Chondrosarcoma (CS) was the third most common primary bone malignancy. Frequently chondrosarcoma was occurring in long bones or in the pelvis. Their localization in the rib is rare.A 45-year-old male presented to our institution with a lump in the left breast. A physical exam revealed a large, fixed 10 cm mass occupied the entire right breast. Clinical presentation had supposed initially as a sarcoma of the breast. Preoperative unenhanced CT imaging showed well-defined round heterogeneous soft tissue density with hypo dense areas.A core-needle biopsy was taken, which was suggestive of chondrosarcoma grade II. The whole tumor was excised en-bloc along with 4th, 5th and 6th ribs. Reconstruction of the defect was undertaken with polypropylene plate and ipsilateral pedicle latissimus dorsi muscle flap was placed on the alloplastic mesh. The patient had an uneventful postoperative course and was discharged on the 10th postoperative day. No adjuvant treatment was administrated.En-bloc resection with appropriate margins and thanks to the evolution of reconstructive surgical techniques used to ensure preservation of respiratory mechanics. All this procedure represents the cornerstone and the only curative option. ChondroFrequently chondrosarcoma was occurring in long bones or in the pelvis. Their localization in the rib is rare ,4.Early diagnosis and surgical treatment with widely negative microscopic margins is considered as the gold standard therapy and offers the best chance for cure.In this article, we present a patient with thoracic chondrosarcoma centered in the 4; 5 anterior thoracic rib. We also detail our operative technique in our institute and review current literature on this topic.This work have been made following the SCARE Guidelines .2A 45-year-old male with no known history of cancer presented to our institution with a lump in the left breast that had been gradually increasing for 14 months.A physical exam revealed a large, fixed 10 cm mass occupied the entire right breast -A. The mPreoperative unenhanced CT imaging showed well-defined round heterogeneous soft tissue density with hypo dense areas -B, necroA core-needle biopsy was taken, which was suggestive of chondrosarcoma grade II.Surgery was initiated for wide excision. Intra-operatively, it was found to be arising from the 4; 5 th rib and pushing the lung without invading it. The whole tumor was excised en-bloc along with 4 th, 5th and 6th ribs with a surgical margin of more than 2.0 cm -A, B. ThIn final histopathology report, grossly the tumor has blue-grey color and was attached to bone on one margin and covered by the breast in on one surface. The mass measured 18 cm × 14 cm×13 cm.Histological section showed mesenchymal proliferation organized in lobulated architecture with abundant cartilaginous matrix and myxoide areas separated by fibrous bands and bony trabeculae bands. Chondrocytes contain enlarged, hyperchromatic nuclei showing high atypia. Mitosis are rare. The margins are free of tumor cells -D.The patient had an uneventful postoperative course and was discharged on the 10th postoperative day. No adjuvant treatment was administrated. The patient has now been followed up for 8 months after the excision with no evidence of tumor recurrence.3Chondrosarcoma of the rib is a uncommon malignant tumor . Chest wIt is important to keep in mind that a computed tomography (CT) scan is the best imaging of choice.Recommended to delineate intraosseous or extra osseous involvement and defining vascular or neural involvement ,7,8.Surgery considered as the standard treatment with en-bloc resection and a sufficient margin . Because chondrosarcoma is not responsive to chemotherapy and radiotherapy [However, in most cases complete resection of large tumor results in a wide defect, requiring most often reconstructive surgery. In rare cases, chondrosarcoma could invaded adjacent organs necessitating a major surgery. such a case was reported by Abraham et al , pneumonPrognostic of chondrosarcoma is relatively good with a reported 5-year survival rate ranging between 64 and 80% ,10.Most of study concluded that survival was influenced by: tumor diameter <5 cm, tumor location, high histological grade and quality of margins ,12.A largest studies of chest wall chondrosarcomas included 96 patients was reported by McAfee et al . In 10 yThe risk for developing local recurrence or metastasis formation depend in anatomical locations. It was higher, when tumor were localized in sternal, scapular, clavicular, or vertebral .Widhe et al. of the Scandinavian Sarcoma Group studied 106 consecutive patients with chest wall chondrosarcomas. The authors observed that prognostic factors for local recurrence included the surgical margin and histological grade, while prognostic factors for metastases included the histologic grade, tumor size, and local recurrence .Fortunately, in our case there was no involvement of lung parenchyma so a wide resection of all thoracic diseases with appropriate margins it is the rule.There is no indication of neoadjuvant radiation or chemotherapy in a suitable surgical candidate with a resectable thoracic chondrosarcoma .Generally, chondrosarcoma is radio- resistant and chemo-resistant ,4. Howev4The cornerstone and the only curative option for CS was en-bloc resection with appropriate margins and thanks to the evolution of reconstructive surgical techniques, we could ensure the preservation of respiratory mechanics.We confirm that we have no conflict of interest.No financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.We confirm that we has been no significant financial support for this work that could have influenced its outcome.Ethical approval for this study was obtained from the medical and ethic committee of the Salah Azaiez Institute.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Written informed consent was obtained from the patient for publication of this case report and accompanying images.IZ, RBN and NT performed the clinical evaluation of the patient. IZ and NT conceived of the report. IZ, LC and IJ performed the literature search and drafted the report. RC and KR critically reviewed and edited the manuscript. All authors read and approved the final manuscript.N/A.The Guarantor: Tounsi Nesrine.Not commissioned, externally peer-reviewed.


Tumor Treating Field (TTFields) therapy has demonstrated efficacy in a Phase 3 study of newly diagnosed glioblastoma (GB) following radiation (RT) and temozolomide (TMZ). We report the appearance of an isolated satellite anterior temporal lobe lesion, 2 months post primary RT/TMZ directed at the primary GB (MGMT methylated) parietal lobe lesion and one adjuvant cycle of TMZ and TTFields. The mean RT dose delivered to the temporal lobe lesion was negligible, i.e., 4.53 ± 0.95 Gy. Mapping of the generated TTFields demonstrated that both lesions were encompassed by a field intensity in a therapeutic range. The temporal lobe lesion remained under the control of TTFields up to 12 months, at which point progression on a T1 contrast MRI resulted in surgery and a definitive diagnosis of GB without MGMT methylation. The primary parietal lobe at this time was in remission. Molecular sequencing on the GB tissue from multiple time points demonstrates clonal evolution of the cancer over time and in response to treatment. Tumor Treating Field (TTFields) therapy has demonstrated efficacy in a Phase 3 study of newly diagnosed glioblastoma (GB) following radiation (RT) and temozolomide (TMZ) , as wellIn the report to follow, an analysis of a satellite lesion that developed after standard RT and TMZ therapy in a newly diagnosed GB patient is presented. Therapy with TTFields had been initiated 1 month prior to the appearance of the satellite lesion. The patient was followed longitudinally with MRIs every 2 months; additional analysis of the radiation dose exposure, as well as the TTFields intensity, was performed. The differential diagnosis at the time included an MRI artifact or lesion induced by TTFields, vs. progressive disease. After 12 months, the aforementioned lesion was resected. Molecular alterations from baseline, post-progression on TTFields and following a further recurrence were assayed. The results below summarize these collective findings.In March 2016, a 51-year old male presented with left-sided numbness and weakness. A MRI demonstrated a 35 × 25 × 29 mm partially cystic or necrotic, enhancing mass with internal hemorrhage in the right parietal lobe. Subtotal resection was accomplished in March 2016 confirming a grade 4 astrocytoma with IDH1/2 wild type, MGMT methylated, and negative 1p19q co-deletion.Standard radio-chemotherapy was completed in June 2016 , includiChanges of residual tumor in the right parietal lobe was presumed to be progression vs. pseudo-progression, and the patient continued with six cycles of adjuvant TMZ, which was completed in December 2016. The changes in the parietal lobe lesion resolved over time, confirming pseudo-progression. In spite of the appearance of the temporal lobe lesion, it was decided to continue therapy with both TMZ and TTFields (with frequent monitoring), as the possibility of an artifact of TTFields therapy and/or an unusual form pseudo-progression was raised.On a series of follow-up MRIs from August 2016 to August 2017, the initial parietal lobe lesion regressed with adjuvant TMZ and appeared stable on both T1+contrast and T2/FLAIR MRIs. The new enhancing lesion in the temporal lobe (during adjuvant TTFields/TMZ therapy) decreased from 9 to 7.7 mm in diameter with decreasing enhancement from August 2016 to November 2016 Figure . The lesThe patient was then treated (September 2017–November 2017) with radiation (60 Gy in 30 fractions), targeting the temporal lobe resection cavity. An MRI in January 2018 demonstrated a possible new nodule (0.7 × 0.7 cm) on the edge of the resection cavity. A subsequent MRI in February 2018 confirmed progression with an increase in the aforementioned nodule to 1.4 × 1.8 cm. In March 2018, the patient underwent reoperation with a gross total resection as part of the TOCA 5 Tocagen Inc. clinical trial and was randomized to the control arm post-operatively. He started bevacizumab therapy in April 2018 which maintained his surgically obtained complete remission until relapse in August 2018.BRAF (V600E), PTEN (319fs), and the TERT promoter (C228T). Following progression on TTFields, the separate anterior temporal lesion was resected. This lesion possessed these identical BRAF, PTEN, and TERT alterations, and was also found to possess a deep deletion of CDK2NA and an activating mutation in mTOR (V2006I). The lesion in the anterior temporal lobe that recurred following radiation was also sequenced following resection. This lesion was hypocellular, and similar to the prior resection exhibited mitosis, nuclear atypia and no necrosis; the same BRAF, mTOR, and TERT abnormalities were still able to be observed. No new alterations were detectable in this sample.Molecular analyses demonstrate that at resection of the primary parietal lobe lesion this cancer possessed mutations in Additionally, a retrospective analysis demonstrated the TTFields intensity was in a therapeutic range for both the parietal lobe and temporal lobe lesion, i.e., 1 V/cm Figure .MGMT testing performed by LabCorp, NC; IDH testing done by PCR, UW Health Clinical labs, WI, 1p19q testing by FISH, Wisconsin State Laboratory of Hygiene.Using image registration software  that imports the radiation dose, the axial contrast-enhanced 3D T1-weighted images  were fused into a coordinate system of the treatment planning CT. A region of interest was drawn around the anterior temporal lobe lesion, and dosimetric analysis revealed the prior RT dose to the lesion.In order to estimate field intensity distributions within the lesions, numerical simulations were performed using finite differences Time Domain (FDTD) calculations and a realistic head model as described in Wenger et al. . Brieflywww.strataoncology.com).Patient samples were sequenced through STRATA Oncology CLIA-certified laboratory using the StrataNGS platform. This panel covers 88 genes and examines predefined variants including single and multinucleotide alterations, small