Ectopic Cushing’s syndrome is a severe form of Cushing disease. Treatment usually involves the resection of the adrenocorticotropic hormone producing tumor. In certain cases, bilateral adrenalectomy is carried out as a final resort in treatment. We present a patient who had a lung carcinoid tumor, which was producing adrenocorticotropic hormone and causing ectopic Cushing’s syndrome. Lung wedge resection failed to normalize cortisol level, and he had bilateral adrenalectomy. Ten years later, he had a recurrence of Cushing’s disease due to lymph node metastasis of his carcinoid tumor. An elevated cortisol level, or hypercortisolism, can be due to several conditions that secrete cortisol or adrenocorticotropic hormone (ACTH) in large amounts. Patients with Cushing syndrome (CS) have typical features of hypercortisolism including abdominal striae, round face, fatigue, central obesity, hypertension, myopathy, osteoporosis, lipodystrophy, acne, hirsutism, oligomenorrhea, amenorrhea, and cognitive dysfunction including depression and memory loss .Several etiological forms of CS can be distinguished: the ACTH-independent CS resulting from over-secretion of cortisol in the adrenal gland known as primary CS, the ACTH-dependent CS resulting from overproduction of ACTH from pituitary gland known as Cushing disease, and finally, the ACTH-dependent CS resulting from the overproduction of ACTH outside the pituitary gland, known as Ectopic Cushing Syndrome (ECS) -3. IatroEctopic ACTH hyper-secretion from non-pituitary tumors was reported for the first time in 1928. It accounts for 10-20% of all cases of CS .The first step in diagnosing CS is to confirm the high cortisol level, which is mainly undertaken using three tests: 24-hour urinary cortisol level, midnight salivary cortisol level, and low-dose dexamethasone suppression test. The high-dose dexamethasone suppression test is mainly used to differentiate between the pituitary ACTH-secreting CS and ECS. MRI of the pituitary gland is the first radiological test to be carried out, in order to differentiate between these two entities causing ACTH-dependent cortisol hypersecretion. If MRI is negative, inferior petrosal sinus sampling (IPSS) is recommended by current guidelines .We present herein, a rare challenging case of a 38-year-old male patient presenting with recurrent CS after bilateral adrenalectomy, which was found to be the result of ECS, secondary to carcinoid tumor of the lung.A 38-year-old male was diagnosed with Cushing's syndrome in 2003. He was found to have ectopic ACTH production, secondary to a right lung tumor. He underwent right middle lobe wedge resection in 2004. Pathology revealed a carcinoid tumor; symptoms persisted. Octreotide scan in 2005 showed recurrent lesion in the hilar region. He had a redo right thoracotomy that failed to locate any tumor. He underwent a bilateral adrenalectomy in 2006 and was put on maintenance-dose hydrocortisone. His symptoms were finally under control. He failed to follow up with the endocrinologist.He was submitted to our practice in 2016, and was noted to have easy bruising, flushing, weight gain, and central obesity. His hydrocortisone was titrated down without relief. Workup for recurrence of his Cushing's revealed a 24-hour urine cortisol of 900 mcg . ACTH level was 187 pg/ml . Morning cortisol level post 1 mg dexamethasone suppression was 14.2 mcg/dl .Magnetic resonance imaging of the pituitary did not reveal any tumor. Computed tomography (CT) scan with adrenal protocol showed bilateral adrenal hyperplasia Figure , which wAn octreotide scan with Single Photon Emission Computed Tomography (SPECT) was consistent with right hilar carcinoid tumor Figure .CT chest showed a small right hilar soft tissue density around the bifurcation of the right mainstem bronchus, in line with octreotide scan findings.Ultrasound-guided endobronchial biopsy was consistent with a lymph node harboring a carcinoid tumor. This was found to be unresectable due to its small size. He was treated with octreotide and radiation therapy to right hilum. Treatment was successful, and the patient went into adrenal insufficiency, which was treated with hydrocortisone.CS is associated with high morbidity and mortality . The majTreatment of ECS is aimed at lowering ACTH level and normalizing cortisol level . This isSurgery is the treatment of choice for resectable bronchial carcinoid tumors with good prognosis and survival . CertainPatients who undergo bilateral adrenalectomy as a definitive treatment for ECS, should have long-term follow-up. Bronchial carcinoid tumors should be monitored and managed accordingly after adrenalectomy. Regrowth of remnant adrenal tissue is possible in the presence of long-term ACTH stimulation, and may lead to overt CS again. Treatment of ACTH-producing tumor with radiation therapy, along with octreotide, might be a good option for recurrent disease.


A combination of intestinal malrotation and distal cholangiocarcinoma is considered a rare condition and poses some difficulties in surgical management. We present a case of a patient with asymptomatic nonrotation of the midgut with a concomitant distal cholangiocarcinoma who underwent successful pancreaticoduodenectomy.A 52-year-old Sudanese man presented to our hospital with progressive painless jaundice associated with dark urine, pale stool, and itching for the last 2 months. He had no other complaint or significant previous medical history apart from being an ex-smoker. His clinical examination revealed a palpable gallbladder and scratch mark. His other systems were unremarkable. His blood test results showed a normal complete blood count, elevated total bilirubin (mainly direct bilirubin), elevated alkaline phosphatase, and normal cancer antigen 19-9 and carcinoembryonic antigen. Ultrasound, computed tomography of the abdomen, and magnetic resonance cholangiopancreatography showed a dilated intrahepatic and extrahepatic biliary system down to the distal part, where the lumen was obstructed by a periampullary mass measuring 2.4 by 2.1 cm. The patient’s gallbladder was distended. He had no liver metastases or ascites and few lymph nodes. Inversion of the superior mesenteric artery and superior mesenteric vein but no invasion was seen, and malrotation of the bowel was observed with the large bowel on the left side and the small bowel to the right of the abdomen. Endoscopic retrograde cholangiopancreatography showed a fleshy ampulla that was stented. Laparotomy showed malrotation, with the duodenum straight on the right side of the midline, and Ladd’s band crossed the second portion of the duodenum. The vessels were approached from the lateral side meticulously after kocherization of the duodenum and pancreas, dissection along an extended portion of the superior mesenteric artery to assure preservation of the superior mesenteric artery and branches going to the jejunum, Ladd’s procedure, division of the jejunum 10 cm below the uncinate process of pancreas, and modified pancreaticoduodenectomy were performed, and anastomoses were performed in the standard fashion. The patient had an uneventful postoperative course, started oral feeding after 5 days, and discharged to home on day 10 for regular follow-up. Histopathology confirmed distal cholangiocarcinoma, and the patient was referred for further oncological management.Pancreaticoduodenectomy can be safely performed in patients with intestinal malrotation with some modifications of the standard approach. Meticulous dissection after preoperative identification of vascular anomaly and a lateral approach are of great help to reduce morbidity. Intestinal malrotation occurs during the sixth to tenth weeks of embryological development. It affects the position and peritoneal attachments of the bowel with alteration in vascular and anatomic relationships , 2, and A combination of intestinal malrotation and distal CCA is considered a rare condition and is challenging, especially with regard to surgical management. Although malrotation is conventionally viewed as a pediatric condition, it can be found in adult patients in nearly 10–20% of cases, and despite this congenital development, it rarely presents with gastrointestinal neoplasms , 6.A 52-year-old Sudanese man presented to our outpatient clinic with progressive painless jaundice associated with dark urine, pale stool, and itching for the last 2 months. He had no fever or alteration in the level of consciousness. He had no other complaint and no significant previous medical history apart from being an ex-smoker. His clinical examination revealed deep jaundice and a palpable gallbladder and scratch mark. His other systems were unremarkable. The results of his blood test showed a normal complete blood count, elevated total bilirubin (mainly direct bilirubin), and elevated alkaline phosphatase but normal aspartate transaminase and alanine transaminase, normal cancer antigen 19-9 and carcinoembryonic antigen. Ultrasound, computed tomography of the abdomen Figs.  and 4 shBased on the above data, a decision was made to perform laparotomy and pancreaticoduodenectomy (PD). Laparotomy showed that the small bowel was on the right side and the large bowel was on the left side of the midline, and the cecum and appendix were seen on the left upper quadrant Figs.  and 6. TMalrotation is a congenital intestinal gestational disorder that affects not only the positioning of the midgut but also its vascular supply, and sometimes the ligament of Treitz is in abnormal position or even absent. It is generally a disease of childhood, but it can have significant implications later in adult surgeries as well, and sometimes it can cause recurrent abdominal pain and volvulus –8, but iCCA is a rare malignancy and accounts for 2% of all malignancies. It arises from the malignant growth of the epithelial lining of the bile ducts and can be found all along the biliary tree. It can be classified into subtypes based on location: intrahepatic, perihilar, and distal , with thCCAs are usually identified at advanced stages , and malPD for periampullary tumors remains the standard procedure and can be performed safely with low mortality and morbidity rates . During et al. reported a case of a 69-year-old woman with a 2-cm pancreatic head mass and nonrotation of the intestines in whom an exploratory laparotomy was performed that confirmed the presence of intestinal nonrotation with the small bowel in the right abdomen, absence of a ligament of Treitz, and large bowel all within the left abdomen. Ladd’s bands were present across the second and third portions of the duodenum and were divided [et al. [et al. [To the best of our knowledge, few case reports in the literature mention patients with intestinal malrotation requiring PD. Plackett  [et al.  reported [et al. . Baer et [et al.  studied  [et al. .We conclude that PD can be performed safely in patients with intestinal malrotation, and preoperative understanding of the vascular anatomy, particular attention intraoperatively, and a lateral approach in the dissection will reduce complications. Modifications to the standard approach to PD were needed in our patient.


