall, rectum and vagina; fistula formation and tubal infertility.We present the case of a 77-year-old patient with an abdominal lithopedion suspected to be 40 years old, incidentally discovered.A 77-year-old female patient from Tumaco, in the Pacific coast of Colombia, presented with 8 days of generalized abdominal pain associated with symptoms of absent peristalsis. She referred 4 pregnancies, of which she had had 3 normal vaginal deliveries and 1 miscarriage (40 years prior), which was recognized by the patient as her last pregnancy. Additionally, she mentioned a family history of colon cancer. Upon admission to the emergency department, she was hemodynamically stable, with no signs of peritoneal irritation but a positive ascitic wave. There were no palpable masses, and symptomatic treatment was initiated. Blood tests were requested, which were not suggestive of intrabdominal infection. Plain abdominal X-rays did not show any significant finding; abdominal ultrasound documented a narrow hepatic angle and thickness in the right colon mucosa. Given that imaging findings were not conclusive, a contrasted abdominal CT was performed, revealing thickening of the ascending colon walls, signs of ileocolic intussusception and heterogeneous calcifications in the lower left pelvis compatible with a mummified fetus . After tLithopedion is a rare entity with a variable clinical course. It may be asymptomatic for many years or, less frequently, it may present with persistent or recurrent abdominal pain, chronic constipation, intestinal obstruction or obstructive uropathy.With the advances in antenatal diagnostic techniques of different fetal conditions, lithopedion is much less frequent. However, in neglected regions with difficult access to basic health services, as in the case presented, the timely identification of infrequent antenatal conditions might be difficult.In this case, a lithopedion suspected to be 40 years old was found by means of a contrasted abdominal CT scan. In case it is not possible to correctly measure the length of the long bones, which is usually presented as anthropometric data, BPD is accepted as the most reliable measurement. In this case, it corresponded to a gestational age of at least 18 weeks.


The formation of an intradural extramedullary arachnoid cyst is a rare complication of spinal anesthesia. We present a case of a 34-year-old female patient who developed neurological symptoms including a bilateral reduction in sensation and strength in the lower limbs following a C-section under spinal anesthesia. MRI of the thoracic spine revealed a lesion at the level of T11/T12 and the upper limit of the L1 vertebral body, which was pushing the cord to the side, and a diagnosis of the intradural extramedullary arachnoid cyst was established. The prognosis for this condition is good and surgical excision leads to resolution of the symptoms. Proper and prompt diagnosis is crucial to rule out other differentials and prevent permanent neurological damage in these patients. Lower back pain is a common complaint among adults and can result from various underlying conditions . One sucArachnoid cysts are commonly encountered cystic lesions within the central nervous system, which are increasingly identified through advanced neuroimaging modalities. These lesions are considered to be incidental findings and are thought to arise from congenital malformations of the arachnoid membrane . ArachnoSpinal anesthesia is a commonly used technique for a variety of surgical procedures. While generally considered safe, it is not without risks. One rare complication that has been reported in the literature is the formation of intradural extramedullary arachnoid cysts following spinal anesthesia. These cysts can cause a range of symptoms, including lower back pain, radiculopathy, and myelopathy . The patThe patient was a 34-year-old female with no significant medical history before her pregnancy. She had had an uneventful pregnancy and undergone a C-section six months ago under spinal anesthesia for the delivery of her first child. The C-section procedure had been reportedly successful, and there had been no immediate postoperative complications.The patient presented to the clinic with a complaint of persistent lower back pain for the past six months. She described the pain as a dull, aching sensation in the lower back, which occasionally radiated to both legs. Along with the pain, she reported experiencing numbness in both lower limbs. The patient expressed concern about the gradual worsening of her symptoms over time and the limited relief obtained from over-the-counter pain medications. During the physical examination, the patient's vital signs were within normal limits. Her general appearance was unremarkable, and there were no signs of distress. The patient demonstrated reduced sensations in bilateral lower limbs below the knee level. She denied any urinary or fecal incontinence. She