insertions/deletions, fusions, exon skipping mutations, copy number variation, and microsatellite instability (In this report, we present the first instance of a grade 4 astrocytoma controlled by systemic TMZ and TTFields, with negligible radiation exposure. The patient's initial parietal lobe lesion was MGMT methylated, not IDH mutated, and not 1p19q deleted; the resected temporal lobe lesion was similar histologically, but was not MGMT methylated. Based on the MRIs between June 28th to August 14th, 2016 (Figure As the temporal lobe tumor appeared after initial concurrent radiation and TMZ treatment, this tumor may have been TMZ resistant, which is consistent with the absence of methylation on MGMT promoter. Alternatively, a resistant TMZ clone may have evolved over time. The initial radiation field was reconstructed, showing that the temporal lobe was exposed to minimal radiation at the time, 4.53 ± 0.95 Gy. This region, however, was within the TTFields effective region, suggesting that the suppression of tumor growth from August 2016 to 2017 was under the control of adjuvant TMZ and/or TTFields.The original plan for the placement of Optune™ arrays using the NovoTAL™ methodology  targetedBased on the molecular sequencing we can see that the cells within the anterior temporal lobe lesion developed from cells in the original primary parietal lobe lesions as the exact alterations were identified in both instances. The additional alterations identified presumably arose through clonal selection. While many factors could have potentially played into this selection process, we propose that it is quite plausible that the activating mutation in mTOR and/or the deep loss of CDKN2A could be inducing the resistance to TTFields therapy.Over the last few years, new mechanistic insights have been gained into the anti-cancer effects of TTFields. These potential mechanisms of action include disruption of key cellular functions, such as mitosis, DNA repair, mitochondrial function, and the folded protein response, leading to the induction of cellular stress, autophagy and apoptosis , 8–10. TIn summary, this report provides evidence that TTFields may offer prolonged therapeutic benefit for some patients with recurrent GB. The molecular analysis of this patient's cancer over time provides potential insight to mechanisms by which resistance to TTFields might occur. This work also raises several interesting questions about how clonal evolution and spread through the central nervous system occurs, whether targeting therapies, such as mTOR or BRAF inhibitors, could be used in settings like this, and whether more routine molecular profiling should be obtained for patients with GB. Clearly, as we learn more about the biology of individual patients with GB this will lend itself to more precision-based treatment strategies for patients.This is a case report regarding a patient treated with FDA approved standard of care treatment. Informed consent was obtained.HN contributed to the clinical history review, literature review, and manuscript preparation. SH evaluated radiation dosing and reviewed the manuscript. SS reviewed pathology. AF reviewed the manuscript and MRI scans. HR identified the patient, reviewed the clinical history and the literature, and prepared the manuscript. DD performed the genomic analyses and edited the manuscript.HR and DD have support for laboratory research from Novocure, Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Fibroma of the tendon sheath most often presents around small joints and involves the tendon and tendon sheaths of the fingers, hands, and wrist. In rare instances, it presents as an intra-articular mass. It has never been described in the hip joint. In the current case presentation, this benign tumor was found to be the source of a patient's atypical severe hip pain. Arthroscopic resection of this tumor alleviated the patient's pain. Fibroma of the tendon sheath (FTS) is a benign fibroblastic neoplasm that most often presents as a circumscribed nodular mass around small joints and involves the tendon and tendon sheaths of the fingers, hands, and wrist . In rareA 29-year-old female presented for evaluation of progressive right hip pain over the course of several months without a known injury event. She endorsed a constant pain, feelings of tightness in the hip, and a sensation of hip stiffening with ambulation. Physical exam demonstrated significant pain and guarding with passive hip motion, particularly hip flexion past 90 degrees, and provocative maneuvers such as both flexion/adduction/internal rotation (FADIR) and flexion/abduction/external rotation (FABER), suggesting an intra-articular source of her discomfort. There was no palpable mass or neurologic deficits.The radiographic workup included an AP of the pelvis and special views of the right hip including Dunn lateral and a false profile. Radiographs revealed evidence of a mild mixed-type femoroacetabular impingement . There was no evidence of degenerative changes (Tönnis grade 0). Advanced imaging with a magnetic resonance arthrogram was available for review at the initial visit and demonstrated a pedunculated intra-articular mass in the superolateral aspect of the joint, near the femoral head-neck junction .Hip arthroscopy was performed in a supine position for resection of this lesion. The patient was placed in manual traction and standard midanterior and anterolateral portals were established. An extended intraportal capsulotomy was performed to allow for better access to the anterolateral femoral neck. On initial diagnostic arthroscopy, she was noted to have a concomitant anterior-superior labral tear. Minimal acetabular bone was resected and a three-anchor labral repair was performed. The traction was then released and evaluation of the peripheral compartment commenced. A nodular mass was encountered at the anterior and anterolateral femoral head-neck junction  and exciPathological examination of the mass was remarkable for a multinodular proliferation of benign fibroblasts with variable cellularity including hyalinized hypocellular areas Figures . The fibPostoperatively, the patient was made 50% weight-bearing on the right lower extremity with crutches for one month. No brace was utilized. She began physical therapy the second week. At her first follow-up appointment 10 days postoperatively, she noted resolution of her hip pain and prior symptoms of “tightness.”FTS is defined as a benign fibroblastic nodular neoplasm that arises from the synovium of a tendon sheath. . It has Arthroscopic treatment of pigmented villonodular synovitis of the hip (the suspected diagnosis prior to pathologic examination) is well described . AdvantaIn addition to the intra-articular mass, a very mild cam deformity was noted on our workup. While it is not possible to say if, and to what extent, this was contributing to her symptoms, the acute and rapidly worsening nature of her pain, as well as the subjectively more severe nature of her presentation than the authors typically see associated with cam impingement, lead the authors to believe the major factor in her disability was the FTS. A labral tear was identified and repaired during arthroscopy. This is a common sequelae of hip impingement . The locTo our knowledge, this is the first description of FTS presenting in the hip. The patient's pain and disability was out of proportion to what is typically seen in a FAI case presentation. The case was unusual in having a multinodular intra-articular growth pattern. The described treatment with arthroscopic resection was successful in this instance.


Giant synovial osteochondromatosis of the thigh is a highly unusual disease without standard diagnosis and curative managements so far. Our focus is to report a very rare case of giant synovial osteochondromatosis successfully operated by surgical treatment. The management of these unique cases has certain educational significance in clinical practice.A 63-year-old previously healthy man presented to our institution with a 4-year history of continuous progressive hip pain and local numbness of right side in January 2018. One month ago, the patient felt that the above symptoms were aggravated, and the right hip and proximal thigh were significantly swollen.Computed tomography and magnetic resonance imaging of the hip revealed the irregular mass in his right thigh. Post-operative pathology confirmed the diagnosis of synovial osteochondromatosis of the thigh.Considering the large volume of the mass and possibility of malignancy, the patient underwent surgical exploration and complete tumor resection.The patient's neurological deficits and symptoms improved significantly after the surgery, and the postoperative period was uneventful at the 1-year follow-up visit. There were no complications associated with the operation during the follow-up period.Taken together, the lesion's clinical features, imaging results, and pathological characteristics are unique. Synovial osteochondromatosis of the thigh, although rare, should be part of the differential diagnosis when the patient presents with local pain, numbness, swelling or other symptoms. We recommend surgical treatment for the occupying lesion when the tumor has caused symptoms or neurological deficits. Although rare, SOC should be considered in differential diagnosis of cases presenting with similar symptoms.Synovial osteochondromatosis (SOC) is a monoarticular, synovial, proliferative disorder. It is a rare entity which presents with multiple cartilaginous nodules in synovial joints, bursae or tendon sheaths.To the best of our knowledge, this is a less-documented case of giant synovial osteochondromatosis of the thigh in a man presenting with continuous progressive hip pain, local numbness and swelling, who underwent total resection of the space-occupying lesions. In the follow-up visit, the patient's conditions improved significantly postoperatively. After reviewing pertinent literatures, we discussed common clinical considerations in patients with giant synovial osteochondromatosis of the thigh and management considerations for these patients.2A 63-year-old previously healthy man presented to our institution with a 4-year history of continuous progressive hip pain and local numbness of right thigh in January 2018. Upon examining and questioning, the patient stated he has been experiencing a gradual increase in his hip pain, as well as worsening numbness and swelling of the right thigh. In the medical journal of his current illness, the pain in his right hip can reach 4–5 points using the visual analogue scale and cannot be alleviated with rest and hot compresses. One month ago, the patient felt that the above symptoms were aggravated, especially during sleeping and sitting. He denied history of injury and any other underlying diseases. No pertinent family history was identified, including hypertension and cancer.Physical examination showed a mass sized 12 × 24 cm in the proximal thigh, which was hard in texture, unclear in boundary, adherence to surrounding tissues, poor mobility, and no tenderness. However, low skin temperature and varicose vein were not found on the surface of the mass. Routine laboratory studies were almost within normal range, except that the tissue polypeptide specific antigen was significantly elevated to 101.55 U/L . Plain radiographs showed irregular shadow of a soft tissue mass in his right thigh Fig. A–I.Considering the large volume of the mass and possibility of malignancy, surgical exploration and complete tumor resection were performed according to the designed surgical procedure. After successful anesthesia, the patient was placed in a supine position, with the right buttock being cushioned high. During the operation, multiple cystic masses in the deep muscles were seen, with a size of about 24 × 15 × 10 cm extending from the upper middle of the thigh to the right hip  is the active intrasynovial stage during which there is no free articular body. Stage II (mid-term stage) is the transition stage from intrasynovial lesions to free bodies. In this stage, there are both active intrasynovial lesions and free articular bodies. In stage III (late stage), there are multiple free articular bodies in the absence of intrasynovial involvement.