Soft tissue sarcomas affecting the root of an upper extremity raise the question of limb amputation depending on their location, size, and malignancy. Malignant triton tumors are a rare subtype of neurofibrosarcomas that have been poorly reported in the literature. We report the case of a challenging reconstruction of the upper extremity using a pedicled latissimus dorsal flap.A 25-year-old Occidental man was referred to our sarcoma unit for the management of a large, high-grade malignant peripheral nerve sheath tumor with no regional or distant extension and very fast progression. He was treated first by concomitant neoadjuvant radiotherapy and chemotherapy. Carcinologic excision was performed “en bloc” including the skin, the tumor, and the flexor muscles of our patient’s elbow. Coverage of the skin defect and elbow flexion restoration were achieved by using a homolateral pedicled musculocutaneous latissimus dorsi flap. Histological analysis showed an R0 resection. The reconstruction process recovered a complete bending of his elbow. He is still in remission at 26 months follow-up.A malignant triton tumor is a rare, aggressive, and high-grade sarcoma. It was successfully treated and this case report describes an effective treatment modality. Reconstructive surgery, allowing large, complete tumor removal, is indispensable after neoadjuvant chemotherapy and radiotherapy. Sarcomas are rare malignant tumors associated with a unfavourable prognosis. They can affect all tissues and there are many histological forms. Limbs represent 65% of the locations: 50% at the lower extremity and 15% at the upper extremity –4. MaligWe present the case of a young man with a rare subtype of MPNST with a rhabdo-myo-chondrosarcomatous contingent who was able to keep his affected limb functional because of neoadjuvant radiochemotherapy and large excision surgery with reconstruction in one step.A 25-year-old Occidental man was referred to our sarcoma unit after an inadequate “whoops” surgery excision for a 5.3 cm mass of the biceps brachial muscle of his right dominant upper extremity. A histological analysis revealed a high-grade MPNST sarcoma. He had no significant past medical history. He smoked half a pack of cigarettes a day for 5 years. No case of NF1 had been found in his past family history. A chest computed tomography (CT) scan and positron emission tomography (PET) scan work-up for spread were negative, and a postoperative magnetic resonance imaging (MRI) was performed. The tumor was staged T2N0M0 according to the TNM classification.Our multidisciplinary staff decided to start a neoadjuvant radio-chemotherapy treatment, which was urgent in view of the aggressivity of the tumor, the incomplete initial surgery, and the macroscopic residue shown on the MRI. Our patient initially refused this treatment. He came back 5 months later with a voluminous painful and fast-growing mass affecting the anterolateral surface of his arm with a radial paralysis. The tumor worsened and was evaluated T3bN0M0 at this time. He finally accepted the treatment.Chemotherapy with an anthracycline and ifosfamide, that is Adriamycin (doxorubicin) and Holoxan (ifosfamide), and concomitant radiotherapy were administered. More specifically, four cycles of doxorubicin and ifosfamide, including 3 days of treatment every 21 days, were administered. Regarding radiotherapy, our patient received 50.4 Gray in 28 fractions of 1.8 gray each.The surgical procedure was planned 6 weeks after the last radiotherapy session Fig. . A MRI sThe skin coverage and elbow flexion restoration were performed by a large homolateral pedicled latissimus dorsi (LD) flap with a large vertical skin island (30 × 12 cm). The LD muscle was harvested with its distal insertion fascia, on the iliac crest, in order to create a neotendon. There was no detachment of the LD muscle from his humeral tendon. A subcutaneous tunnel was made under the remaining skin of his arm and the flap could go from the back to his arm. Reconstruction of the flexion of his elbow was done suturing the remaining tendon of the biceps brachial muscle to the LD flap neotendon. The donor site was closed with high tension because of lack of laxity in this young patient.The mass was sent to histology, showing a complete excision of the tumor R0 with a minimum margin of 0.5 mm against the humeral impression including the interposition of the periosteum  or MPNST with heterologous chondrosarcomatous and rhabdomyosarcomatous heterologous contingent. There was 50% necrosis and 25% viable tumor cells indicating a partial therapeutic response to chemotherapy. No postoperative complication was noticed Fig. . Our patPhysiotherapy was started at 6 weeks. At 6 months, he was able to get back to work and physical activity. He recovered a full range of motion of the elbow (video 1). The average active bending of the elbow was 140°. At 2-year follow-up, no recurrence was diagnosed .Additional file 1:Video 1. Postoperative monitoring.We report the case of a young man with a MTT. He had a limb-sparing excision with functional reconstruction and kept a full range of motion. We share this case because triton tumors are very rare and few cases are reported.c-myc oncogene is probably responsible for its aggressive biological behavior [MTT is a rare subtype of MPNST; it is a neurogenic tumor in which the neurological component induces the production of skeletal muscle , 11. Thibehavior , 21. Thebehavior , which cbehavior –25.There are no specific guidelines for the management of MTTs and therefore the guidelines used are those for STSs. International recommendations have been established to manage such tumors, in an attempt to standardize the therapeutic approach to sarcomas and to get better results , 26–28.A consensus appeared: as soon as a sarcoma tumor is suspected, a thorough imaging assessment must be associated with a biopsy to allow preparation of the surgical procedure in the framework of a multidisciplinary consultation. The excision should take off the whole tumor en bloc. The adjuvant treatment may include radiotherapy and chemotherapy after multidisciplinary consultation.Thus, the management of MTTs is that of high-grade sarcomas according to the classification of sarcomas by the National Federation of Cancer Control Centers . The onlOur resection has been classified R0 according to the Union for International Cancer Control classification. There was an area where the nerve was only separated from the tumor by fat, leaving doubt about R1 excision on histological analysis. This risk, anticipated on imaging and identified during the operation, was accepted because in the worst case it would have corresponded to a programmed R1 resection. In fact, the Toronto Margin Context Classification does not find any significant difference in long-term survival between a programmed near-positive margin excision (R1) and a healthy margin excision (R0) .et al. [However, this lack of consistency between and within margin classification systems has been highlighted . We beliet al.  in whichet al. . In factet al. . Chemothet al. , 39. Theet al. –9. Curreet al. . We beliet al. –43. In fet al. .With advances in chemotherapy and surgical techniques, the trend in the treatment of sarcomas continues to progress towards limb conservation . When thA skin paddle combined with a flap of LD muscle is particularly useful in such cases, as presented here, where there is a defect in the soft tissues of the arm. It is a reliable flap, especially in irradiated areas with a high risk of scarring disorders, which allows the safe coverage of a very large cutaneous defect. The result in terms of flexion recovery is obtained immediately, which allows very early rehabilitation . All othMTTs are a rare subtype of high-grade STSs that can affect upper extremities. Reconstructive surgery associated with radiochemotherapy is essential for tumor control, oncologic outcome, and limb function preservation.


Carcinoid tumor is one of the most frequent neuroendocrine tumors, and the majority of which are usually observed in the lungs and gastrointestinal tract. The prevalence of ovarian carcinoids is merely 0.1% in ovarian neoplasms and 1% in carcinoid tumors. We described 2 rare cases in our hospital of primary ovarian carcinoid (POC), causing carcinoid syndrome (CS) of the diarrhea, constipation, and carcinoid heart disease. Besides, we also reviewed related literatures about its origin, variant, clinical manifestation, diagnosis methods, pathological features, treatment strategies and prognosis from 2009 to 2019.Case 1 was a 61-year-old postmenopausal woman and presented with diarrhea, abdominal pain, enlargement, bloating and dizziness. Case 2 was a 49-year-old patient who complained of constipation, abdominal pain, bloating, and headache.Both patients were diagnosed as primary ovarian carcinoid, insular type.Total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), omentectomy, pelvic lymphadenectomy, and appendectomy without chemotherapy were performed in case 1. Cervix resection, right salpingo-oophorectomy, appendectomy, and pelvic lesion resection with chemotherapy was conducted in case 2.Both patients achieved satisfactory treatment effects. The follow-up period was 18 and 17 months in case 1 and case 2, respectively. Case 1 encountered carcinoid heart disease and received percutaneous transluminal coronary angioplasty (PTCA) postoperatively. Case 2 suffered multiple metastases postoperatively. However, after effective treatment, both patients were in good condition during follow-up duration.POC is an extraordinarily rare disease, and commonly with a satisfactory outcome. TAH+BSO with or without postoperative chemotherapy has been considered as an acceptable treatment strategy for POC patients. Most carcinoid tumors usually influence the function of bronchopulmonary and gastrointestinal tract,Noh et al2This case report was approved by the institutional review board of the Second Hospital of Jilin University. Informed written consent was obtained from the patient for the publication of this case report and accompanying images.3We reported 2 cases of POC with different clinical symptoms and reviewed relevant literatures in PubMed, Web of Science Core Collection, Library of Congress and LISTA from 2009 to 2019  to docetaxel . Seven months after surgery, metastases were found in the liver and paraaortic lymph nodes, however, not observed in the spleen. At the last 17-month follow-up visit, the patient felt headache sometimes, constipation occasionally and denied any other discomfort symptoms.6Carcinoid tumor is one of the most prevalent neuroendocrine tumors, and the majority of which are usually observed in gastrointestinal and bronchopulmonary systems, however, with other locations like gynecologic organs relatively rare.[Regarding the origin of OC, currently, it is still unclear. Vora et alConsidering clinical manifestations, most patients are perimenopausal or postmenopausal females aged from 14 to 83 years.It is difficult to make accurate diagnosis of OC preoperatively. Ge et alThe treatment strategy of POC should take its stage, histology type, patient age, and fertility needs into consideration.The prognosis of POC is extraordinarily good in early stage, however, there also remains malignant potential,7POC is an extraordinarily rare disease, and usually with a satisfactory outcome. TAH+BSO with or without postoperative chemotherapy are acceptable treatment choices for primary ovarian carcinoid patients.Conceptualization: Li-Rong Zhai, Manhua Cui.Data curation: Li-Rong Zhai, Dong-Wei Huang.Formal analysis: Xi-Wen Zhang, Tong Yu, Zhen-De Jiang.Funding acquisition: Yan Jia.Investigation: Yan Jia.Methodology: Xi-Wen Zhang, Tong Yu, Zhen-De Jiang, Dong-Wei Huang.Resources: Tong Yu, Zhen-De Jiang, Dong-Wei Huang.Supervision: Yan Jia, Manhua Cui.Visualization: Tong Yu.Writing – original draft: Li-Rong Zhai, Xi-Wen Zhang, Tong Yu.Writing – review & editing: Yan Jia, Manhua Cui.