did not report any difficulties in initiating or stopping urine flow.An MRI scan of the lumbosacral spine and dorsolumbar junction was performed. The MRI images revealed an intradural, extramedullary cystic lesion opposite T11/T12 and the upper limit of the L1 vertebral body in the thoracic spine. The lesion appeared hyperintense on T2 and hypointense on T1, and it was expanding the thoracic canal, pushing the cord to the side , which can occur after iatrogenic events, trauma, and subarachnoid hemorrhage, are difficult to treat because they are often large, ventrally located, and may contain arteriovenous malformations .Despite the availability of various surgical techniques, there is currently no consensus on the optimal surgical management approach . In mostPost-spinal anesthesia intradural extramedullary arachnoid cyst formation is a rare but potentially serious complication of spinal anesthesia. MRI is the diagnostic tool of choice for the evaluation of arachnoid cysts, and surgical excision is the treatment of choice. The prognosis for patients with intradural extramedullary arachnoid cysts is generally good if the cyst is excised promptly. Physicians should be aware of this potential complication of spinal anesthesia and consider it in the differential diagnosis of patients with neurological symptoms following spinal anesthesia.To minimize the risk of intradural extramedullary arachnoid cyst formation following spinal anesthesia, anesthesiologists should prioritize maintaining a sterile environment through strict aseptic techniques. Careful selection of the appropriate needle size and minimizing unnecessary manipulation of the needle within the subarachnoid space is crucial to reduce the likelihood of dural injury, which may contribute to the development of arachnoid cysts. By diligently implementing these preventive measures, anesthesiologists can significantly enhance patient safety during spinal anesthesia procedures and reduce the risk of this rare complication.


Intracranial epidermoid cysts are benign lesions and are rarely seen in clinical practice. Owing to similarities in imaging findings to those of common cystic lesions, the preoperative diagnosis is rendered challenging. Here, we present a case report of an epidermoid cyst at the right oculomotor nerve, which was initially misdiagnosed as a common cyst. A 14-year-old female child was admitted to our department due to a previous magnetic resonance imaging scan of a cystic lesion on the right side of the saddle that was suspected to be an oculomotor nerve cyst. In our department, this patient underwent a complete surgical resection of the tumor, and the pathology results revealed an epidermoid cyst. This is the first study that reported an epidermoid cyst at the right oculomotor nerve entering the orbit, mimicking a common cyst in imaging. We hope that this study would allow clinicians to consider this type of lesion as a differential diagnosis. Moreover, we suggest that specific diffusion-weighted imaging scan should be performed to aid in the diagnosis. Intracranial epidermoid cysts are exceedingly rare and account for approximately 0.2%–1.8% of all intracranial tumors  and can A 14-year-old female child was admitted to our hospital with complaints of sudden onset of dizziness, headache, visual deficit in the right eye, nausea, and vomiting for nearly 5 months. The patient’s past medical history was unremarkable. She underwent head magnetic resonance imaging (MRI) scan at a local hospital, which revealed a well-defined hypointense lesion at the right side of the saddle on T1-weighted images and a small cystic and homogeneous hyperintense lesion on T2-weighted sequences, measuring approximately 1.0 cm × 1.2 cm (^9/L (3.5–9.5 × 10^9/L), lymphocyte at 9.7% (20%–50%), and eosinophil at 0.0% (0.4%–8.0%). Moreover, the plasma adrenocorticotropic hormone was decreased at 2.39 ng/L (5.0–78 ng/L), and the sex hormone test revealed a decreased testosterone level with <0.03 ng/ml (0.07–0.78 ng/ml). The liver function tests were within the normal range. Considering the imaging features and the clinical manifestation, a primary diagnosis of a small cyst in the right oculomotor nerve root sheath or arachnoid cyst was established.Thereafter, she was referred to our department due to an equivocal imaging diagnosis. Physical examination showed that the diameter of the right pupil was approximately 5 mm, and the direct and indirect light reflex was unappreciated. However, the diameter of the left pupil was approximately 3 mm, which was within the normal range and was sensitive to light reflexes. The laboratory blood tests showed the following: neutrophil at 86.1% (40%–75%), white blood cell count at 12.8 × 10As the patient already underwent MRI and CT imaging at the local hospital, she therefore did not undergo another imaging examination at our hospital. Consequently, she was then scheduled for tumor resection on the right side