–3,10,11Synovial osteochondromatosis (SOC) is a benign disorder of nodular cartilaginous neoplastic development of the synovium that can lead to multiple loose bodies within the articular space.,13 Calcification occurs at the last stage and may not be observed in some patients at earlier stage. Intraarticular liquid-like masses, non-calcified masses or swellings which can be differentiated with MRI or CT scan.–15 However, difficulties of diagnosis despite CT and MRI should also be considered. In neglected cases or in cases with a long-term disease course, changes in bone or joint cartilage induced by multiple intraarticular lesions, bony erosion, or presence of local osteoporosis make accurate preoperative diagnosis much more difficult. Imaging studies including CT, MRI, bone scan and PET/CT are non-specific, making it difficult to differentiate SOC from other common occupying lesions.–17 However, imaging studies may play a crucial role in the decision making of surgical intervention. In our case, the entire size of SOCs was 24 × 20 × 12 cm, and our case had been one of the biggest SOCs ever reported in literature.The most common radiologic findings, free bodies with varying sizes, can be seen at any place in the tumor cavity.–21 Malignant transformation was reported in few cases at long-term follow-up visit.,22 While the literature describes the knee as the most common location of the usual form of SOC, the location in the thigh is extremely a rarity.Differential diagnosis of synovial osteochondromatosis includes many other occupying diseases. SOC should be differentiated from multiple benign or malignant lesions such as synovial hemangioma, pigmented villonodular synovitis, synovial cyst, osteosarcoma and synovial sarcoma.–3,23,24 Further reports and analyses of the giant form of SOC are necessary to improve our understanding of this pathological entity and its differences from the usual form to optimize proper clinical management. In our reported case, pathology results showed significant chondroid metaplasia without cellular atypia, which was consistent with synovial osteochondromatosis.The “gold-standard” diagnosis of SOC relies on pathological findings. The main pathological characteristic is chondroid metaplasia of the subintimal tissue of synovial joints.–3,25–27 In the literature, early arthroscopical or open debridement, synoviectomy, and removal of free cartilage masses at an early stage before cartilage damage occurs have shown to be efficient treatments.–27 Severity of disease course and affected location should also be considered when surgeons decide whether surgery should be performed.,26 Additionally, in some cases that had osteochondroplasty after debridement osteoarthritis did not relapse in 2-years follow up and successful results were achieved.–28 Under this circumstance, surgical extent, surgical procedures, and postoperative complications are critical factors that need further investigation. According to our single-center experience, we prefer and recommend open surgery for patients with giant SOCs due to the size of the mass.The treatment of first choice for SOC is surgical excision with an open or arthroscopical approach.In conclusion, this is the first report of giant synovial osteochondromatosis of the thigh in a patient. Although uncommon, synovial osteochondromatosis of the thigh should be part of the differential when the patient presents with atypical symptoms. Surgical treatment is a definite therapy of first choice. Our case highlights the significance of accurate diagnosis and proper treatment for synovial osteochondromatosis. With an accurate diagnosis, proper planning, and accurate surgical manipulation, synovial osteochondromatosis can be diagnosed and managed much more effectively.We would like to thank our colleagues at the Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College.Conceptualization: Shuzhong Liu, Xi Zhou, An Song, Yipeng Wang, Yong Liu.Funding acquisition: Shuzhong Liu, Yipeng Wang, Yong Liu.Investigation: Shuzhong Liu, Xi Zhou, An Song, Zhen Huo, Yong Liu.Resources: Shuzhong Liu, Xi Zhou, Zhen Huo, Yipeng Wang, Yong Liu.Supervision: Yipeng Wang, Yong Liu.Writing – original draft: Shuzhong Liu, Xi Zhou, An Song, Yong Liu.Writing – review & editing: Shuzhong Liu, An Song, Yipeng Wang, Yong Liu.


Brunner's gland hamartoma is a rare benign duodenal tumor. It occurs in Brunner's glands, which are found in the duodenum and produce secretions that protect the duodenum from pancreatic enzymes, gastric acid, and other agents. Endoscopic or surgical resection is required for these hamartomas. Duodenal intussusception is a relatively rare condition, usually caused by the presence of benign tumors, such as fibroadenomas, lipomas, papillomas, or sometimes with malignant neoplasms.3, consistent with Brunner's gland hamartoma.We report a case of giant Brunner's gland hamartoma in the duodenum causing antiperistaltic intussusception in a 45-year-old female patient. The patient reported a 3-year history of chronic anemia, and this mass was detected incidentally by computed tomography (CT) during investigations for chronic anemia and weight loss. Pre-operative abdominal and pelvis contrast revealed a sausage-shaped intraluminal structure with alternating fat planes and vessels distended in the third part of the duodenum up to the first part of the duodenum. Pancreas-sparing duodenectomy was performed. The patient recovered very slowly and was discharged on postoperative day 15 in good condition. Histology showed a large polypoid mass measuring 12.0 × 7.5 × 2.0 cmBrunner's gland hamartoma can present with features of duodenal intussusception or ampullary obstruction but is rarely seen to cause retrograde jejuno-duodenal intussusception. Pancreas-sparing duodenectomy is the best surgical option in adult patients with intestinal intussusception associated with giant lesions close to the ampulla of Vater, especially in the presence of features of malignancy. •Brunner's gland hamartoma is a rare benign duodenal tumor.•Adult intussusception is usually caused by benign or malignant tumors, but rarely to be caused by Brunner's gland hamartoma.•Pancreas-sparing duodenectomy is the surgical option for lesions close to the ampulla of Vater. This tuIntussusception occurs when one segment of the bowel slides into the lumen of an adjacent bowel segment ,5. Adult2Helicobacter pylori (H. pylori) infection, chronic renal failure, peptic ulcer disease, and chronic pancreatitis. Her family history was unremarkable. The patient did not have any prior surgeries or history of malignancy. Workup for her chronic anemia included CT scan of the abdomen and pelvis with intravenous and oral contrast, which revealed duodenal intussusception. The patient was booked for upper gastrointestinal endoscopy in the referral hospital but missed her appointment and asked for a referral to another hospital.A 45-year-old woman with a 3-year history of chronic anemia was followed up at the Gastroenterology outpatient department of another hospital, with a 6-month history of abdominal pain. The pain was intermittent, worse in the mornings, and localized to the epigastric region. The patient noticed that her abdomen became distended after meals and distension was relieved after a bowel movement. The patient noticed a 12-kg weight loss over the last 6 months. There was a history of nausea but no vomiting. The patient denied any history of loss of appetite, diarrhea or constipation, and upper or lower gastrointestinal bleeding. There was no significant past medical history other than anemia and multiple blood transfusions. The patient denied any history of tobacco smoking, alcohol consumption, drug abuse, 9/L (4.5-11.0 × 109/L); and platelet count, 323 × 109/L (150-450 × 109/L). Other laboratory profiles were unremarkable. Contrast CT of the abdomen and pelvis revealed significant dilation of the stomach with no detectable gastric lesion. The third part of the duodenum was distended by a sausage-shaped intraluminal structure with alternating fat planes and dilated vessels reaching up to the first part of the duodenum, suggesting retrograde jejuno-duodenal intussusception. There was no detectable soft tissue lesion, and the rest of the bowel was unremarkable . Her vitals were stable, and she was afebrile . On examination, her abdomen was soft and laxative, with no tenderness, or organomegaly. A complete blood count on the day of admission revealed the following: low hemoglobin level, 7.2 g/dL (12.0–17.0 g/dL); mean corpuscular volume (MCV), 78.0 fL (80.0–100.0 fL); low hematocrit, 24.8% (40.0%–51.0%); leukocyte count, 8.2 × 10markable A–C. EndoThe patient underwent laparoscopic exploration, which revealed antiperistaltic intussusception in the proximal jejunum . A jejunA cholecystectomy was performed, and a pediatric feeding tube was passed through the cystic duct to locate the ampulla of Vater. The mass was not resectable without affecting the ampulla, so the decision was made to perform a pancreas-sparing duodenal resection. The excised duodenum with mass was sent for histopathological examination B.3. Microscopic examination revealed a bowel mucosa with underlying submucosa showing lobules of benign normal-appearing Brunner's glands separated by fibrous stroma. The nodular proliferation of Brunner glands was accompanied by cystically dilated ducts and adipose tissue with no microscopic features of malignancy  into the receiving proximal end of the bowel (the intussuscipiens) . The patIn our case, retrograde intussusception was caused by Brunner's gland hamartoma, which triggered antiperistaltic activity.Since its first description in the 19th century, <200 cases of Brunner's gland hamartoma have been reported in the medical literature . Nearly H. pylori infection, which is very common in patients with Brunner's gland hamartoma, causes this condition [The exact pathogenesis of Brunner's gland hamartoma is unknown. A theory is that hyperacidity causes hyperplasia of Brunner's glands; however, only 45% of patients with this condition had increased gastric acid secretion and 20% of patients with Brunner's gland hyperplasia had gastric hypoacidity, making this theory unlikely . There iondition . HoweverMedical professionals have also suggested that this condition may be associated with chronic renal failure, peptic ulcer disease, and chronic pancreatitis . Our patThe diagnostic modalities of Brunner's gland hamartoma are imaging and endoscopy. Nevertheless, to arrive at a definitive diagnosis it is necessary to conduct histopathological examination .According to Hirasaki et al. , the besWhen formulating a diagnosis, it is important to distinguish Brunner's gland hamartoma from other types of duodenal lesions such as polypoid adenoma of the superficial mucosal glands, leiomyoma, malignant tumors, and aberrant pancreatic tissue . EndoscoOne of the most common treatments of Brunner's gland hamartoma is endoscopic removal. However, if unsuccessful, surgical excision is required . In most4Brunner's gland hamartoma can present with the features of duodenal intussusception or ampullary obstruction, but it is rarely seen to cause retrograde jejuno-duodenal intussusception. For giant lesions close or attached to the ampulla of Vater, a pancreas-sparing duodenectomy is the best surgical option, especially if the patient has features of malignancy. There is need for further research into the pathogenesis of Brunner's gland hamartoma, as our case did not support any of the current hypotheses on the pathogenesis.Ethical approval was obtained from the Institutional Review Board (IRB) of the King Fahad Specialist Hospital, Dammam, Saudi Arabia. The ethical approval was signed on 06th November 2018.This study did not receive any funding from governmental or private organizations.All authors MYD, AAA, LAA, ZHA, OHA participated in Concept, data collection, and Literature search. Writing of the paper were made by MYD and OHA. Histopathological part and images were performed by LAA. All authors read and approved the final manuscript.The authors declare no conflict of interest.N/A.Dr. Mohammed Yousef Aldossary.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Not commission, externally peer reviewed.