Perforation of small bowel due to ingested fish bone is rare, the most common site is ileum and occasionally, it can involve the appendix and/or Meckel diverticulum. We report six patients who, developed bowel perforation after fish bone ingestion, four of them found to have rent in the ileum and two through Meckel's diverticulum and presented with abdominal pain and localized peritonitis. All underwent surgical exploration and removal of the fish bone and closure of the small intestine/excision of the diverticulum. Foreign body ingestion should be kept in mind in suspicious cases, and laparoscopy is very important to diagnose such rare cases as they may commonly be missed by imaging. Perforation of the gastrointestinal (GI) tract due to an ingested fish bone (FB) is a rare event occurring in less than 1 percent of patients . It is gWe collected the data of six patients from the Cerner record system of Hamad General Hospital, Doha-Qatar, over the period of 3 years, i.e., from 2016 to 2019. The study involved all the patients with intraoperative fish bone perforating the small bowel. The record included the patient's demographics, presenting symptoms, imaging, and intraoperative findings.All patients had history of pain of 1-4 days duration. All of them had localized right lower quadrant abdominal pain mimicking acute appendicitis. None of the patients reported nausea, vomiting, anorexia, or fever. There was no history of bleeding per rectum or constipation. All of our patients were healthy and young with no past medical or family history. The age ranged from 24-48 (mean 37 yrs.). 9/l to 15 × 109/l and C-reactive protein in the range of 12 to 98 mg except case number 3 who had normal white cell count but high C-reactive protein. All the patients underwent a computed tomography (CT) scan of abdomen with oral and intravenous contrast except cases number five and six.On examination, the patients were hemodynamically stable without signs of sepsis, tachycardia, or hypotension. The abdominal examination revealed tenderness in the right lower quadrant along with rebound in all of the cases. There was no palpable masses. All of them had high white blood cell counts in the range of 9 × 10The CT scan of case number 1 showed normal appendix and some mesenteric lymph nodes but no foreign body. The patient had continuous right abdominal pain which was not relieved with analgesia, so he was taken to the operating room for diagnostic laparoscopy. A fish bone was seen penetrating the wall of the ileum. It was safely dissected out, and the defect was primarily repaired with 3/0 PDS. Retrospectively, the CT scan was discussed with the radiologist, and the foreign body was pointed out to be seen in the image as described in In case number 3, the CT scan did not show foreign body but it showed inflammatory changes in the appendix and adjacent cecal wall. He underwent diagnostic laparoscopy with foreign body removal from the terminal ileum and appendectomy. The perforation was sutured. The histopathology showed normal appendix. Similar to the first case, the foreign body was not reported either, before the CT scan. Figures  and 5.In cases 5 and 6, the clinical picture and abdominal examination was consistent with acute appendicitis. An open procedure by grid iron incision was carried out as the patients were thin and lean. We found the fish bone perforating Meckel's diverticulum in both cases. The fish bone was removed along with the resection of the segment of small bowel with perforated Meckel's diverticulum as the base of both diverticulae were thick and had abnormal consistency especially the case number 6 . The conFish bones, chicken bones, and tooth picks are the most common foreign materials to cause bowel perforation due to their sharp ends , 8. HoweManagement of these patients can fall under two categories: either to perform laparoscopic exploration as we carried out in four of our patients or take them for open surgery by laparotomy or traditional appendectomy incision as we did in two patients who were found to have perforation of Meckel's diverticulum despite that they had all the classic clinical features of acute appendicitis and therefore, no imaging was done. Most of the previously reported cases were managed operatively with the resection of small bowel and anastomosis , 17. TheThis case series stresses the importance of excluding other diagnosis such as foreign body perforation in individuals with abdominal pain. Despite the availability of imaging, unexpected diagnoses can still be missed and are usually made intraoperatively. Early diagnostic laparoscopy plays an important role as it helps intraoperatively to diagnose as well as to decide what surgical corrective intervention is required.


This is a case of a two-year-old boy with a ganglion arising from the sternoclavicular joint. Ganglia are rare in the pediatric population, with less than 2% occurring under the age of 2 years old. Additionally, sternoclavicular joint ganglia are also exceedingly rare. The case illustrates the importance of keeping ganglion within the differential diagnosis for palpable subcutaneous masses, even in young children, especially when they are seen to connect to the joint. A two-year-old boy was referred to Radiology for sonographic examination of a palpable mass overlying the left sternoclavicular joint. The mass was found one month prior to presentation and had been slowly increasing in size. According to the mother, the patient did not complain of any pain or pruritis, and the only symptoms appreciated were intermittent low fevers which began after the mass was noticed. Lack of symptomatology thereby led to the delay in presentation to a healthcare provider. After one month without regression, the patient's parents decided to seek medical care.On physical exam, the mass was noted at the superior aspect of the left sternoclavicular joint. Palpation elicited no pain and demonstrated a mobile, firm, mildly compressible subcentimeter bump. A chest X-ray was performed which demonstrated no lytic or blastic lesions of the sternum, clavicle, or scapula.There were no radiopaque soft tissue densities or ectopic calcifications noted, and the joints themselves were normal in appearance. No masses were visualized in the superior lobes of the lungs. CBC, ESR, LDH, and CRP showed no abnormalities.Ultrasound imaging was performed which demonstrated a 6 × 4 × 4 mm irregular anechoic, thin-walled structure, without internal color Doppler signal, and with increased through transmission consistent with a cyst which demonstrated a narrow neck diving deep into the left sternoclavicular joint . There wGanglia, also referred to as ganglion cysts, are fluid-filled soft tissue swellings that occur most commonly over the dorsal surface of the wrist. These ganglia can occur at any point in life although their incidence is the highest between the second and fourth decades . Cases oGanglia are most often characterized by a communicating pedicle between the lumen of the cyst and the synovium of their source joint . It is tConversely, injection of contrast into the joint space led to anterograde flow of contrast medium into the cystic space . The fluGanglia can be preliminarily diagnosed with physical exam through transillumination of the mass. A ganglion will transilluminate due to its fluid composition in comparison to a solid mass which will not. Ultrasound imaging is the fastest and simplest imaging modality for diagnosis with MRI functioning as a confirmatory method if ultrasound is equivocal. Typical ultrasound findings demonstrate anechoic, cystic architecture with well-defined margins and posterior enhancement due to the fluid-filled nature of the cyst , 6. In aAdditional findings noted by Teefey et al. include the presence of internal reflectors and vascular flow feeding the cystic tissue . The preThe use of MRI is largely reserved for cases of equivocal sonogram findings accompanied by a high degree of clinical suspicion for a ganglion. Findings corroborate those seen on ultrasound with cysts appearing as unilocular or multilocular fluid collections adjacent to the affected joint. On T1 imaging, the cysts will normally demonstrate low signal although the presence of various proteinaceous effusions or bleeding into the cyst may intensify the signal. On T2 imaging, the cysts predictably contain a high-intensity signal due to their high fluid content .In conclusion, ganglia are a relatively common type of soft tissue mass in the adult population, most commonly occurring about the joints of the wrist. Although the imaging characteristics of the ganglion described in this case report are typical, it is particularly rare given the atypical joint involvement and the young age of the patient.