of the saddle. During craniotomy, we found that the tumor was located on the right oculomotor nerve entering the orbit, which was characterized as cystic with a smooth surface and clear and transparent sac, approximately 1 cm × 1 cm in size  of MRI can reflect the movement of water molecules in tissues and is often used to distinguish benign and malignant lesions in clinical practice. Notably, DWI can be effective in differentiating epidermoid cysts from arachnoid cysts, which shows the relative restriction of the diffusion of the epidermoid cysts as a characteristic feature, while arachnoid cysts show isointensity to cerebrospinal fluid on all magnetic resonance sequences without diffusion restriction , 11. HowTotal resection of the epidermoid cysts by craniotomy is still the ultimate goal of management ; howeverIn conclusion, this is the first case report of epidermoid cysts located at the right oculomotor nerve entering the orbit and misdiagnosed as a common cyst. We hope that this case will aid clinicians in arriving at a clinical differential diagnosis; we also suggest that DWI scanning should be performed to help with the equivocal diagnosis. Due to its low occurrence and the lack of comprehensive assessment of this kind of lesion, more relevant evidence and case reports are needed to further elucidate this disease entity.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Chengdu Third People’s Hospital. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.YH contributed to the conception and design of the study, as well as the writing. SZ revised the manuscript. All authors contributed to the article and approved the submitted version.


Testicular neoplasms, or testicular cancer, are not typically seen in the emergency department (ED) since their presentation involves a painless hard mass that emerges slowly over time. Uncommon presentation of testicular neoplasm to the ED with acute onset of scrotal pain may present challenges as an incomplete physical examination without supplemental imaging and laboratory workup may overlook the diagnosis of testicular neoplasm. As a result, a delay in proper treatment may occur. Early recognition of testicular neoplasm can decrease morbidity and mortality and improve overall patient survival. Here, we present a case of a 32-year-old male who presented in the ED with an acute onset of testicular pain localized on the posterior right side of the scrotum. Despite the unusual presentation, a complete physical examination, including a complete genitourinary system exam, was performed. During the physical examination, a high index of suspicion for testicular neoplasm was present. Necessary imaging and laboratory workup were ordered. Based on the findings, testicular neoplasm was highly suspected. Thus, surgical intervention was pursued to remove the suspicious mass and pathology revealed a mixed germ cell tumor. Further imaging and laboratory workup showed metastasis into other organ systems, and medical management was chosen to treat the metastatic neoplasm systemically. Testicular tumors are relatively rare, accounting for 1-2% of cancer among men in the United States (US), with a persistent increase in incidence over the past 10 years and doubled over the past 40 years in most countries worldwide. However, the mortality rate has declined across the board owing to advancements in chemotherapy. Testicular tumor is the most common solid malignant tumor in young men aged 15-35 years in the US [Testicular tumors are classified into two groups according to their pathology: (1) germ cell tumors (GCTs) and (2) non-GCTs. GCTs originate from the germinal epithelium. Non-GCTs originate from the gonadal stroma. Tumors originating from germ cells comprise most of the testicular tumors, approximately 95% of them. GCTs are further categorized into two categories: (1) seminomatous, which comprise about 45%, and (2) non-seminomatous tumors, which may be prevalent among the population either in their pure or combined form .Mixed GCT is a type of testicular tumor with two or more GCT types within a single mass. Mixed GCTs account for one-third of all testicular GCTs . TesticuThe etiology of testicular tumors is multifactorial, including genetic and environmental risk factors. Based on a case-control study in the Czech Republic, a multivariate analysis of risk factors for testicular cancer in hospitals showed multivariate-adjusted OR for all testicular germ cell cancer: atrophic testis 5.9), family history of prostate cancer (4.8), cryptorchidism (3.8), and in univariate analyses (OR) cryptorchidism with delayed orchidopexy after five years old (5.7) [.9, familThe U.S. Preventive Services Task Force, National Cancer Institute, and American Academy of Family Physicians recommend against routine screening for testicular cancer in asymptomatic adolescents and adults due to its low prevalence, limited accuracy of screening tests, and no evidence of incremental