Mycobacteriumabscessus (M. abscesscus) is exceedingly rare with only eight cases reported in literature.Vertebral osteomyelitis (VO) is an uncommon infection with Staphylococcus aureus as the most commonly implicated organism. VO caused by nontuberculous mycobacteria (NTM) such as M. abscessus. The patient further underwent an anterior T12-L2 corpectomy and debridement with instrumented fusion, as well as a posterior T9-L4 instrumentation and fusion. He received multi-agent antibiotic therapy; however, was ultimately unable to tolerate the aggressive treatment regimen and his prolonged postoperative course.We report a rare case of an 82-year-old male with a remote history of trauma who was diagnosed with NTM vertebral osteomyelitis. The patient initially underwent a vertebroplasty of T12 and kyphoplasty of L1 for pathologic compression fractures. Subsequent cultures revealed Nontuberculous mycobacteria vertebral osteomyelitis is exceedingly rare. NTM vertebral osteomyelitis is challenging to treat. Surgical management plays a limited role in early VO, but is the mainstay treatment in chronic VO. Early recognition of the condition and shared patient management with multidisciplinary teams is key to successfully treating cases of NTM VO. S. aureus is the most commonly isolated pathogen, other atypical organisms include Gram-negative Bacilli, Streptococci, as well as Mycobacterium species [Mycobacteriumabscessus (M. abscessus), is an extremely rare cause of vertebral osteomyelitis. M. abscessus is a rapidly growing mycobacterium found in soil, plants, and aqueous environments, including municipal drinking water and sewage systems [abscessus have been reported in the literature, and four were in immunocompromised hosts [M. abscessus in an immunocompetent individual residing in a non-mycobacterium endemic region.Since the first case was described in 1929 by Wilensky et al., vertebral osteomyelitis has remained relatively rare. A delay in diagnosis and treatment is associated with significant morbidity and mortality . Althoug species –8. Treat systems –12. It h systems . To our ed hosts . The treed hosts , 12. We M. abscessus at 6 weeks. The infectious disease (ID) service was consulted for further management. The smear was presumed to be a contaminant given his history and presentation.An 82-year-old male presented with a remote history of prior falls and a recent traumatic compression fracture of his L1 vertebral body. He reported no previous fractures, weight loss or antecedent pain. He was initially treated with a brace and underwent physical therapy. At follow-up, he had no neurological deficits but demonstrated severe recurrence of pain with progressive functional impairment refractory to conservative management. An MRI showed a worsening L1 vertebral body collapse, a T12 inferior endplate fracture, and a L2 superior endplate fracture  drug abuse; one of which was diagnosed with Hepatitis C virus [A Pubmed review of the literature published between 1965 and 2017 demonstrated only eight cases of vertebral osteomyelitis caused by  C virus , 16, 17. C virus . Among t C virus . Only twM. abscessus, are naturally occurring organisms found in water and soil and can inhabit body surfaces and secretions through the environment. In most immunocompetent individuals, exposure does not lead to disease. Therefore, isolated cultures of NTM can be often be considered colonizers or contaminants [Early diagnosis requires a thorough history, physical exam, laboratory testing, and imaging. Even in disseminated disease, blood cultures are often negative and offer limited value. Definitive diagnosis depends on bone and soft tissue sampling for culture and histologic examination . Nontubeaminants .Recognition of the disease requires a high index of suspicion and an extensive workup. Prompt diagnosis ensures improved long-term outcomes, especially when the clinical course presents as an indolent, prolonged, and destructive process that is unresponsive to empirical antibacterial agents.M. abscessus, prompting initiation a multi-drug antibiotic regimen.Our patient hailed from a non-endemic region and presented with nonspecific symptoms of back pain and a remote history of blunt trauma. Thus there was a low index of suspicion of osteomyelitis as the underlying cause. He continued to have pain while undergoing conservative treatment, prompting operative management and a bone biopsy. A second positive culture via image-guided bone biopsy redemonstrated M. abscessus localized to the spine presents a unique challenge, as there is a lack of consensus on antimicrobial agents, combination therapies, and duration of treatment [M. abscessus are most commonly related to pulmonary or skin and soft tissue infections, with limited evidence of successful treatment in the spine. Moreover, M. abscessus has demonstrated resistance to standard antituberculous agents and antimicrobial therapies [As in the majority of cases of vertebral osteomyelitis, initial treatment consists of medical and antibiotic therapy, in conjunction with external bracing. However, reatment . Case reherapies , 22.M. abscessus are not susceptible to macrolide-based chemotherapy. Recent advances have been made possible by new molecular testing methods. Studies have determined that macrolide resistance is conferred by the erm(41) gene in some M. abscessus species, rendering macrolide-based chemotherapy against the organism futile. Thus molecular testing may further help guide treatment and predict outcomes [The macrolide antibiotic clarithromycin is a mainstay of multi-agent therapy, it is often administered in combination with amikacin, cefoxitin, and tigecycline, but may also be delivered alone. Regimens often consist of weeks to months of parenteral treatment followed by oral therapy. However, certain isolates of outcomes , 22.Surgery has a limited role in the early treatment of vertebral osteomyelitis. Indications are usually reserved for compression or instability leading to a neurologic deficit, or systemic sepsis with discernable foci . HoweverM. abscessus in the spine. While few prior cases have demonstrated successful outcomes with medical management alone [M. abscessus vertebral osteomyelitis. However, appropriate patient selection when considering an extensive surgical procedure is also critical to achieving a satisfactory clinical outcome.At present, there are no standard guidelines for treating nt alone , 18, 24,nt alone , 19, 20.


Metastatic tumors to stomach are extremely rare with very few cases being described so far in the surgical literature. Colonic tumors metastatic to stomach represent a rarer entity and present a surgical challenge for diagnosis and management to the clinician. We, hereby present a case of adenocarcinoma of transverse colon metastatic to stomach more than 6 years after the index malignancy, presenting clinically with features of gastric outlet obstruction. It was treated with open subtotal gastrectomy, with diagnosis being made on histopathologic examination using special immunochemical stains. Adjuvant treatment in the form of chemotherapy was given and follow up cross sectional imaging showed no evidence of residual disease so far. •Extreme rarity of this pathological entity.•Diagnostic challenges faced in such a clinical scenario.•Forming a very rare and interesting differential diagnosis of gastric outlet obstruction.•First case reported to present 6 years after the index colonic primary. The most common sites of the primary malignancy have been found to be the lung, breast and skin  in a descending order  but colo2A 76-year-old lady, a known diabetic, hypertensive and hypothyroid presented with upper abdominal discomfort, bloating and repeated bouts of bilious vomiting for 5 days. Six years prior, she had undergone a right hemicolectomy for a caecal carcinoma. There was a 10 × 8 cm ulcero-proliferative mass in the caecum which was infiltrating posteriorly into the right psoas muscle. The omentum, peritoneum, mesentery and the other organs were free of any metastatic deposits. Histopathology showed a moderately differentiated adenocarcinoma of the caecum (pT3N0Mx); none of the 16 resected lymph nodes were involved and the proximal, distal and retroperitoneal margins were free of tumor. She underwent 6 cycles of Capecitabine based adjuvant chemotherapy and was being followed up as an outpatient. She was apparently well till 6 years ago, when she developed sudden upper abdominal discomfort associated with bilious vomiting. It was managed conservatively, and relevant investigations were done.On examination, she was hemodynamically stable. Abdominal examination revealed epigastric distension with no discrete lump or organomegaly. A contrast enhanced CT scan of the abdomen revealed a long 15 cm circumferential mural thickening of the terminal ileal loop, extending up to the site of the previous ileo-transverse anastomosis, with surrounding pericolic stranding. Upper GI endoscopy revealed a large ulcero-proliferative growth in the antro-pyloric region . Pre-opeAt operation, she had an ulcero-proliferative growth in the antro-pyloric region causing luminal stenosis and gastric dilatation with enlarged lymph nodes in the surrounding perigastric region. A subtotal gastrectomy with resection of a mid ileal intraluminal polyp with excision of a suspicious omental nodule and anatomical repair of incisional hernia was done. Reconstruction was done by side-side hand sewn gastrojejunostomy using an isoperistaltic loop of jejunum. She developed left pleural effusion and respiratory distress, necessitating an ICU stay for 5 days. The patient was eventually discharged in a stable condition on day 10th of surgery. She received 5 cycles of Capecitabine and Bevacizumab based chemotherapy on an outpatient basis. Follow up CT abdomen performed in August 2017 was grossly normal, with no evidence of any recurrence or residual mass.Gross examination of the specimen revealed a nodular ulcero-infiltrative mass on the mucosal surface of the stomach measuring 6 × 5.5 cm . The ove3The published literature reveals a very low incidence of metastases to the stomach, with most studies reporting an incidence ranging between 0.2 and 0.7% . In a seThe presence of metastasis to the stomach has been found to be a marker of advanced disease. Kobayashi et al., in their series of nine patients found concomitant distant metastases to lymph nodes and lungs in more than 50% of the cases . Melanom4The present report describes a rare gastric tumor which turned out to be a metastasis from a caecal carcinoma for which the patient had undergone a right hemicolectomy as much as six years previously.Patient consent had been obtained for possible publication of this case report.None.1.Samrat Ray: First and corresponding author; collected the data; first assistant in the surgery; prepared the first draft of the manuscript.2.Amitabh Yadav: Chief operating surgeon. Supervised the manuscript preparation.3.Sunila Jain: Histopathologist reporting the slides and doing immunohistochemistry. Inputs in the manuscript from the pathologist.4.Samiran Nundy: The main supervisor of the project. Final corrections done by him.None.NA.Samrat Ray.Patient informed consent had been obtained for possible publication of this case report.Not commissioned, externally peer reviewed.