Hepatoid adenocarcinoma (HAC) is an uncommon and aggressive type of adenocarcinoma, typically affecting the middle-aged and elderly. The morphological features of the HAC resemble hepatocellular carcinoma. Presenting symptoms may include upper abdominal pain, hematemesis, back pain, and palpable abdominal mass. HAC has no proven therapy, and the prognosis is extremely poor. Early surgical removal with chemotherapy remains the standard of care. We describe one of the youngest patients in the literature with HAC who presented with acute pancreatitis. The diagnostic workup was confused by diffuse lymphadenopathy and elevated β-human chorionic gonadotropin making lymphoma and germ cell tumor likely possibilities until immunohistochemistry confirmed the diagnosis. Hepatoid adenocarcinoma (HAC) is a rare extrahepatic subset of adenocarcinoma associated with elevated α-fetoprotein (AFP). It is often metastatic at the time of diagnosis and carries a poor prognosis overall. The morphology of HAC closely resembles that of hepatocellular carcinoma (HCC), both of which commonly produce AFP presenting a diagnostic challenge. The diagnosis is usually made by hematoxylin and eosin staining and immunohistochemical (IHC) staining. HAC typically presents in the fourth to sixth decade. Presenting symptoms include upper abdominal pain, hematemesis, back pain, weakness, and palpable abdominal mass. We present one of the youngest cases of HAC reported in the literature involving a 28-year-old man with acute pancreatitis making it a rare presenting symptom.A 28-year-old previously healthy white man of eastern European descent presented with a 2-week history of vomiting, anorexia, and abdominal pain. Physical examination was significant for mild tenderness in the epigastrium and left upper abdomen. Routine laboratory investigations were remarkable for abnormal liver blood tests—aspartate aminotransferase was 150 U/L, alanine aminotransferase was 387 U/L, alkaline phosphatase was 234 U/L, and total bilirubin was 2.5 mg/dL. Lipase was elevated at 1132 U/L and lactate dehydrogenase was 391 mg/dL. Abdominal ultrasound revealed lymphadenopathy posterior to the pancreatic head and dilatation of the proximal extrahepatic bile duct up to 11 mm.Magnetic resonance cholangiopancreatography showed bulky retroperitoneal, periportal, mesenteric, retrocrural, and lower thoracic lymphadenopathy and extrahepatic and intrahepatic biliary ductal dilatation with ill-defined thickening of the gastric antrum Figure . SubsequSurgical excisional biopsy of supraclavicular lymph node was performed for tissue diagnosis. Initial endoscopic retrograde cholangiopancreatography (ERCP), performed for abnormal liver function tests  and the need for biliary decompression, showed nonbleeding cratered gastric ulceration on lesser curvature, duodenal infiltration, and biliary stricture requiring stenting with a plastic stent and obtained the biliary brushing Figure . The pat4 Men are more commonly affected than the women.3 The characteristic features of HAC are hepatoid differentiation of cancer cells, the production of large amounts of AFP, and coexistence of both adenocarcinomatous and hepatocellular differentiation.2 The stomach is most commonly involved by HAC; however, other organs such as ovaries, lungs, urinary bladder, gallbladder, pancreas, uterus, testis, and retroperitoneum have also been reported to be involved.5 Patients with HAC frequently present with liver metastases.6HAC was first reported by Bourreille et al in 1970 after which Ishikura et al proposed the term “HAC of the stomach” because of its morphologic similarity to HCC. HAC constitutes 0.38%–1.6% of all gastric cancers, with an incidence of 0.58–0.83 cases per million inhabitants.7 Imaging might show extensively thickened gastric walls (as in our case) and sometimes a polypoid mass.9 Although most patients with HAC (70%–80%) will have elevated serum AFP levels ranging 1.0 to 700,000 ng/mL, not all HAC produce AFP and almost 46% of patients with HAC do not produce AFP.11 Ectopic β-hCG production is common in epithelial tumors from ovaries, cervix, lung, colon, and mainly the stomach and might suggest an aggressive nature of the tumor.12The differential diagnosis of HAC includes HCC, pancratoblastoma, acinar cell carcinoma, and neuroendocrine tumors. The clinical signs/symptoms and imaging findings are very nonspecific. Hence, the diagnosis is mainly based on the morphologic features and characteristic IHC features, irrespective of the serum AFP levels or tissue AFP staining by IHC.13 At the molecular level, p53 mutation is a common finding.15 Similar to HCC, cancer cells from HAC are immunoreactive with AFP, polyclonal CEA, CK8, and CK18 and produces AFP and β-hCG.6 Not any single IHC stain can differentiate HAC from HCC, but a panel of IHC stains with detailed history and endoscopic and imaging findings are essential for definitive diagnosis of HAC. Typical IHC profile promising in the differential diagnosis of HAC include anti-sal-like protein 4 (SALL-4) glypican-3, α1-AT, α1-antichemotrypsin, CD10, CDX-2, MUC1, and PLUNC.16 Moreover, AE1/AE3, CK18, and CK19 are usually positive among epithelial markers in HAC.5 SALL-4 expression  and the absence of expression of bile salt export pump and multidrug-resistance protein 3—2 transporters specific to hepatocytes—are helpful in distinguishing HAC from HCC.18Morphologically, HAC cells are composed of large eosinophilic or clear cells in a sheet-like or trabecular pattern with sinusoidal vascular channels.19 Successful treatment of HAC has been reported using cisplatin and etoposide.20 In metastatic disease, cisplatin-based chemotherapy appeared to be the most efficient first-line systemic treatment with almost 75% showing clinical response.20 Our patient died due to HAC 16 months after diagnosis. Further investigation is needed to identify the risk factors, supplement the diagnosis, and optimize the management of HAC.The rarity of HAC precludes the establishment of standardized treatment guidelines, and most data guiding the management remain anecdotal. Surgical removal of the tumor, wherever possible, remains the cornerstone of the treatment. However, surgery is not always possible because of the aggressive nature of the tumor and rapid metastasis. Adjuvant chemotherapy has shown to improve survival.Author contributions: R. Chaudhari, K. Murphy, S. Schwartz, and J. Chaudhari wrote the manuscript. F. Nunes and I. Ho approved the final manuscript. R. Chaudhari is the article guarantor.Financial disclosure: None to report.Previous presentation: This case was presented at the International Liver Cancer Association; September 20-22, 2019; Chicago, Illinois.Informed consent was obtained for this case report.


Intrahepatic cholangiocarcinoma masquerading as liver abscess, and presenting with fever, is a very rare situation and should be considered in nonresolving liver abscess. Only few cases were reported in the literature. This entity is characterized by late diagnosis and poor prognosis. Intrahepatic cholangiocarcinoma masquerading as liver abscess, and presenting with fever, is a very rare situation and should be considered in nonresolving liver abscess. Only few cases were reported in the literature. This entity is characterized by late diagnosis and poor prognosis. Here, we report a case of an unusual first presentation of ICC with histological confirmation after an immunohistochemistry study, which was difficult to diagnose because of a radiological aspect mimicking a liver abscess on the enhanced contrast abdominal CT scan.2A 43‐year‐old man with a history of long‐standing alcohol consumption was admitted in our gastroenterology department due to abdominal pain located in the epigastric region with a history of intermittent fever and weight loss but not associated with any chills or night sweats. He denied any drug consumption, vomiting, jaundice, or pruritus. On examination, the temperature was 38°C, the abdomen was tender on palpation of upper quadrants, a 2‐cm tender hepatomegaly, blood pressure was 120/80 mm Hg, and pulse was 85 bpm.3). C‐reactive protein (CRP) level was high (131 mg/L). Other parameters including hemoglobin, platelet count, renal function tests, and serum electrolytes were normal. Serum test for human immunodeficiency virus (HIV) and hepatitis C virus was negative. Hepatitis B markers were positive for HBs antigen; HBc and HBs antibodies were also positive. The HBs antibodies level was about 11 IU/L. Hepatitis B viral load was positive (105 IU/mL).Liver function tests showed serum aspartate aminotransferase (AST) levels about 2 times the upper limit of normal. Gamma‐glutamyl transferase (GGT) and alkaline phosphatase (ALP) levels were, respectively, 2 times and 3 times the upper limit of normal. Alanine aminotransferase (ALT) and total bilirubin levels were normal. A moderate increase of leukocytes was noted . His tumor markers were as follows: alpha‐fetoprotein (AFP) 5833.2 IU/mL, carcinoembryonic antigen (CEA) 1.9 μg/L, and CA 19‐9:5.5 IU/mL.In view of nonamelioration of symptoms and elevated level of AFP, another CT scan was performed and showing an increasing size and number of hypodense liver lesions with peripheral enhancement.Because of ambiguous imaging findings, we performed a needle biopsy of the lesion that revealed large tumor cells with fairly clear limits and low cytoplasmic abundance, prominent nucleoli, arranged in a cord‐like pattern, and abundant fibrous stroma Figure . Immunoh3After hepatocellular carcinoma, cholangiocarcinoma represents the second most common primary hepatic tumor.Intrahepatic cholangiocarcinoma mimicking liver abscess is very rare. There has been no case reported till date from Tunisia. Pyogenic hepatic abscess results from a bacterial infectious process associated with destruction of the hepatic parenchyma and stroma. Escherichia coli is the most commonly isolated microorganism.Surgical resection is the standard treatment for cases of single ICC nodule with no evidence of metastasis.4In conclusion, ICC mimicking liver abscess represents a difficult situation: clinical features, laboratory tests, and radiological findings could be nonspecific. Imaging modalities such as contrast‐enhanced CT scan could also be helpful in certain cases. It should be noted that in patient with liver abscess without a clear etiology, tumoral origin must be suspected. The confirmation remains histological and immunohistochemical in all cases.None.HY: concepts; HH, HY, HK, and AA: design; HY, HH, HK, and SH: definition of intellectual content; HY and HH: literature search; HY, HH, HK, and NM: manuscript preparation; HY: manuscript editing; HY, HH, NM, HK, SB, and SH: manuscript review; HH: guarantor.Yes.


Taenia solium causes cysticercosis that commonly involves the central nervous system. Other sites of manifestation are eye, gastrointestinal system, skeletal muscles and subcutaneous tissues. Isolated muscular involvement is rare with only a handful of cases reported in the literature. We present this case of an isolated symtomatic hand swelling due to Myocysticercosis which pose diagnostic dilemma. This should be considered in differential diagnosis in our developing nation and especially in endemic region. High resolution ultrasound of the hand (thenar region) helped in the diagnosis and is often diagnostic like in our case. The treatment of choice of an isolated symptomatic lesion without involvement of central nervous system is surgical excision which we did followed by short course of antiheminthic and anti-inflammatory medication for two weeks.Larval form of  High resolution ultra sound is a reliable diagnostic measure for the isolated intramuscular and subcutaneous lesion. It is safe, non-ionising, cost-effective and widely-available imaging tool for diagnosis of Myocysticercosis.Cysticercus cellulosae is the larval form of Taenia solium which causes cysticercosis.A 36 years old female from Gandaki Province , Nepal presented to our Orthopaedic outpatient department with progressive swelling over the palmar aspect of left hand over thenar eminence for 2 months duration. Intially it was pain free but since two weeks she developed pain which was progressive mild to moderate in intensity and dull aching nature and continous type. There was no history of fever, trauma, seizure and fits, sensory or motor deficit in affected hand.On examination there was a 2×3 cm swelling over the thenar eminence of her left hand with normal overlying skin. Swelling was soft, mild tenderness with normal surface temperature. The surface was smooth, margins were ill defined and fluid thrill was absent. The swelling was fixed to underlying structures but overlying skin was free .Sonography of left hand was suggestive of a well defined cyst measuring 1.5×2.5×1.0 cm within thenar muscle with intracystic echogenic contents and tiny cysts within with adjacent inflammatory changes suggesting feature of Myocysticercosis. No vascularity noted on colour Doppler. On changing position of left hand this focus (nidus) showed mobility. On the basis of above findings diagnosis of Myocysticercosis was made. There were no neurological features and ophthalmologic examination  was normal. It was an isolated symptomatic lesion so we excised the lesion in total .This was also later confirmed by histopathological evaluation as shown . Due con4 Many factors like geographical location, ethnic group, religion, socioeconomic status, education, food habits, hygiene and sanitation and standard of living are associated with the disease burden.5 In the context of Nepal, the majority of population belonging to Rai, Limbu, Magar and Sarkies ethnic groups, taenia infestation is high. It is due to rearing of pigs, high consumption of pork, poor sanitary measures and poor socio-economic conditions.6 Taenia solium, is becoming an increasing problem in Nepal with high prevalences of porcine cysticercosis and human taeniasis/cysticercosis detected in epidemiological studies undertaken in different parts of the country. Pig farming and marketing have increased dramatically in the country in recent years due to increased consumer demand for pork as the country's caste system has become relaxed. Postmortem surveys of pigs at slaughter establishments in Kathmandu and Dharan municipality showed 14%  and Magnetic Resonance Imaging (MRI). Diagnosis of the lesion in our case was made by High resolution Ultrasound. It is a safe, non-ionising, non-invasive, cost-effective and widely available modality of investigation by which definitive diagnosis can be ascertained confidently. The salient diagnostic feature is that of the cysticercus itself, which appears as an oval or round well-defined cystic lesion with an eccentric echogenic scolex in it.8Taenia solium infestation is a preventable disease in the community. Prevention of community outbreak can be done by good personal hygiene, proper hand washing and sanitation. Raw vegetables and salads should be washed properly with safe water before consumption and proper fecal disposal is essential. Deworming in regular period and adequate cooking of pork meat is requirement for killing intestinal worms and cysticercosis larva. Treatment depends on numerous factors like the site, number of cysts and presence of symptoms. Isolated myocysticercosis usually requires no treatment unless it is painful which requires surgical excision.