benefit of screening.Testicular cancer is curable even when metastasized. The overall five-year survival rate is 97% with effective treatment .A 32-year-old male presented to the ED for an acute onset of a painful swelling localized on the posterior side of the right scrotum. The patient was sexually active, a former one-half pack per day smoker of five years, and reported being hit with a cardboard box on the scrotum a few weeks ago. The patient described an intermittent history of unilateral swelling and painful sensations emanating from the right posterior scrotum with accompanying dysuria. He admitted to recent changes in urinary frequency with normal urine flow upon voiding but denied any history of hematuria. Furthermore, the patient denied a recent onset of fever, weight loss, and general fatigue. An initial impression of acute epididymitis was made. Upon performing a physical examination, a unilateral, warm, erythematous, firm, right testicular mass was discovered in a normal orientation.An ultrasound was performed, which revealed a 3.1 x 3.4 x 2.6 cm heterogeneous intratesticular mass with a small hydrocele, which was present on the right testicle , embryonal carcinoma (50%), yolk sac tumor (15%), and malignant teratoma (20%) limited to the testes with good risk. There were negative margins showing no lymphovascular invasion. The pathologic stage classification is pT1b, cN1 M1a, and S1.Given the pathological report, post-orchiectomy staging/metastatic workup with CT chest, abdomen, and pelvis scan with and without contrast revealed a large indeterminate lobular, right upper lobe lung cancer, measuring 4.4 cm Figure . There wThe patient had a PET scan, which reported a right upper lobe mass, measuring 3.33 cm x 3.76 cm with a maximum SUV of 7.3, which was consistent with metastatic disease. Additionally, there was a metastatic lesion in the right hemipelvis measuring 1.6 x 1.26 cm with an SUV of 5.1.Blood workup was rechecked, which showed that AFP was elevated at 350.9 U/L, LDH was 111 U/L, and beta-hCG was within normal limits. The patient was referred and seen by the medical oncology team for further management. The patient was started on first-line chemotherapy with bleomycin, etoposide, and cisplatin and scheduled for a PET scan upon completion of treatment.Acute testicular pain is a common presentation in young adults, primarily due to epididymitis and testicular torsion, but rarely due to testicular tumors. In comparison to the common incidence of torsion per year, testicular GCTs are relatively rare, accounting for only 1-2% of cancers among men in the US .The common presentation of testicular tumor is a painless testicular nodule or swelling with a negative transillumination test, unlike our patient who initially presented with testicular pain, which usually leads to diagnostic delay due to uncommon presentation. Diagnostic delay is a very well-recognized phenomenon in the literature with previous studies reporting that up to one-third of testicular tumors were initially misdiagnosed as epididymitis or hydrocele . An examThere are case reports that reported testicular tumors that presented with acute testicular pain; in most of them, the pain is attributed to the tumor causing a torsion due to the mass effect or intratesticular bleeding. Another example of a case in which a testis tumor in an adult, presenting with torsion of the testis, was reported by Seaman et al.  This artIn our case, an ultrasound done for testicular pain revealed a 3.1 x 3.4 x 2.6 cm heterogeneous right intratesticular mass and elevated tumor markers for which our patient underwent radical right orchiectomy with a lateral inguinal approach; the finding is pT1b mixed GCT with seminomatous component (15%), embryonal carcinoma (50%), yolk sac tumor (15%), and malignant teratoma (20%) limited to the testes.A retrospective case note analysis of patients undergoing radical orchiectomy over an 11-year year period in Hull, UK, shows that presentation with pain did not appear to correlate with any particular histological subtype of neoplasm or stage of disease. However, those presenting with GCTs and testicular pain were more likely to suffer disease relapse than those presenting with painless testicular enlargement (1.6% compared to 2.6%) [Scrotal pain is an uncommon presentation of testicular tumors, as presented in our case report. Our recommendation upon reviewing our case would be testicular neoplasm should not be overlooked for a patient presenting to the ED with a sudden onset of pain localized on the posterior scrotum as this could change the management and outcomes. In addition to a complete genitourinary physical exam, physicians should include testicular tumors in their differential diagnosis and obtain imaging with tumor markers, such as AFP, LDH, and beta-HCG earlier in the workup. These steps may help identify testicular tumors early, which could result in better treatment outcomes.