Spontaneous diaphragmatic rupture (SDR) is a very rare surgical emergency. A possible explanation for SDR might be a sudden increase of intra-abdominal pressure due to intense coughing, physical exercise, vomiting, or delivery. A 66-year-old male patient presented with recurrent coughing, dyspnoea, and intermittent fever. Although initial CT scan was inconspicuous, a follow-up CT scan revealed SDR of the left hemidiaphragm with herniation of the left colonic flexure, stomach, and parts of the greater omentum. Emergency laparotomy confirmed SDR. The ruptured anterior-lateral part of the diaphragm was closed, and additionally, a composite mesh was applied to reinforce the suture line. A right-sided hemicolectomy with primary anastomosis had to be performed. SDR is a rarity and can cause exceptional clinical features that may lead to inaccurate diagnosis and therapeutic delay. Therefore, of paramount importance, medical practitioners need to be aware of this important differential diagnosis for spontaneous dyspnoea or tachypnea. Rupture of the left diaphragm and herniation of intra-abdominal organs like the stomach, spleen, and colon are mostly caused by blunt or penetrating abdominal trauma. Spontaneous diaphragmatic rupture following coughing, delivery, or extensive exercises is very rare . In an aA 66-year-old male patient presented with back pain and infection-exacerbated COPD in our emergency department. Medical history revealed COPD Gold grade 1, hypertension, and alcohol abuse as relevant comorbidities. The reason for admission was severe prolonged coughing and dyspnea with fever up to 38 degree Celsius. The patient complained about constipation for three days and back pain as well as lower abdominal pain. Furthermore, he mentioned falling out of his bed during sleep the night before admission. He denied loss of appetite, nausea, and vomiting. Medical history revealed an arterial hypertension, an extensive alcohol abuse, and a 30-year history of cigarette smoking.2. Blood tests indicated no relevant systemic infection with leukocytosis of 11.27 × 109/L and an elevated C-reactive protein (CRP) of 26 mg/L. Because of increasing CRP and leukocytes, antibiotic therapy was initiated. Initial CT scan demonstrated an intact diaphragm  and the patient is restless and in distress. Due to herniation of the colon and small intestine, bowel sounds can be auscultated during chest examination whereas breathing sounds are decreased. With the results and suspicions of clinical examination, mostly the diagnosis is confirmed by chest X-ray or CT scan. Reduction of herniated organs and closure of the diaphragmatic defect is usually performed transabdominally. As in traumatic diaphragmatic rupture, a running suture as well as an interrupted suture is suitable. We prefer a strong absorbable running suture, and depending on the coexisting organ damage, we recommend in a noncontaminated abdominal cavity an augmentation with a composite mesh. In accordance to this, our patient has experienced two possible reasons for his diaphragmatic rupture. Before admission, he fell out of his bed, and on admission, he suffered from severe coughing. Although the initial CT scan and chest X-ray showed a regular anatomical situation of intra-abdominal and intrathoracical organs, maybe a clinically inapparent slight rupture became clinically symptomatic after the violent coughing episodes.Barclay-Buchanan reported just two years ago a 69-year-old patient who presented at the emergency department with dyspnea after the Valsalva maneuver for chronic constipation. A CT scan showed a large anteromedial diaphragmatic rupture with herniation of the stomach, small intestine, and colon into the right hemithorax. The patient was admitted to the palliative care service for other reasons and died within 24 hours. A differential diagnosis in this patient could be incarceration of a preexisting undiagnosed diaphragmatic defect as a result of rising intra-abdominal pressure during bowel movements .Hamaji et al. reported in 2013 another patient with SDR two days after her first uncomplicated vaginal delivery. A chest computed tomography revealed a left-sided diaphragmatic hernia with dislocation of the left colonic flexure and mesenteric and omental fat. A left oblique lateral thoracotomy was performed, and a 5 cm rupture of the diaphragm was diagnosed. After reduction of the herniated abdominal contents, the defect was repaired with two layers of nonabsorbable running stitches [The literature review by Losanoff et al. found 28 detailed reports about SDR between 1956 and 2009; thus SDR is a very rare visceral emergency. Two-thirds of the patients (69%) suffered from a left-sided rupture and one patient from a bilateral defect . The undAnother rare origin of SDR is reported by Yang from Korea. As a result of static sport activity, a 29-year-old woman presented to the emergency department with worsening pain in the epigastric area after a Pilates session. On the CT scan, an air-fluid level of the stomach which was herniated in the left hemithorax was present. Left-sided thoracotomy revealed a 7 cm × 5 cm rupture of the left posterior medial diaphragm with a perforation of the stomach. 16 days after transthoracic repair of the diaphragm and stomach, the patient was discharged without any complications .Spontaneous diaphragmatic rupture is an uncommon entity but a life-threatening condition. Mostly, the underlying mechanism for the tremendous increase of intra-abdominal pressure is not obvious and needs a low level of suspicion for timely accurate diagnosis and treatment. Although extremely rare, this possible differential diagnosis should be considered in patients with dyspnea, chest pain, and a history of an episode with Valsalva-like rise of intra-abdominal pressure and absent trauma. SDR is associated with high morbidity and mortality rates; therefore, early diagnosis is of paramount importance. Treatment options are exclusively surgical repair and exploration via a laparoscopic or open transabdominal or transthoracical approach and direct closure. An augmentation with a composite mesh can be decided on a case-by-case basis .


Pleomorphic xanthoastrocytoma (PXA) is a rare astrocytic glioma, characterized by large pleomorphic and frequently multinucleated cells, spindle and lipidized cells, a dense pericellular reticulin network, and numerous eosinophilic granular bodies according to the grade II glial tumor standards of the World Health Organization’s (WHO) 2016 guidelines. PXA rarely transforms into anaplastic PXA or glioblastoma (GBM) and anaplastic PXA, classified as WHO grade III, has a more aggressive clinical behavior with poorer prognosis than PXA.Here we describe an unusual case of PXA in a 19-year-old woman, first admitted with headache and a mass in the left temporal lobe in 2005 that was removed. Twelve years later, she returned with left temporal headache, diplopia and tinnitus. A local tumor recurrence was found, and a second resection was performed. The specimen showed highly malignant findings, such as necrosis, microvascular proliferation, and multiple mitoses. The integrated diagnosis was made as high grade glioma, probably derived from PXA. Immunohistochemical (IHC) stains were positive for oligo2, and approximately 21% positive for Ki-67, while negative for CD34, IDH1 R132H. INI1 and ATRX were retained. As the histological classification was glioblastoma, the patient received GBM-appropriate chemotherapy and radiation therapy and outpatient follow-ups have demonstrated no obvious symptoms for 1 year after surgery. Additional molecular analyses found BRAF V600E mutations in both resections, supporting the idea that the recurrent tumor had derived from PXA.This case highlights the complexities of differential diagnosis based on the World Health Organization’s 2016 guidelines. More integrated criteria to differentiate anaplastic PXA from GBM and epithelioid GBM, combined with genetic screening results, might be needed. Pleomorphic xanthoastrocytoma (PXA) is a rare astrocytic glioma, characterized by large pleomorphic and frequently multinucleated cells, spindle and lipidized cells, a dense pericellular reticulin network, and numerous eosinophilic granular bodies (EGBs) according to the grade II glial tumor standards of the World Health Organization’s (WHO) 2016 guidelines . HistoloAlthough the WHO 2016 classification incorporated molecular testing, diagnoses of anaplastic PXA and GBM are still based on histopathological findings. Here, we present a case of such a complex differential diagnosis of GBM, solely by histology, after taking the clinical course and molecular findings into account.A 19-year-old Japanese woman presented with a left temporal headache. Magnetic resonance imaging (MRI) of the brain revealed a well-defined, heterogeneously enhanced tumor in the left temporal lobe, approximately 10 mm in size, showing high-intensity on T2-weighted images  was performed for 1p, 19q, CDKN2A, IDH1 R132H (c.395G > A), R132C (c.394C > T), IDH2 R172K (c.515G > A), R172M (c.515G > T) and Pyrosequence for IHD1 R132, IDH2 R172, BRAF V600E, H3F3A K27, H3F3A G34, HIST1H3B, TERT C228T, FGFR1 N546, and FGFR1 K656. The analysis detected a BRAF V600E mutation in both the initial and recurrent tumors, with mutant allele findings at 16 and 49%, respectively. Both 1p/19q and CDKN2A were intact in the initial specimen, but a 19q deletion and CDKN2A homozygous deletion were detected in the recurrent specimen. IDH1/IDH2, H3F3A, HIST1H3B, TERT, and FGFR1 were intact in both specimens. From this analysis the tumor was assumed to have been derived from pleomorphic xanthoastrocytoma.In our case, PXA shifted to a more aggressive phenotype with GBM-like features 12 years after the initial surgery. Despite several reports on malignant transformation from PXA to GBM , 9, geneIn the current case, the molecular analysis detected BRAF V600E mutations in both the initial and recurrent tumors but the 19q and CDKN2A homozygous deletions observed only in the recurrent specimen served as evidence of malignant transformation. The fact that the tumor origin and BRAFV600E mutations were shared in both resections suggest a PXA-derived pathology but PXA-like histology was absent. Histologically, PXA demonstrates spindle shaped cells, pleomorphic nucleated cells, and EGBs while anaplastic APXA is additionally defined when mitoses number 5 or more per high-power field  and TERTEpithelioid GBM (E-GBM), on the other hand, has frequent BRAF V600 E mutations in 16.6~93% of cases –14 and EThere have been several reports of BRAFV600E-inhibitors as a potential treatment option for gliomas –19. BurgIn conclusions, we present a case of malignant transformation of PXA into GBM. Although diagnosed as GBM by histology, the molecular findings implied a PXA origin. In order to properly categorize these disease entities, more integrated criteria, including molecular information, may be needed.


Primary mature retroperitoneal teratomas are rare tumors most commonly occurring in adult females. These tumors are usually asymptomatic since they have no attachments to specific organs. We present a rare case of a 28-year-old male with 2-month history of lower urinary tract symptoms, who was found to have a primary mature cystic teratoma abutting the prostate. Dermoid cysts or mature teratomas are neoplastic structures composed of tissues from at least two of the three germ layers  , 2. They3 in volume. Pelvic Magnetic Resonance Imaging (MRI) showed a large mass confined to the pelvis measuring 7.2 cm in the largest diameter with predominance of cystic component without evidence of fatty content, calcification, fluid-fluid level, or suspicious enhancing nodular soft tissue thickening.A 28-year-old male patient with psoriasis presented to our facility with two-month history of lower urinary symptoms and increased bowel movements. Physical examination and laboratory studies were unremarkable. Suprapubic ultrasonography done outside our hospital showed an enlarged prostate measuring 72mm x 76mm x 67mm and 194 cmThe mass was seen in the perirectal space, displacing and exerting mass effect on the seminal vesicles, prostate and abutting the bladder without clear connection with the digestive system .Patient underwent a surgical resection through a suprapubic midline incision; the mass was approached from the left side after liberating and reflecting the bladder medially. Macroscopically, the mass weighs 157g and measures 7.5 x 5 x 5.5cm. It is covered by a thin membrane and is focally congested . Cut surMicroscopically, the excised cystic mass is covered with a thin fibrotic wall and lined by mature squamous epithelium with few skin adnexae and hair shafts filled with fibrillary keratin. Pathology was consistent with mature cystic teratoma . PatientPrimary retroperitoneal teratomas constitute about 1-11% of all primary retroperitoneal tumors , 15. TheTeratomas may be classified according to their location, content, epithelial lining, and degree of maturation . DependiBenign teratomas are usually asymptomatic and many are discovered incidentally. Symptoms are mainly related to the mass effect of the tumor; hence they appear later as the tumor grows in the retroperitoneum and they include flank or abdominal pain, urinary symptoms as in this patient, and gastrointestinal symptoms such as constipation . PhysicaWith the increased use of imaging, retroperitoneal teratomas increased in incidence. Plain radiographs may visualize calcifications but lead to nonspecific findings. Ultrasonography may be superior to radiography in delineating the cystic component but has limited specificity. Computed tomography scans and MRI are more appropriate. MRI can visualize the degree of invasion of adjacent structures as well as tumor content and may indicate if a wider resection is required , 21.Complete excision of the mass is curative and is the mainstay of treatment since histological assessment is important for confirmation of the diagnosis and should be attempted since primary retroperitoneal teratomas in adults rarely infiltrate adjacent tissues . In our Mature (benign) retroperitoneal dermoid cysts compressing the prostate are extremely rare. Imaging should be considered when evaluating young male patients presenting with lower urinary tract symptoms. Surgical excision is the mainstay and gold standard treatment that allows symptomatic relief of the patient as well as definitive histologic diagnosis.