A benign duodenal stricture is a well-documented condition of humans that has not been characterized in dogs. In this case report, the clinical, radiographic, ultrasonographic, endoscopic, surgical, and histopathologic findings of a single benign duodenal stricture in a Golden Retriever are reported. Definitive diagnosis was made possible with the utilization of esophagogastroduodenoscopy (EGD). Surgical correction of the stricture, paired with dietary therapy that utilized a highly digestible diet, resolved the clinical signs in the case reported. Several inciting causes were identified as possible drivers of stricture formation, including nonsteroidal anti-inflammatory drug (NSAID) administration, mucosal ulceration, traumatic injury, or inflammatory intestinal disease. A benign duodenal stricture should be considered an infrequent cause of intermittent, chronic gastrointestinal signs that may have a favorable outcome via surgical correction and dietary management. Duodenal strictures are rare in veterinary medicine and have not previously been reported in the canine species. They are most often identified as a sequela to another disease process or insult. The majority of the published cases have been attributed to ongoing inflammatory bowel disease, mucosal ulceration, NSAID usage, neoplastic malignancies, and pancreatitis –8. TheseAn 8.5 yr old, 30.7 kg male neutered Golden Retriever presented to Purdue University Veterinary Teaching Hospital (PUVTH), for referral evaluation of a 5-year history of intermittent vomiting, regurgitation, and loose stool. Review of primary care veterinarian medical records revealed that control of intermittent gastrointestinal signs was achieved with empirical metronidazole (16.2 mg/kg PO q 12) and metoclopramide (0.65 mg/kg PO q 12). The patient had also chronically received deracoxib (2.44 mg/kg PO q 24), sucralfate (1 gram PO q 12), tramadol (1.62 mg/kg PO q 12), and methocarbamol (16.2 mg/kg PO q 8) for pain management related to osteoarthritis and intervertebral disc disease. Six weeks prior to admission to PUVTH, the referring veterinarian discontinued the deracoxib when gastrointestinal clinical signs began to worsen. The patient otherwise had no past pertinent medical history, was up-to-date on core vaccinations, and received regular preventative healthcare which included an annual fecal analysis. The patient had a regular travel history to central Canada.At presentation, the owner reported increasing lethargy and weight loss (5 kg) occurring over a six-week duration. The patient's appetite increased following a change from dry to canned food; however, no correlated changes in gastrointestinal clinical signs were reported. The patient had a complete blood count, biochemical profile, thyroid level, thoracic and abdominal radiographs, and a barium upper gastrointestinal tract contrast study prior to referral. No abnormalities were noted on laboratory analyses, thoracic radiographs, or abdominal radiographs. Barium contrast study revealed residual fluid retained within the stomach and suspected pyloric thickening.Upon intake at PUVTH, physical examination was unremarkable. Initial diagnostic workup included the following: a complete blood count, blood chemistry, urinalysis, resting cortisol, cobalamin, folate, trypsin-like immunoreactivity (TLI), abdominal radiographs, and ultrasound. No abnormalities were identified with these first-line diagnostics. Thoracic radiographs revealed fluid opacity in the caudal esophagus consistent with either esophagitis, esophageal reflux, or less likely a mass lesion.Due to the persistence of gastrointestinal clinical signs and the lack of a definitive diagnosis on initial evaluation, the patient underwent endoscopic esophagogastroduodenoscopy (EGD). Static photographs are provided from performed EGD . EndoscoFollowing EGD, a contrast (barium) upper gastrointestinal study was performed using static radiographs and fluoroscopy. Fluoroscopic evaluation revealed the barium passing through the pyloric canal, into the proximal duodenum, prior to identifying a stenotic segment of the proximal duodenum proximal to the cranial flexure. The barium pooled proximally to the stenotic area of the duodenum showing a “beak sign”. The stenotic areas and “beak-sign” are well visualized on the provided radiographs as well Figures .Proximal gastrointestinal ultrasound following administration of the barium allowed for visualization of a focal narrowing of the lumen of the proximal duodenum aborad to the pylorus and orad to the cranial duodenal flexure. Orad to the narrowing, the focal widening of the proximal duodenum could be visualized. Summary of imaging findings were consistent with a proximal duodenal stricture.Based on tentative diagnosis of the benign duodenal stricture, the dog underwent an abdominal exploratory surgery, stricture correction, and full-thickness gastrointestinal biopsies. A proximal duodenal stricture was confirmed at the time of surgery with a large amount of omental and mesenteric adhesions present. The biopsy and enterotomy taken at the stricture site were closed in a transverse fashion  to relieve the stricture and attempt to confirm a benign cause of stricture formation. Biopsies from the jejunum and ileum were also collected. Analysis of the biopsies revealed transmural granulomatous and lymphoplasmacytic enteritis at the site of stricture with focal mucosal ulceration and hyperplasia. Additional peritonitis was noted and attributed to a likely partial rupture at the stricture site. These findings were consistent with a benign, proximal duodenal stricture. The jejunal and ileal biopsy findings were unremarkable.The dog recovered uneventfully from surgery and at the two-week postoperative recheck was free of clinical signs. Initially, it was planned that after the full-thickness biopsies of the stricture were obtained, the dog would return for a more aggressive surgical correction  if indicated. However, based on the observed clinical response, it was deemed unnecessary. Resolution of clinical signs was achieved for 18 months postoperatively with dietary therapy utilizing a highly digestible diet (Hill's Prescription Diet i/d Digestive Care); at which time, the dog was euthanized following acute collapse, hemoabdomen, and a suspected hemangiosarcoma based on masses identified by abdominal ultrasound (liver and spleen) and cytology (liver).This report describes a case of a benign duodenal stricture in a dog. In humans and other veterinary species, duodenal strictures appear to be an uncommon phenomenon and often a sequela to other disease processes. A medical literature search reveals most cases of duodenal strictures have been reported in association with inflammatory bowel disease, mucosal ulceration, NSAID usage, neoplastic malignancies, and pancreatitis –8. TheseIn humans, although uncommon, duodenal strictures are a complication reported secondary to Crohn's disease . In thosAlternatively, the prevalence of chronic enteropathies in the canine population is significant and there are no available reports demonstrating the phenomenon of strictures developing secondary to inflammation as seen in people. In people, it is typically very chronic and severe cases that develop gastrointestinal strictures related to IBD. The dog reported here had milder, intermittent signs, not matching the expected severity which would cause a stricture in other species. Furthermore, the biopsies, which were consistent with a chronic enteropathy, were mostly showing a mild inflammatory reaction and only noted in those taken at the site of stricture. All additional biopsies along the remaining length of the intestinal tract were not indicative of significant widespread lymphoplasmacytic infiltrative inflammation. All biopsy reports were characterized based on the attending pathologist's interpretation of the tissues but were not evaluated using WSAVA histopathology guidelines. This lack of standardization makes assessment of the degree of inflammation challenging in these samples. Therefore, the biopsies are more likely simply indicative of focal lymphoplasmacytic intestinal inflammation at the site of stricture and very unlikely to be related to a focal form of a chronic enteropathy such as inflammatory bowel disease. Based on this information, the clinical response seen following surgery is most likely indicative of removing the stricture and its role causing a partial obstruction resulting in the clinical signs.Another potential explanation for the duodenal stricture in the dog reported here is the prolonged history of an upper-end maintenance dose (2.44 mg/kg) of the NSAID deracoxib. When deracoxib was given in a randomized, placebo-controlled trial to healthy dogs at a 1.5 mg/kg dose, the gastric mucosa was not significantly different than dogs receiving a placebo; however, medications were only administered for 28 days and the impact of chronic therapy is unknown . AdditioThe mechanism of ulceration associated with NSAID use is multifactorial. The common result of these mechanisms is damage and injury to the gastrointestinal mucosa . The bioWithin other veterinary species, duodenal strictures have been reported, with the highest frequency occurring in foals. In these veterinary reports, the clinical presentation and suspected mechanisms revolve around gastrointestinal mucosal ulceration prior to stricture formation. In foals, specifically, concerns related to NSAID involvement has prompted the recommendation that treatment and prophylaxis be centered around mitigating overuse of NSAIDs and coadministration of antiulcer medication . Within Helicobacter pylori, tuberculosis), caustic injury, traumatic injuries, and other diseases  are conditions that may possibly cause duodenal stricture [In humans, many other causes of gastrointestinal tract ulceration (peptic ulcer disease), infection  for three months, although most had reemergence of clinical signs at six- and 12-month follow-up [Ultimately, this patient was managed with dietary therapy and surgical resection; however, duodenal strictures in people are also managed with balloon dilation and stenting which may have been viable alternative approaches in this case . In thisollow-up . Again, ollow-up .Another interesting aspect of the case reported here is that many initial imaging modalities utilized in the primary care diagnostics workup were unable to diagnose the duodenal stricture as the reason for worsening gastrointestinal tract signs. Advanced imaging techniques utilized initially were unable to precisely detect the lesion in this case. Ultimately, it was only with the additional step of EGD that it was possible to diagnose a stricture in this patient and later on modification to advanced imaging (barium study with fluoroscopy). While the authors recognize EGD is not a feasible or warranted diagnostic modality for all gastrointestinal workups, this case underscores the important role endoscopy can play when advanced imaging studies remain inconclusive in a patient not responding to medical management and dietary therapy.In summary, this report details a benign duodenal stricture in a dog presenting with gastrointestinal clinical signs. Surgical correction of the stricture and maintenance therapy utilizing a highly digestible diet completely resolved the gastrointestinal signs in this dog. While many drivers of stricture formation have been identified in the human and veterinary medical literature, pinning down a specific mechanism in this case is not clear. The most likely contributor might have been chronic deracoxib NSAID administration; however, an intestinal inflammatory process, idiopathic local mucosal ulceration, or a past pancreatitis event are also considerations.