Nodular fasciitis is a benign proliferation of myofibroblasts that usually arises in subcutaneous tissues of the trunk, neck, head, and upper extremities of young adults. It is not reported to arise in the joints.In this report, we describe a rare case where nodular fasciitis occurred in an intra-articular location in the right knee of a 20-year-old man. The patient presented with 3-months’ duration of knee pain without history of trauma to the extremity. Physical examination revealed pain, joint effusion, and limited range of motion (ROM) of the affected knee. Magnetic resonance imaging (MRI) showed a 2.5 × 2 × 1 cm lesion in front of the posterior cruciate ligament. Arthroscopically, the soft tissue mass was removed and pathologically diagnosed as a rare, benign, intra-articular nodular fasciitis. Symptoms resolved 1 month after the operation and no recurrence was found at the 6 months follow-up.The present paper describes detailed characteristics of intra-articular nodular fasciitis and provides an updated comprehensive summary of 21 prior case reports. Nodular fasciitis is a benign myofibroblastic proliferation commonly found in young adults aged between 20 and 40 years , 2. It uA 20-year-old man presented with a history of right knee pain of 3-months duration without any trauma or undue exercise. Physical examination showed joint effusion and limited range of motion. There was no locking in the joint and no palpable mass. He had no other significant past history.The patient did not receive any conservative treatments. He did not receive any plain x-radiography. An MRI of the right knee showed that the intra-articular lesion was located around the posterior cruciate ligament. The lesion showed iso-intensity or lower intensity compared to surrounding muscle in T1 weighted MRIs, and high signal intensity in T2 weighted MRIs , pigmented villonodular synovitis (7 cases), giant cell tumour (4 cases), inflammatory arthritis (3 cases), complex ganglion (2 cases), lymphoma (1 case), gout (1 case), desmoid-type fibromatosis (1 case), low-grade myofibroblastic sarcoma (1 case), cartilage bodies (1 case), haemarthrosis (1 case), osteochondral fracture (1 case), malignant fibrous histiocytoma (1 case), haemangioma (1 case), lipomas (1 case), haemangiopericytomas (1 case), parosteal osteosarcomas (1 case), localized nodular synovitis (1 case), and fibromyxoid sarcomas (1 case). Three of 21 cases did not undergo arthroscopic surgery. The duration of follow-up ranged from 2 months to 86 months. No recurrence was observed.Lesion sizes ranged from 1 to 6 cm  in the largest dimension. All tumours were a solid mass in gross appearance, usually grey or yellow.Histologic features showed typical nodular fasciitis, which was composed of cytologically bland and uniform plump spindle cells. The spindle cells were arranged within a variably loose myxoid to collagenous stroma in the form of short intersecting bundles. The loose myxoid to collagenous stroma contained scattered lymphocytes and red blood cells.By immunohistochemistry, all cases showed that the spindle cells were diffusely positive for alpha-smooth muscle actin (SMA). All cases except one were negative for desmin. All cases except one were negative for caldesmon. None showed positive for nuclear beta-catenin and S-100 protein. One case in the shoulder showed positive for protein gene product (PGP) and negative for anaplastic lymphoma kinase 1 (ALK1) in the spindle cells. Another case in the shoulder showed negative for CD34 and CD68. Three cases in the knee showed positive for vimentin in the spindle cells. One case in the knee showed positive for muscle-specific actin, CD10 and negative for bcl-2 and cytokeratin AE1/AE3.Only three cases, including one shoulder and two knees, did not undergo arthroscopic surgery to excise the lesion. Most patients’ symptoms were relieved a few days after surgery. For the patient with the lesion in the hip, partial weight-bearing on crutches and progressive post-operative mobilization were recommended, and the patient’s symptoms were relieved 3 weeks after surgery. Another case in the knee was recommended immobilization and non-steroidal anti- inflammatory drugs (NSAIDs) for 10 days, followed with physiotherapy with progressive mobilization; the patient’s symptoms were relieved 6 months after surgery. No recurrences were reported in any follow-up.Intra-articular nodular fasciitis is rarely reported. Until now, only 21 cases of intra-articular nodular fasciitis have been documented in the literature , pigmented villonodular synovitis (7 cases), giant cell tumour of tendon sheath (4 cases) or desmoid-type fibromatosis (1 case). These possibilities are excluded by histologic examinations. Histologically, the lesions showed typical nodular fasciitis, which is composed of cytological bland and uniform, plump spindle cells. The spindle cells were arranged within a variably loose myxoid to collagenous stroma in the form of short, intersecting bundles.Desmoid-type fibromatosis is an abnormal growth that arises in the connective tissue, including abdominal wall, shoulders, upper arms, and upper legs . It is aPigmented villonodular synovitis  and giant cell tumour of tendon sheath  were included in the giant cell tumours (GCT) of the synovium and tendon sheath . HistoloSynovial chondromatosis is determined by histological evaluation. The number of nodules in synovial chondromatosis can be counted in the thousands. Microscopically, the nodules are composed of hyaline cartilage with synovial tissue lining on the outside . The choTendon sheath fibroma should also be distinguished from nodular fasciitis, because tendon sheath fibromas share most of the immunohistochemical markers with nodular fasciitis, such as positive vimentin, smooth muscle actin and negative desmin . HoweverIntra-articular fasciitis presented with some distinctive features from extra-articular fasciitis. On one hand, prominent stromal hyalinization is quite common in intra-articular lesions caused by repeated, frictional trauma. On the other hand, haemosiderin deposition is also frequently seen in tissues adjacent to intra-articular nodular fasciitis secondary to trauma.Intra-articular nodular fasciitis, as in the musculoskeletal disorders, is usually identified with MRI. On the other hand, it was reported that ultrasound is also helpful in identifying the intra-articular nodular fasciitis . For musIn summary, nodular fasciitis can occur in the joints, most frequently in the knees and shoulders, without gender preference, in patients between 10 to 50 years old. It generally has a longer preoperative history than other cases of nodular fasciitis. The lesions show iso-signal or lower intensity compared to muscle in T1-weighted and hyper-intensity T2-weighted MRIs. The histological features are typical of nodular fasciitis, consist of a bland fibroblastic proliferation arranged in irregular fasciitis with tissue-culture-like appearance. It appears not to recur, though the number of reported cases is limited. Awareness of the occurrence of nodular fasciitis within joints including knees, shoulders, hands, ankle and hip will lead to the correct diagnosis. Additional reports about intra-articular nodular fasciitis cases in the elbow and other joints are needed in the future.


Plexiform schwannoma is a rare variant of schwannoma that accounts for only 5% of all schwannomas. Herein, we present a rare case of plexiform schwannoma of the tongue in a pediatric patient with neurofibromatosis type 2 (NF2). A 13-year-old female presented with a growing left-sided tongue mass. The patient has a past medical history of NF2. The tongue mass was excised and histopathological examination revealed a spindle cell tumor with multinodular growth pattern, with Verocay bodies' formation. Tumor cells were strongly positive for S-100 protein and negative for smooth muscle actin (SMA), and EMA highlighted perineural fibroblasts surrounding tumor nodules. These findings were diagnostic of plexiform schwannoma. Plexiform schwannoma of the tongue is an extremely rare tumor seen in patients with NF2. Clinical examination and histopathological evaluation are important for diagnosis of plexiform schwannoma. Schwannoma, also known as neurilemmoma, is a benign tumor of Schwann cells in the neural sheath of myelinated nerves throughout the body . Up to 4Neurofibromatosis type 2 (NF2), an autosomal dominantly inherited disease caused by structural mutation of the neurofibromin 2 (NF2) tumor suppressor gene on chromosome 22, is characterized by bilateral acoustic schwannoma in more than 90% of all patients. , 5. PlexA 13-year-old female presented to pediatric otolaryngology clinic for follow-up of a left-sided tongue mass, first detected in 2015, which was recently getting bigger and causing dental problems and difficulties with chewing. The patient has a past medical history of NF2, with bilateral acoustic neuromas , diagnosed more than 10 years ago. During this period, she underwent removal of a right optic nerve glioma and several neurofibromas of the skin. She also has a strong family history of NF2, with her father and two sisters also diagnosed with NF2.Oral cavity examination revealed a well circumscribed mass on the left anterior tip of the tongue . The masExcisional biopsy of the tongue mass was performed under general anesthesia. The mass was removed with 2.0 mm margins around the lesion . The posHistopathological examination revealed a spindle cell tumor with multinodular growth pattern, resulting from interlacing fascicles of Schwann cells (plexiform growth) . Most ofPlexiform schwannoma usually presents as a single lesion in the skin and less commonly in the deep tissues , 12. HarPlexiform schwannoma occurs at any age but usually involves younger adults, being quite rare in children. Most plexiform schwannomas are solitary, sporadically occurring tumors, typically arising from superficial tissues (79%), occurring most commonly in the head and neck region 23%), and account for 15% of cutaneous schwannomas %, and ac.Oral lesions of all types are present in about 75% of patients with NF1, in which the tongue is the most common location, while oral manifestations among NF2 cases are extremely rare , 15. TheTongue schwannoma presents as a painless slowly growing mass and is usually asymptomatic unless enlarged in size –21. NisaGiven the child's presentation of a slowly growing mass of the tongue, a wide range of benign soft tissue lesions should be considered as differentials. Lingual schwannoma, neurofibroma, amyloid tumor, lipoma, hemangioma, lingual thyroid, cystic lesions such as dermoid cysts and mucoid cysts, and benign salivary gland tumors are some examples of many on the list , 24. As The diagnosis of plexiform schwannoma relies on the characteristic gross and histopathologic examination that demonstrates a multinodular growth pattern of predominantly hypercellular Antoni A areas consisting of fusiform Schwann cells with a typical palisading pattern around central eosinophilic areas, known as Verocay bodies . In our Conventional and plexiform schwannomas can be differentiated from other nerve tumors by using immunohistochemical staining, where schwannoma shows strong, diffuse S-100 staining, a membrane protein currently considered the most sensitive marker for tumors originating from Schwann cells . Given tTransoral excisional surgery is the treatment of choice of oral plexiform schwannoma . HoweverPlexiform schwannoma is a benign tumor of Schwann cells, very rarely seen in patients with NF2. Clinical examination and histopathological evaluation are important for diagnosis of plexiform schwannoma. Surgical removal is the best treatment for these tumors, with extremely low recurrence rate.