A retrorectal epidermoid cyst is an uncommon congenital lesion that arises from the remnants of the embryonic tissues. This type of cyst is difficult to diagnose before surgery. In this study, we report a rare case of a giant retrorectal epidermoid cyst in a 30-year-old woman. Initially, the condition was diagnosed as a perianal abscess and treated with incision and drainage. Since the abscess recurred, a pelvic magnetic resonance imaging was ordered, which revealed an 8.2 cm perianal cyst with appearance not compatible with an abscess. Postsurgical histologic analysis confirmed a retrorectal epidermoid cyst. Postoperative course was uneventful, and the woman was discharged on postoperative day 3. She was doing well at 4 months of follow-up. This report suggests that retrorectal cysts should be considered in cases of recurrent perianal swellings/abscesses. Epidermoid cyst is one of the slow-growing benign subcutaneous lesions that may be observed throughout the body ; howeverA 30-year-old woman, gravida 2 para 2 with a recurrent perianal abscess, was referred to the outpatient surgical department in our hospital for further evaluation and treatment. The woman had a history of perianal pain and swelling that were treated as a perianal abscess. She had undergone incision and drainage of the swelling 4 weeks before her visit to our hospital. She complained of increasing perineal swelling and discomfort over the last 6 months and denied symptoms of fever, constipation, perianal discharges, or other gastrointestinal symptoms. Her menstrual cycle was regular without abnormal uterine bleeding. The rest of the systemic review and her medical history and family history were unremarkable. Physical examination revealed normal vital signs; no signs of fever were observed. Abdominal examination was unremarkable. Pelvic examination revealed a large protruding mass at the natal cleft of the perineal area with no signs of inflammation that were appreciated like redness, warmth, or tenderness. The mass was of cystic consistency and the size was around 6 cm. The mass occupied the area between the anus and coccyx. The digital rectal exam revealed a round nontender soft mass in the posterior wall with a regular shape. Pervaginal examination was unremarkable. Laboratory investigation showed normal counts of total and deferential white cells and normal level of hemoglobin.Magnetic resonance imaging (MRI) of the pelvis showed a 4.2 × 8.2 × 6 cm cystic lesion posterior to the anorectal canal and indenting the levator ani posteriorly. The lesion had a very thin rim of peripheral enhancement and minimal fat stranding posteriorly toward the natal cleft. It exhibited heterogeneity on a T2-weighted MRI image in homogenous fluid signals without restricted diffusion, solid component, or communication with the anorectal canal. Other pelvic organs were unremarkable . Based oHence, based on these clinical and imaging findings, a decision to operate was made. The surgical excision of the mass was performed posteriorly through a 5 cm midline perineal incision. The woman was placed in the prone jackknife position, revealing the swelling more prominently . During Majority of the retrorectal lesions originate as developmental masses. The lesions can be classified into congenital, inflammatory, neurogenic, osseous, and miscellaneous lesions . RetroreEpidermoid cysts are very slow-growing masses; consequently, many of them are asymptomatic . The earThe feasibility of the laparoscopic approach is controversial, especially in solid tumors . A previA retrorectal epidermoid cyst is a rare entity, which should be considered when encountering a patient with recurrent perianal swellings/abscesses. The current case report contributes to the current medical literature by providing evidence on the importance of MRI in the diagnosis of an epidermoid cyst. We highly recommend using MRI as an initial diagnostic modality for early detection and differentiation of the epidermoid cyst from other pelvic lesions. Findings of the current study may significantly help clinicians achieve better treatment outcomes in treating retrorectal epidermoid cyst.


Hearing aid impression material composed of vinylpolysiloxane is an ideal bolus material which may be used to aid in delivery of adjuvant radiation to complex surgical defects of the head and neck. It is affordable, easily accessed, and efficient. Hearing aid impression material composed of vinylpolysiloxane is an ideal bolus material which may be used to aid in delivery of adjuvant radiation to complex surgical defects of the head and neck. It is affordable, easily accessed, and efficient. The goal of sparing critical structures, while still attempting to deliver therapeutic doses to target tissues, may be limited by tumor location, patient anatomy, and postsurgical defects. Treatment of superficial lesions in the head and neck is a particular obstacle because of the inherent contour irregularities which impact the ability to deliver a consistent dose of radiation. A bolus is a tissue equivalent material used to overcome irregular surfaces and provide a buildup of dose to the surface receiving the radiation therapy. Custom‐shaped boluses have successfully been applied in the treatment of postmastectomy, paraspinal muscle, and head and neck defects.We present a case of a 71‐year‐old man with advanced squamous cell carcinoma of the maxilla with extension to the orbit and overlying skin who underwent composite craniofacial resection and orbital exenteration without reconstruction. A bolus material was needed to help deliver adjuvant radiation therapy to this large, irregular surgical defect of the midface and orbital apex. Vinylpolysiloxane, a silicone elastomer traditionally used to craft ear impressions for hearing aids, was adapted to the defect and served as a consistent prosthetic throughout the patient's 6‐week course of radiation. Here, we describe a novel method of fabricating a bolus for head and neck therapy that is both cost‐effective and efficient.2A 71‐year‐old man presented with a slowly enlarging, cutaneous lesion of his right cheek of several years' duration. A CT scan demonstrated a 7.5 cm mass of the right maxilla with infiltration into the soft tissue of the right cheek, extension into the masticator space, temporalis muscle, and the extraconal fat of the right orbit with destruction of the inferior and medial orbital wall. A biopsy of the lesion was consistent with squamous cell carcinoma. He underwent composite craniofacial resection with maxillectomy and orbital exenteration and was found to have tumor extension well into the infratemporal fossa, pterygopalatine fossa, and lateral wall of the nasopharynx. A major reconstructive effort was not undertaken so as to avoid covering residual tumor and to allow for expeditious healing in anticipation of likely chemoradiation. His final pathology was consistent with squamous cell carcinoma measuring 4.6 × 3.5 × 2.6 cm in size and invading into the orbit, buccal mucosa, skin of the cheek, and skeletal muscle. There was neither perineural nor lymphovascular invasion noted. Negative margins were obtained except on the deep aspect of the resection which had detached fragments of tumor, therefore limiting evaluation. There were no involved lymph nodes. His final pathologic staging based on the American Joint Committee on Cancer (AJCC) 7th edition staging system was T4aN0M0.The patient had an uneventful recovery and met with radiation oncology and hematology oncology for discussions regarding adjuvant therapy. Following extensive discussions at our multidisciplinary tumor board, and with the patient, the decision was made to undergo active surveillance. Unfortunately, three months postoperatively, the patient had evidence of early local recurrence. He underwent treatment with four cycles of cisplatin/docetaxel with a good clinical and radiographic response. Although the site of his previous index tumor and surgical defect presented unique challenges, multidisciplinary recommendations were to proceed with adjuvant consolidative radiotherapy.® from Westone , polylactic acid (PLA), thermoplastic polyurethane (TPU), and polyvinyl acetate.Alternatively, we describe an accessible solution for delivering adjuvant radiation to a complex defect of the head and neck using vinylpolysiloxane as bolus material. For years, vinylpolysiloxane has been used as an impression material in the field of prosthodontics, restorative dentistry, and audiology. The material is packaged separately in two components, a base and an accelerator, which can then be mixed together in equal parts. Once mixed together, there are two minutes of working time and 6 minutes of setting time. From a patient perspective, the material is nontoxic, odorless, and tasteless which is advantageous when applied to mucous membranes of the upper aerodigestive tract. Polyvinyl siloxanes are an ideal impression material as they exhibit long‐term dimensional stability and are not susceptible to changes in humidity nor undergo further chemical reactions once set. Most importantly, they are accurate at recording fine surface details and have the best elastic recovery properties compared with other impression materials.It is critical to have a bolus material that conforms accurately to the field of interest as increases in air gaps lead to reduction in the dose delivered to the treatment target.The homogeneity and moldable features of vinylpolysiloxane make it an ideal bolus material for delivering therapy to superficial areas of irregular contour in the head and neck region. The cost, simplicity, and efficiency of production using this material offer a distinct advantage over alternative substances or boluses requiring 3D printing. To our knowledge, this case report is the first application of vinylpolysiloxane as a bolus material and represents a unique solution to delivering adjuvant radiation to complex head and neck defects.The authors declare that there is no conflict of interest regarding the publication of this article.All authors were in involved in the writing, revisions, and final review of the manuscript.