Prior to the development of en bloc techniques, vertebral invasion by non-small cell lung cancer (NSCLC) had been considered a relative contraindication to surgical intervention. However, reports in the literature have demonstrated increased progression-free survival with the use of neoadjuvant chemotherapy followed by anterior en bloc resection of the residual tumor. Stereotactic spine navigation has been shown to improve accuracy during complex vertebral osteotomies, improving patient outcomes. We report a 53-year-old woman with an NSCLC in the left upper lobe, a periosteum attachment of the second and third thoracic vertebrae , and an infiltration of the corresponding nerve roots. We describe a surgical approach for the resection of NSCLC with vertebral infiltration utilizing stereotactic spine navigation and intraoperative computed tomography (CT)  for a posterior approach laminectomy, osteotomy, and partial vertebrectomy, followed by trans-thoracic en bloc resection of a superior pulmonary sulcus tumor with nerve root infiltration. Posterior approach vertebral osteotomy and en bloc resection for superior sulcus NSCLC infiltrating the vertebrae utilizing stereotactic spine navigation and intraoperative CT (O-Arm) is a viable alternative to the traditional anterior approach. Non-small cell lung cancer (NSCLC) comprises the majority of lung cancer diagnosed in the United States and confers an overall five-year survival of less than 18% . HoweverOur patient is a 53-year-old woman with a posterior, stage IIB NSCLC in the left upper lobe who received neoadjuvant carboplatin, pemetrexed, and radiotherapy. One year following diagnosis, the patient was found to have tumor attachment to the T2 and T3 vertebrae Figures -1B  and After the initial incision was made in the operating room, we exposed the spinal processes, lamina, and transverse processes from T1 through T5 and 5 cm of the ribs from the left costovertebral junction on the side of the tumor. At this point, images were taken with the O-Arm. We then registered the patient's spine to the StealthStation  navigation suite using the stereotactic probe. Then, using spine navigation, the instrumentation was placed at the level above and below the tumor-infiltrated vertebrae. We did not place screws on the left T2 and T3 vertebrae Figure . Here, wThe final surgical pathology report revealed moderately differentiated, acinar predominant stage IIB adenocarcinoma with a single focus, all three resected lymph nodes, and six margins were negative for tumor. The nearest margin was 4 mm from the tumor, confirming the accuracy of our planned trajectory on the StealthStation. One year later, the patient was doing well, with no evidence of tumor recurrence. The patient declined any further therapy during that time and was subsequently lost to follow-up.Tumors in the superior pulmonary sulcus have a particular propensity to invade the spine, historically considered to be a contraindication to surgical resection . HoweverIn our case, the lack of direct tumor invasion into extraforaminal, proximal neurovascular structures coupled with the precision provided by stereotactic spine navigation allowed for posterior vertebral osteotomy to facilitate an anterior en bloc resection. Specifically, the navigation probe allowed for accurate prediction of the trajectory of the ultrasonic aspirator, along with real-time measurement of depth throughout the drilling process. Though this approach is similar to the process described by Kent et al., we utilized stereotactic spine navigation for additional precision to avoid entering the periosteum of the vertebrae and tumor capsule . A resecWith this case, we contribute to the growing body of literature a description of the utility of intraoperative stereotactic navigation for en bloc resection of extra-spinal tumors invading the vertebral column. This procedure can be performed in one day or staged on two different days depending on the logistics of the healthcare facility and surgical team workflow. It is our hope that stereotactic navigation will be viewed as a powerful tool for the relief of tumor burden from complicated anatomical structures in a safe and reliable manner.The use of stereotactic spine navigation enabled a posterior approach vertebral osteotomy followed by a lateral approach for the resection of a superior pulmonary sulcus NSCLC, allowing for precise removal despite the proximity of neurovascular structures. This technique potentially simplifies the en bloc resection of thoracic tumors infiltrating vertebral bodies.


Barolith, a mixture of inspissated barium and feces, is a rare complication of barium‐contrast studies that lead to intestinal obstruction. With the high morbidity associated with barolith impaction, we recommend that physicians be more aware of complications, increase prompt diagnosis, and initiation of laxatives once discovered. These patients develop paradoxical small volume stool leakage, which often times can be misinterpreted as diarrhea. This case report describes a 64‐year‐old woman who presented with the chief complaint of “diarrhea and abdominal cramps” and was diagnosed with overflow incontinence secondary to intestinal obstruction from inspissated barium and feces forming a “barolith” which was a result of barium contrast roentgenography performed 9 months prior to the onset of presentation. No underlying colonic pathology was identified.2We report a case of a 64‐year‐old woman presented to the emergency department with an acute onset of diarrhea and cramping abdominal pain for two days. She was in her normal state of health until 9 days prior to the admission, when she became increasingly constipated. This was later followed by the onset of liquid stools at hourly intervals.Her review of systems was positive for loss of weight of 10lbs over 8 weeks and was negative for any associated fever, chills, nausea, vomiting, melena, or hematochezia. On examination, she appeared cachectic and malnourished with dry mucous membranes, soft and nontender abdomen with hyperactive bowel sounds. Rectal exam revealed normal tone and no sign of appreciable fecal impaction.Her past medical history was significant for well‐controlled hypertension and stage III gastric cancer. At the time of initial diagnosis, staging computed tomography (CT) scan with intravenous (IV) and oral contrast revealed peri‐gastric lymphadenopathy and focal thickening of the stomach wall. To the best of our knowledge, no further barium studies had been performed. She later underwent total gastrectomy with D2 nodal dissection with esophagojejunostomy. The patient was subsequently started on adjuvant chemotherapy. Three weeks after completion of her chemotherapy, the patient presented with the above symptoms. The patient underwent abdominal plain film imaging Figure A along w3In the geriatric population, the association between fecal incontinence and constipation has long been recognized with fecal impaction accepted as being the most common cause of involuntary stool loss.The pathophysiology of constipation and stool incontinence is multifactorial. The three major postulated mechanisms are as follows: (a) overflow incontinence from stool impaction, (b) involuntary, usually postdefecation leakage, due to retention of stool in the rectum, and (c) secondary to generalized pelvic floor weakness.Barium sulfate is the sulfate salt of barium which is an alkaline divalent metal. Barium sulfate, a water‐insoluble compound, is used in routine radiological procedures as a contrast medium. It not only remains the gold standard technique for imaging for fine mucosal details but also remains the best technique for demonstrating general gastrointestinal tract configuration and caliber.Baroliths refer to inspissated barium and fecal admixture which is formed after oral or rectal administration of barium sulfate contrast.In a systemic review of 31 cases by Kurer et al, factors contributing to a barolith formation were noted to include the history of abdominal surgeries, gut immobility, underlying pathology, and the patient's age, state of hydration, and diet.Currently, there are no recommended guidelines for the treatment of baroliths. For patients without clear indications for emergency surgery, treatment modalities range from manual disimpaction, enemas, and lactulose. In current literature, we identified three cases where barolith was not dislodged by conservative methods and colonoscopic dissolution was attempted and was successful in all of them.In the presence of the above‐mentioned risk factors, a follow‐up imaging 2‐3 days later is recommended and, if barium residue remains, a laxative should be administered immediately.Our patient had overflow incontinence which was initially interpreted as diarrhea, which later proved to be fecal impaction as was evident from further imaging. Reduced colonic motility from chronic opiates may have contributed to the development of barolith 9 months after initial administration of barium contrast. This case highlights the importance of considering overflow incontinence in the differential diagnosis of patients who have risk factors for chronic constipation and who present with small volume diarrhea and abdominal cramps. Chronic constipation and overflow incontinence are not uncommon in cancer patients who are on opiates for pain control. Complications from these may lead to increased emergency room visits, hospitalizations, and delays in chemotherapy.None declared.PS and BT: wrote the case report with support from MS and PP, who also supervised the project. All authors read and approved the final manuscript.