Intradural disc herniation (IDH) is a rare complication which comprises 0.27% of all herniated intervertebral discs. We are reporting a case of lumbar intradural disc herniation at the L4-L5 levels highlighting challenges in establishing clinical diagnosis and surgical approach involving a transdural microsurgery approach.A 38-year-old gentleman was presented with left radicular low back pain without motoric and autonomic involvement admitted to our neurosurgical service. Spine MRI showed an intradural, extra-axial spinal mass.Lumbar IDH is a rare pathology thus often initially diagnosed as other more common conditions. In our case, the IDH diagnosis was confirmed during surgery as the radiological examination results mimic intradural extra-axial tumor. During surgery, a hard irregular white mass was found shortly after dural incision. Histopathological results showed chondrocytes, fibrotic and necrotic appearances consistent with the diagnosis of disc herniation. Postoperatively, the patient showed improvement and pain alleviation.We observed the beak sign which is one of the important features of IDH imaging. Surgery-wise, the challenge of dissecting the anterolateral part of the duramater from the annulus fibrosus of the intervertebral disc should be noted by the performing surgeon. •Intradural disc herniation (IDH) is a rare complication and comprises 0.27% of all herniated disc.•Radiological findings mimicking for intradural extra-axial spine tumors.•Challenge in dissecting the duramater of the anterolateral segments is a common problem.•A median or paramedian dural incision accompanied by a microsurgical technique.•Better visibility of hernia after a dural incision, avoiding damage to the nervous rootlets. It comprises 0.27% of all herniated discs. The first case was published by Dandy in 1942, and is commonly located at the lumbar region (92%) . Hereby,2A 38 year-old Asian gentleman was referred to our neurosurgical service due to disabling low back pain radiating down the left lower limb for two years. He denied tingling and burning sensation, weakness, nor bladder and bowel problems. In the medical history, there was no co-existing conditions were found. Clinical examination corresponded with L4-L5 roots involvement with positive SLR test. Past medical, surgical, and familial history were insignificant. The T2-weighted sagittal MRI showed a hypointense heterogenous mass at the left L4-L5 level with a beak-like lesion compressing the spinal cord on the axial section , Fig. 2.He was scheduled for hemilaminectomy of the left L4 and L5 levels. The surgery was performed by Z.M., M.T.A and Y.Z who were attending neurosurgeons. Surgery was performed in prone, anti-lordotic position under general anesthesia from the left side. Intra-operatively, a hard, irregular white mass was discovered shortly after dural incision and was easily removed without firm adhesion (2 cm × 1.5 cm x 1 cm) , Fig. 4.3Intradural disc herniation is a rare complication which comprises 0.27% of all herniated discs. It is commonly found at the lumbar region, especially the L4-L5 levels. It poses a diagnostic challenge as the radiological findings could mimic intradural and extra-axial spinal tumors such as schwannoma. Therefore, it is important to include IDH as a differential diagnosis for intradural and extra-axial mass. Generally, the predisposing factor is the dense adhesion between the dural sac and posterior longitudinal ligament . Such tyIDH could be difficult to diagnose, however several MRI signs have been described to aid establishing preoperative diagnosis. Following the gadolinum administration, the most common IDH findings is ring enhancement appearance due to peripheral neovascularization and chronic granulation. However, ring enhancement appearance could be witnessed in other spinal tumors such as schwannoma. In T2-weighted sequence, a sharp beak-like appearance or hawk beak shape is an indicator for IDH which is shown in our case. Preoperative crumb disc is another common sign for IDH, which is caused by an irregularly bordered mass. Based on the anatomical attribute, IDH is classified into two types. The type A in which disc herniation into protrudes into the dural sac is often located in the lower cervical and lumbar region. The type B is disc herniation through the dural sheath of nerve roots, thus could only be diagnosed intra-operative. The main treatment of IDH is surgical removal of the herniated disc material. Meanwhile, the duramater and nerve roots require careful attention during surgical exploration.Challenges in exploring the duramater of the anterolateral segments is a common problem. In previous reports, thick adhesions were present between the disc space and the dura mater at the time of surgery while the dural sac tended to be rough, tense and immobile ,11,12. T4Lumbar IDH is a rare pathology thus often initially diagnosed as other more common conditions. In our case, the IDH diagnosis was confirmed during surgery as the radiological examination results mimic intradural extra-axial tumor. We observed the beak sign which is one of the important features of IDH imaging. Surgery-wise, the challenge of dissecting the anterolateral part of the duramater from the annulus fibrosus of the intervertebral disc should be noted by the performing surgeon.Ethical approval exempted by our institution.No funding1.Muhamad Thohar Arifin: Performed surgery, conception of report, data collection, data analysis, manuscript writing, revision and submission.2.Novita Ikbar K: data collection, data analysis, manuscript writing and manuscript revision.3.Surya P Briliantika: data collection, data analysis, manuscript writing and manuscript revision.4.Yuriz Bakhtiar: performed surgery, conception of report, data collection, data analysis, manuscript writing and manuscript revision5.Jacob Bunyamin: data analysis, manuscript writing and manuscript revision.6.Zainal Muttaqin: performed surgery, conception of report, data collection, data analysis, manuscript writing and manuscript revisionCase report not registered.Zainal Muttaqin, Profeesor Of Neurosurgery Department Faculty Of Medicine Diponegoro University.Written informed consent was obtained from the patient. Information within the paper has been sufficiently anonymised not to cause harm to the patient or family.Not commissioned, externally peer reviewed.No conflicts of interest.


Myxoid liposarcoma tends to be a relatively good prognosis. Follow‐up is recommended once a year from the 5th year after surgery.A 48‐year‐old man had a massive retroperitoneal tumor, measuring approximately 20 cm. Resection of a huge myxoid liposarcoma had been performed on his back 10 years ago and the weight of the mass was 14 kg. The tumor was resected from the right kidney and its weight was 3.6 kg. Pathological examination showed myxoid liposarcoma and therefore, the tumor was diagnosed as recurrent. But after the resection, no recurrence or metastasis was observed.To our knowledge, the case presents the first report where both initial and recurrent tumors were massive and the time for recurrence was 10 years. Therefore, a follow‐up of myxoid liposarcoma might have to be done cautiously throughout the patient's life. CTcomputed tomographyLPliposarcomaMLSmyxoid liposarcomaMRImagnetic resonance imagingThe term of LP follow‐up is recommended once a year after 5 years. In our case, no recurrence was found for 7 years after the first surgery, but the tumor relapsed after 10 years. Imaging follow‐up for LP had to be carried out throughout the patient's life.Soft tissue sarcomas are unusual tumors and include 1.0–1.5% of all malignancies. The most frequent histological types are LP, leiomyosarcoma, and malignant fibrous histiocytoma. LP is characterized by malignancy of adipose tissue, accounts for 10–16% of all sarcomas, and is reported to be caused by unknown genetic alterations. It most commonly affects people in the age group of 50–70 years and is reported to have a slight male predominance.The first‐line treatment for LP without metastasis is to radically resect the tumor. The 5‐year disease‐specific survival rate depends on following the pathological subtypes: 90–100% in well‐differentiated and/or dedifferentiated LP, 88% in myxoid/round cell LP, and 56% in pleomorphic LP.Here, we report the case of a patient with recurrent huge MLS in the retroperitoneum 10 years after the initial operation.A 48‐year‐old man presented at our hospital with bleeding from a huge mass on his back in October 2005 Fig. . Blood tWe report a case of large recurrent MLS over 10 years. MLS usually occurs in the deep‐seated soft tissues of the extremities with the most common occurring sites being the thigh (13–60%) and retroperitoneum (10–36%) and rarely the back.Complete surgical resection with negative microscopic margins is the only curative treatment for MLS. LP tends to form a pseudo‐capsule with an indistinct border.MLS primarily metastasizes to extrapulmonary sites including bones such as spines and other soft tissues such as retroperitoneum, in contrast to the other subtypes of LP which mainly metastasize to the lung.The European Society for Medical Oncology recommends a follow‐up every 3–4 months for the first 2–3 years, then twice a year for up to 5 years, and annually thereafter for patients with intermediate or high‐grade LP. For patients with low‐grade LP, a follow‐up every 4–6 months for 3–5 years and then annually is recommended. Standard follow‐up practice should include the following: imaging (CT/MRI) with a focus on local recurrence and routine chest X‐ray to exclude pulmonary metastases or CT to detect metastases.To our knowledge, this is the first case that the size of both initial and recurrent tumors was massive, 14 kg and 3.6 kg, respectively, and time for recurrence was 10 years.The authors declare no conflict of interest.