This case report shows successful treatment of a refractory sternocleidomastoid branch of the superior thyroid artery (SBSTA) pseudoaneurysm using endovascular glue embolization in a patient who refused surgery.  A 63-year-old female with multiple comorbidities presented with a firm 7 cm tender mass located in the right neck. Ultrasound showed pseudoaneurysm and a 7 × 3.3 × 4 cm multilobular hematoma in the location of the previous central line. CTA showed a corresponding heterogeneous mass. Serial imaging demonstrated enlargement over 2 weeks. Angiogram showed contrast blush off of the SBSTA.  SBSTA was embolized using glue. Repeat angiogram showed embolization and no contrast blush. One month later, the mass was no longer pulsatile but present on physical exam. CTA showed decreased size. 8 months later, her neck was soft without mass.  Pseudoaneurysms of the external carotid artery are rare and usually due to trauma. Pseudoaneurysms after central line placement are documented, but most are complications of femoral central lines. A handful of cases of superior thyroid artery pseudoaneurysms due to several etiologies are reported, but none involving the SBSTA. Therapeutic options include surveillance, compression, thrombin injection, embolization, and surgery. Endovascular management offers an alternative for patients unwilling or unable to undergo open surgery. Pseudoaneurysms are a tear though all layers of an artery allowing blood to leak into the surrounding tissue causing a mass that often gradually expands due to its communication with the arterial lumen. Signs and symptoms of pseudoaneurysms in the neck can include a pulsating mass which is the most common presentation, craniocervical pain, dysphagia, hoarseness, and neurologic deficits due to cranial nerve palsy or stroke.A pseudoaneurysm of the external carotid artery (ECA) is very rare with an incidence of 0.07% and mortality of 30% . It usuaAround 7 million central venous catheters are placed yearly in the United States. It is a relatively safe procedure, but complications do occur. The reported incidence of serious complications varies from 0.4% to 9.9%. Accidental arterial puncture occurs in approximately 5% of all central venous catheter placements and is more likely in internal jugular vein catheterization. This can lead to arterial dissection, arteriovenous fistula formation, hematoma, pseudoaneurysms, and stroke . PseudoaAlthough cases of ECA pseudoaneurysms have been reported as well as a handful of cases of superior thyroid artery pseudoaneurysm, no cases of a sternocleidomastoid artery pseudoaneurysm have previously been reported to our knowledge. The sternocleidomastoid artery is one of the five branches of the superior thyroid artery which is a branch of the external carotid artery. It can be identified because it is the only branch of the superior thyroid artery that courses laterally . This caA 63-year-old woman presented with a firm 7 cm multilobular tender mass located in the region of the right sternocleidomastoid directly above the clavicle. She had multiple comorbidities including renal failure, systemic lupus erythematosus, and protein S deficiency, a history of transient ischemic attack, deep vein thrombosis, and pulmonary embolism, and longstanding malnourishment requiring jejunostomy tube placement. The firm mass was identified 1 month after an unsuccessful attempt at placing a right internal jugular vein central line. When the central line was originally placed, she developed pain and swelling of her neck. The swelling was pulsatile at that time and enlarging. She was offered surgery as the standard of care for her condition which she refused because she did not want to undergo an invasive procedure and was aware of the risks involved with holding her anticoagulant medication. She had two thrombin injections in the mass since without success. She complained of right neck pain. She was not having any difficulty breathing and denied shortness of breath.Soft tissue ultrasound after the two thrombin injections showed pseudoaneurysm and a 7 × 3.3 × 4 cm multilobular hematoma at the base of the right neck. CTA of the neck showed a corresponding heterogeneous mass. The pseudoaneurysm was seen measuring 1.5 cm at the internal margin of the hematoma. Serial imaging with CTA demonstrated enlargement over a 2-week interval .Angiogram showed blush of contrast coming off of the sternocleidomastoid branch of the superior thyroid artery identifying the location of the pseudoaneurysm . This brOn follow-up one month later, the mass was no longer pulsatile but still present on physical exam. CTA of the neck showed a decrease in size from the previous CTA .On follow-up 8 months later, she was found to have a soft neck with no mass on physical exam.Diagnostic imaging can be used when history and physical examination point to possible pseudoaneurysm. Doppler ultrasound is a very helpful and benign test that can reveal a pseudoaneurysm as a spindle shape or sac-like dilation. It can show turbulent flow and vessel dilation with a 95% accuracy for pseudoaneurysm. It is less effective for deeper lesions which may be better seen on contrast-enhanced CT or angiography. Using angiography for diagnostic purposes is not first line since it is a more invasive procedure but can be utilized when it is also intended as a therapeutic option after other imaging has been performed .Therapeutic options include surgical resections, conservative surveillance, compression, thrombin injection, and catheter-based embolization. The gold standard treatment of pseudoaneurysm is surgical repair . As withUltrasound-guided thrombin injection relies on the formation of a clot within the pseudoaneurysm to exclude it from the circulation. Case reports have shown success of ultrasound-guided thrombin injection . This enA study done at the Ninth People's Hospital, Shanghai Jiao Tong University concluded coil embolization by angiography of pseudoaneurysms coming off the external carotid artery is a useful alternative to standard surgical repair and avoids morbidity associated with performing surgery in the face and neck area . Many caPseudoaneurysm should be included in differential for neck mass. A pseudoaneurysm due to central venous catheter placement is a very rare occurrence. Although cases of external carotid artery pseudoaneurysms have been reported, most are due to trauma. A handful of cases of superior thyroid artery pseudoaneurysms have been reported but no cases of sternocleidomastoid artery, a branch of the superior thyroid artery, pseudoaneurysms have previously been reported to our knowledge. This case study shows a successful resolution of a sternocleidomastoid artery pseudoaneurysm using glue endovascularly. Other treatments that were attempted were conservative management and thrombin injections, but these failed to resolve this woman's symptoms. While conservative management and compression may be good therapies to try initially in patients who are not in imminent danger, surgery and endovascular treatment are better therapies in pseudoaneurysms that are resistant to treatment or in unstable patients. Although surgery is the gold standard, endovascular treatment provides a less invasive option when the patient is not a good candidate for surgery or refuses surgical intervention. Thrombin injections may also be attempted but are not as safe without concurrent endovascular cerebral protection.


Boerhaave’s syndrome involves a sudden elevation in the intraluminal pressure of the esophagus, causing a transmural perforation. It is associated with high morbidity and mortality. Its treatment is challenging, and early surgical intervention is the most crucial prognostic element.We present a case of a 32 year-old male who presented after severe emesis with an acute onset of epigastric pain. He was diagnosed with Boerhaave’s syndrome. Displaying signs of shock mandated immediate surgical exploration with laparoscopic primary repair.The golden period of the first 24 hrs of the event still applies to cases of esophageal perforation. The scarcity of these cases makes a comparison between the various treatment methods difficult. Our data support the use of laparoscopic intervention with primary repair as the mainstay of treatment for the management of esophageal perforation.The online version of this article (10.1186/s12893-019-0576-7) contains supplementary material, which is available to authorized users. Boerhaave’s syndrome has long been discussed in the medical literature. Dr. Herman Boerhaave described the first case in 1724 [Boerhaave syndrome or spontaneous rupture of the esophagus is a perforation of the esophagus that results from an abrupt increase in intraesophageal pressure along with negative intrathoracic pressure; for example, after forceful retching or severe vomiting. Esophageal perforation is a rare entity, with an incidence of 3.1 per 1,000,000 per year . BoerhaaHerein, we present a case of Boerhaave’s syndrome, in which laparoscopic repair was successfully performed. In this paper, the authors support the use of laparoscopy for the primary repair of esophageal perforations as the mainstay of treatment. We present this case report to emphasize on the favorable outcome of using laparoscopy in the management of such cases, with an illustration of the intraoperative technique utilized in this case .Additional file 1: A video showing Intraoperative findings and techniques, . (MP4 355452 kb)We report the case of a 32 year-old male patient who presented to our Emergency Department with acute onset of unbearable epigastric pain after severe emesis following food ingestion. The pain was radiating to his chest and back and increases by any movement. Due to severe pain and dyspnea, the patient was unable to lay supine insisted on remaining sitting up for the examination. He had an episode of hematemesis after the start of pain. His medical, family, and psychosocial history were irrelevant. He had no previous surgeries performed. Physical examination revealed an anxious patient who looked pale, and dehydrated. His vital signs were, a temperature of 37.5 C, heart rate of 103 beats/minute, and the rest were unremarkable. Examination of the cardiopulmonary system was unremarkable. Upon examining the abdomen, the epigastric area was tender with guarding in the upper abdomen but soft at the lower part. No rigidity was appreciated.His laboratory investigations showed leukocytosis, WBC was 22 × 109/L. An electrocardiogram was done and showed sinus tachycardia. The chest  device. The left crus of the diaphragm was identified, and the anatomy of the gastroesophageal.(GE) junction was elaborated. We identified a 2 cm longitudinal perforation within the lower third of the esophagus at the posterolateral wall Fig. . We contA feeding jejunostomy was inserted to gain enteral access for postoperative nutritional support, and a nasogastric tube was advanced into the stomach under intraoperative guidance. Drains were placed intrabdominal and posterior mediastinal.The patient was then shifted to the Intensive Care Unit. He was kept on the ventilator post-op and extubated the following day. He was kept on antibiotics and was started on jejunostomy feeding.On postoperative day three, he was transferred to the regular surgical floor. Over a week duration, his leukocytosis resolved. On postoperative day 4, the patient was started on a clear fluid diet, which was well tolerated. One week postoperative, a CT scan of the abdomen-pelvis Fig.  was perfHe was reassessed in the surgical clinics and was doing very well with no complains. An upper endoscopy was performed 2 months after the surgery and confirmed normal esophageal and stomach anatomy.Boerhaave’s syndrome refers to spontaneous esophageal transmural rupture . BoerhaaTo diagnose this condition, physicians need to have a high index of suspicion. Although, there has been a publication where the classical findings of Boerhaave’s syndrome, was described as aiming to help in making the diagnosis. These findings were named as Mackler’s triad, and it includes emesis or retching, chest pain, and subcutaneous emphysema. The author has mentioned in his article that, these signs might not all be present in one case . In the While having the suspicion of Boerhaave’s, radiological studies should be performed to aid confirm the diagnosis and plan surgical intervention. These include plain chest x-ray, which is found to be abnormal in more than 90% of cases, with free air present in the mediastinal or peritoneal cavity . Less ofThe appropriate method for the management of esophageal perforation depends on many factors, such as the severity, time since perforation, the location, age, and status of the patient upon presentation. In such serious condition, surgery is considered as the mainstay treatment, and the outcome depends on early diagnosis, and treatment. The duration between the onset of perforation and surgery should not influence the decision of performing a primary repair.The literature reported that primary repair of the esophagus complemented by mediastinal and chest drainage is associated with a 90% success rate. This is especially true in cases where the esophageal rupture is diagnosed early (within 24 h) with is no associated esophageal diseases –17.If the diagnosis was late (more than 24 h), the outcome was found to be significantly worse, in which operative management is less successful , 19.Recent studies have recommended primary repair for esophageal regardless of the time interval between perforations , 21 and There have been few reports describing the laparoscopic management of this entity. Studies showed that laparoscopic surgery has many advantages over open surgery, which are a shorter length of stay, faster bowel recovery and earlier mobilization, and less blood loss , 24.The trans-hiatal approach results in a shorter length of hospital stay. In a study by Danson et al., the mean length of stay in the laparoscopic approach was 14 days . In contThe golden period of the first 24 h of insult still applies for cases of esophageal perforation. The rarity of these cases makes a comparison between the various methods of treatment difficult. The data presented support the use of laparoscopic operative intervention with primary repair as the mainstay of management of similar esophageal pathology, which showed success even with late presentations. The authors further emphasize the importance of involving a multidisciplinary team in the management of such challenging cases. This includes Intensive care physician, Thoracic surgeon, and laparoscopic surgeon.