Adenocarcinoma is the most common primary pancreatic neoplasm type, followed by secondary pancreatic lymphoma and primary pancreatic lymphoma (PPL). PPL is associated with peripancreatic lymphadenopathy and usually presents as a homogenous mass with extrapancreatic invasion into surrounding structures. However, localized involvement of the distal pancreas is uncommon, and diffuse involvement of the pancreas is even rarer. Herein, we present the case of a 53-year-old woman with PPL of the uncinate process with biliary obstruction mimicking pancreatic adenocarcinoma, successfully diagnosed nonoperatively. Abdominal computed tomography showed an ill-defined uncinate process mass, hypodense with mild enhancement (3.9 × 3.4 × 3.5 cm), infiltrating the second and third parts of the duodenum. Biopsy revealed NHL with no evidence of adenocarcinoma. PPL was diagnosed. She received chemotherapy with a CHOP  protocol with rituximab, which she tolerated with no clinical or radiological evidence of recurrence at 1-year follow-up. Primary pancreatic lymphoma (PPL) accounts for approximately 0.5% of pancreatic neoplasms and <2% of lymphomas , 2 and cA 53-year-old woman presented to the emergency department complaining of intermittent sharp epigastric pain radiating to the back, associated with nausea, scleral and cutaneous icterus, itching, dark urine, pale stool, and early satiety. She had an unremarkable medical and family history. Systemic examination revealed no other symptoms.Upon examination, the patient looked cachectic, conscious, and alert but dehydrated and deeply jaundiced. Her vital signs were within normal limits; she was afebrile. Abdominal examination revealed no scars or prominent veins; the abdomen was soft and lax with mild tenderness at the epigastrium, with no palpable mass, organomegaly, or lymphadenopathy. Normal bowel sounds were audible, with intact hernial orifices. A digital rectal exam showed unremarkable results. Laboratory tests revealed direct hyperbilirubinemia  and anemThe clinical impression was obstructive jaundice requiring further investigation. She was admitted and prescribed intravenous fluid therapy.Chest X-ray showed unremarkable results; abdominal ultrasonography (US) revealed distended gallbladder with no stones or signs of acute cholecystitis (Courvoisier's sign). However, a tortuous cystic duct and dilatation of the intrahepatic and extrahepatic biliary ducts and the common bile duct (CBD) 13 mm) , performed for suspected obstructive jaundice due to malignancy, showed findings similar to US findings and an ill-defined uncinate process mass that was hypodense with mild enhancement (3.9 × 3.4 × 3.5 cm). The mass had infiltrated the second and third parts of the duodenum with no signs of duodenal obstruction and mass effect on the inferior vena cava (IVC). There was extensive lymphadenopathy  with no metastatic deposits in the liver .Chest CT showed no metastatic lung deposits or mediastinal lymphadenopathy. Tumor markers were within the normal range . Magneti4okasule@kfmc.med.sa) waived the need for ethical approval on December 05, 2019 (IRB log number: 19-613E).Duodenoscopy showed mucosal erythema on stenotic and granular major papilla in the periampullary area; thus, a biopsy was performed . EndoscoThe typical age of PPL patients is 35–75 years (mean: 55 years), with a strong male predilection  . PPL prePPL is most commonly located at the head of the pancreas, though it can be found in the body or tail. The tumor size ranges from 4 to 17 cm on radiological scans .Imaging plays a crucial role in pancreatic mass diagnosis . CT is cThere are two different morphological patterns of PPL: localized, well-circumscribed tumors and diffuse tumors infiltrating or replacing most of the pancreas , 10.The radiological criteria for differentiating PPL from more common pancreatic adenocarcinomas are a bulky localized tumor in the pancreatic head, no significant dilatation of the pancreatic duct, enlarged lymph nodes below the renal vein level, invasive tumor growth, and retroperitoneal or upper abdominal organ infiltration . All of However, the definitive diagnosis of PPL is impossible from imaging alone, and pathologic examination  is imperative . ImmunohThe serum CA 19-9 level in PPL patients is usually normal or sometimes slightly elevated in the case of biliary obstruction . In our The management and prognosis of PPL depend on the tumor stage and grade. The most common subtype of PPL is the diffuse large B-cell subtype, and long-term remission has been obtained with chemotherapy (CHOP); in the case of CD20-positive diffuse large B-cell lymphoma, the addition of rituximab increases the remission rate , 15, 16.PPL patients treated with chemotherapy alone have a better prognosis than do pancreatic adenocarcinoma patients. PPL patients have a 5-year survival rate of 26%–66% , 15. ThePPL should be considered in the differential diagnosis of pancreatic head masses, especially when there is extensive lymphadenopathy localized to the peripancreatic region, and should be ruled out with transluminal biopsy to avoid unnecessary surgical intervention. However, if adenocarcinoma cannot be safely ruled out, open biopsy with frozen section should be considered before performing pancreaticoduodenectomy (PD), as most cases are diagnosed post-PD. Furthermore, the more common variant (secondary pancreatic lymphoma) should be ruled out before diagnosing PPL.


A 12-year-old boy being followed up for amblyopia presented to our hospital with visual disturbance in the left eye. The patient’s best corrected visual acuity on Snellen chart was 1.0 in the right eye and 0.3 in the left eye. Increased horizontal cup-to-disc ratio was detected on dilated fundus examination. Retinal nerve fiber layer measurement showed diffuse nerve fiber loss and visual field test showed bitemporal hemianopsia. Magnetic resonance imaging revealed a lesion that filled and widened the sella and suprasellar cistern and compressed the optic chiasm. The patient was operated with transcranial approach. The pathologic examination revealed craniopharyngioma. Amblyopia is poor best corrected visual acuity (BCVA) in one or both eyes due to low vision or abnormal binocular interaction without any detectable structural defect in the eye or visual pathways. Amblyopic vision loss can be corrected if treated at an early age. The most important factors in the development of amblyopia are the severity, timing of onset, and duration of visual impairment. Blurred vision is much more likely to develop into amblyopia in young children. Although variable, the risk of amblyopia is generally higher in the first 2-3 years of life, and the risk is reported to continue until the age of 12.1 Blurred vision caused by uncorrected refractive error appears to be the main factor that prevents the development of central vision in anisometropic amblyopia. Anisometropia is generally defined as a difference in spherical/cylindrical refractive errors of 1.5-2 diopters (D) or more and is more common in hyperopic eyes than in myopia.2Anisometropia and strabismus are among the most common causes of amblyopia.3 It shows a bimodal age distribution, with patients usually diagnosed between the ages of 5 and 14 or after the age of 50.4 Although these tumors are slow-growing and benign, they can cause serious symptoms due to their proximity to important anatomical structures such as the pituitary gland, hypothalamus, and optic chiasm. Clinical manifestations may include endocrine disorders such as hypothyroidism, impotence, and amenorrhea; visual symptoms such as optic atrophy, visual field defect, and decreased vision; and symptoms related to increased intracranial pressure, such as headache, nausea, and vomiting.6 The most frequent ocular signs are bitemporal hemianopsia and optic atrophy. Diagnosis of craniopharyngioma is based on neurological, visual, and endocrine symptoms and the appearance of a calcific solid/cystic lesion on radiologic imaging. The diagnosis is confirmed by pathologic examination.Craniopharyngioma is a benign tumor that develops from the remnant of Rathke’s pouch and is located in the sellar/parasellar region.In this article, we present a patient under follow-up for amblyopia who was diagnosed as having craniopharyngioma after further examination in our clinic.A 12-year-old boy with no disease, history of trauma, or systemic symptoms presented to our hospital with low vision in his left eye. It was learned that the patient was under follow-up at another center for left amblyopia and had been treated with right eye closure for a period of time. His family history included no consanguineous marriage or illnesses that cause vision impairment. Written informed consent was obtained from the patient for the examination and tests. Autorefractometer measurements showed a spherical refraction error of -0.25 D in the right eye and -1.5 D in the left eye. His Snellen BCVA was 1.0 in the right eye and 0.3 in the left eye. Intraocular pressure was measured as 15 mmHg in both eyes. No afferent pupillary defect was detected. Color vision in both eyes was evaluated as normal using the Ishihara color vision test. Anterior segment examination findings were normal. On dilated fundus examination, both posterior poles appeared normal, whereas bilateral optic disc pallor and increased horizontal cup-to-disc (C/D) ratio were observed . Retinal7 Excluding organic pathologies that can lead to optic neuropathy, such as intracranial masses, before making a diagnosis of amblyopia is critical in the follow-up and treatment approach. In the pediatric population, the most common intracranial masses include astrocytoma, ependymoma, and medullablastoma. In addition, considering that in many studies the most common symptom of craniopharyngioma was blurred vision and subsequent decrease in visual acuity, craniopharyngioma seems to be a pathology that should be considered in the differential diagnosis of intracranial masses.9 Especially in patients with vision loss accompanied by symptoms such as headache, nausea/vomiting, growth retardation, delay in the development of secondary sex characteristics, polydipsia, and polyuria, it is important to perform a systemic examination and to consider an organic pathology as the cause of low vision. If there are no accompanying systemic symptoms, as in our patient, a careful fundus examination and the use of auxiliary imaging methods when necessary can provide important information about the cause of low vision. Although craniopharyngioma is a benign tumor, diagnosis and treatment are important due to its close proximity to important anatomical structures. These tumors are most commonly located in the sellar/parasellar region.10 The tumor typically places pressure on the optic chiasm from the anterior and posterior, generally resulting in bitemporal hemianopsia visual field defect. In some cases, homonymous hemianopsia can also be seen.11 Pituitary tumor, suprasellar aneurysm, third ventricular glioma, and tuberculum sellae meningioma are among the pathologies that cause bitemporal hemianopsia visual field defect and should be included in the differential diagnosis of craniopharyngioma.Amblyopia is unilateral or bilateral low best corrected visual acuity (BCVA) caused by poor vision or abnormal binocular interaction in the absence of a structural defect in the eye or visual pathways.13 Initial symptoms are visual in more than half of patients, and about 41-48% of patients may have some amount of visual gain after surgery.14 Poor prognostic factors in postoperative visual gain are severe vision loss and prechiasmatic tumor location.15 Although the transsphenoidal surgical approach is associated with better visual prognosis, it is only effective in intrasellar tumors. In addition, suprasellar positioning is seen in a larger proportion of craniopharyngioma patients.The surgical treatment of craniopharyngioma involves resection of the tumor via a transcranial or transsphenoidal approach while preserving the optic and hypothalamic structures. Total resection or subtotal resection with or without radiotherapy is performed as appropriate according to parameters such as tumor size, growth pattern, and hypothalamus involvement.Undergoing surgery via transcranial approach and having very low preoperative visual acuity seem to be poor prognostic factors in our case. Our patient showed no changes in visual field or BCVA in postoperative evaluations, demonstrating the importance of early diagnosis of intracranial masses causing optic neuropathy in terms of postoperative visual recovery. We believe that early diagnosis may have been possible in our patient with the detection of temporal optic disc pallor and increased C/D ratio, but the diagnosis was delayed because these changes were not detected in the early period. Furthermore, it should not be forgotten that patients diagnosed with intracranial mass may exhibit some amount of anisometropic amblyopia, as in the present case.In conclusion, because diagnosis occurs later in children, visual morbidity is greater, and visual acuity generally remains low after treatment at more advanced stages, early diagnosis of tumors is important to minimize visual sequelae. The most important steps for early diagnosis are a detailed history, careful fundus examination, and visual field testing when necessary. In children with suspicious examination findings and inadequate cooperation, we recommend using additional tests before a diagnosis of amblyopia is made.