Paragangliomas are rare and can occur in many places throughout the body, but mediastinal paragangliomas are even rarer, accounting for less than 0.3% of mediastinal masses. Extremely susceptible to misdiagnosis and mistreatment, which may lead to the death of the patient.We report a case of a giant paraganglioma of the middle mediastinum. A 40-year-old woman was admitted to the hospital with a rib fracture and a chest computed tomography suggesting a giant occupying tumor in the middle mediastinum.Immunohistochemistry revealed positive for S100 fraction and Syn, focally positive for CgA, while negative for CKp and succinate dehydrogenase complex iron sulfur subunit B gene, and Ki67index ≈ 5%. The imaging and immunohistochemical features suggested a final diagnosis of Paragangliomas.This patient underwent lateral open heart surgery to remove a mediastinal mass.One month after being discharged, the patient was contacted by phone for a follow-up visit and reported feeling OK. Unfortunately, as of the date of submission, the patient did not come to our hospital for review.Mediastinal paraganglioma as a rare and potentially malignant tumor susceptible to misdiagnosis and mistreatment. Organ pathology examination is the gold standard for diagnosis, and surgery is an important treatment method. A clear diagnosis and thorough preoperative examination are important guarantees for the success of surgery. Here, we report a case of a giant paraganglioma of the middle mediastinum that was treated surgically and discharged from the hospital.Paragangliomas are neuroendocrine tumors derived from neural crest cells, occurring in about 2 to 5 cases per million,A 40-year-old female presented to our hospital on February 20, 2023, with a mediastinal mass found on chest CT for rib fracture. The patient had no ptosis; no headache or dizziness; no chest tightness or shortness of breath; no chest pain or hemoptysis, and no history of palpitations, panic and facial flushing. The past medical history was not specific. Her temperature was 36.7ºC, heart rate was 82 beats/min, respiratory rate was 18 breaths/min, the blood pressure was 102/67 mm Hg. No positive signs were detected on physical examination. Enhanced CT of the chest suggests: mediastinal widening, and a large morphologically irregular and abnormally enhancing soft tissue occupancy with lobulated growth is seen in the mediastinum during the enhanced arterial phase. Patchy and nodular enhancement is seen in the arterial phase of the lesion, and contrast fills centripetally in the venous phase with an abundant blood supply. The size of the lesion is about 11.5 cm × 6.1 cm × 8.6 cm, up to the entrance of the thorax and down to the upper edge of the left atrium. The lesion is close to large blood vessels and trachea, the trachea and the left and right main bronchi are compressed, consider a tumor lesion -positive paragangliomas can achieve partial remission after treatment with tyrosine kinase inhibitors; Sesti et al reported that the multitargeted RTK inhibitor Sunitinib may be a viable treatment option for patients with inoperable paragangliomas. Overall, paragangliomas are clinically rare and the specific efficacy of various adjuvant therapies for paragangliomas still requires extensive clinical data to evaluate.The efficacy of chemotherapy in paraganglioma is uncertain, and it was previously thought that chemotherapy was insensitive to paraganglioma due to drug resistance. However, some patients can be completely cured after combination chemotherapy with cyclophosphamide, vincristine and dacarbazine, and stabilization of multiple metastatic paragangliomas of the bladder with octreotide in combination with cyclophosphamide, vincristine and dacarbazine chemotherapy has also been reported. with the highest rate of mutations in the B subunit, and mutations in the B subunit imply an increased risk of metastasis. Therefore, it has been proposed that all paraganglioma patients, as well as the immediate relatives of patients with gene abnormalities, undergo genetic testing.There is a family association between paraganglioma and the mitochondrial SDH gene, with 25% to 50% of cases being inherited. Paraganglioma risk is definitely raised by mutations in the SDH gene,In this case the tracheal bulge was significantly distorted by the tumor compression and the patient discovered a mediastinal mass by coincidence. However, the patient did not experience any discomfort, such as dyspnea or shortness of breath. Due to the lack of pathological diagnosis, the clinical diagnosis was considered to be hemangioma, and the location of the tumor was biased to the right side, so the right side open thoracotomy was performed without extracorporeal circulation, and the tumor envelope was seen to be intact during the operation, with no signs of tumor infiltration. The intraoperative bleeding was about 2400 mL, and the blood volume was supplemented with suspended red blood cells and plasma to stabilize the hemodynamics.The biggest mistake in the treatment of this patient was the failure to perform preoperative vascular imaging and the lack of consideration for preoperative prophylactic embolization to prevent major intraoperative bleeding. This led to significant hemodynamic fluctuations during the surgery. Preoperative angiography is crucial for such mediastinal tumors that exhibit widespread enhancement on enhancement in order to evaluate the tumor’s vascular supply and, if required, carry out prophylactic embolization. suggest that approximately 31% of patients with benign paraganglioma cannot be cured by surgical resection; according to Van Slycke et al, the average local recurrence rate of extra-adrenal paraganglioma at 5 years after surgery was 15 ± 7%, and the average local recurrence rate at 10 years was 23 ± 9%, the recurrence rate was 23 ± 9%. Paraganglioma patients must thus undergo long-term follow-up, and high-risk patients, such as those who are younger, have genetic problems, have big tumors, or both, should undergo annual follow-up for the rest of their lives.Paragangliomas generally have a good prognosis, but they have malignant potential and may manifest malignant behavior clinically even if the tumor is benign. Recurrence and metastasis may also occur after resection of paraganglioma, and the most common metastatic complements are lung, lymph nodes, and bone. Data from Erickson et alConceptualization: Shaopeng Xu, Jinchen Du, Linchong Ma, Qingxin Li.Data curation: Shaopeng Xu, Lei Zou.Formal analysis: Shaopeng Xu, Jinchen Du.Funding acquisition: Gawei Hu.Supervision: Gawei Hu, Qingxin Li.Validation: Gawei Hu.Writing – original draft: Shaopeng Xu, Linchong Ma.Writing – review & editing: Gawei Hu, Qingxin Li.


Tuberculosis in India has been a constant health issue. The revised national tuberculosis control program has suggested antitubercular drug regimens according to WHO guidelines for pulmonary and extrapulmonary tuberculosis. Here is an uncommon case of an adult presenting with a single lytic lesion of the lateral condyle of the femur; he had no history of primary foci of pulmonary tuberculosis and curettage of the lesion and histopathological examination of the bone tissue showed tubercular etiology. The patient, hence, was started on antitubercular drugs and at a six-month follow-up, resolution of the lesion was noticed. It is most common in the spine followed by the femur, tibia, and small bones of hands and feet, requiring CT or MRI imaging and histopathological examination for diagnosis. Though the incidence of skeletal tuberculosis has decreased among the European population, it is still on the rise among Asian, African, and American populations. The metaphysis is the most common site of the initial lesion, which could either be contained or spread to the epiphysis, where it could affect the adjacent joint. Skeletal tuberculosis affecting the metaphysis in long bones is more commonly noted in children than in adults. Also disseminated tuberculous infection affecting a single bone and manifesting as focal lytic cortical lesions is rare and unusual [Tuberculosis remains a major international health problem and the leading cause of avoidable death despite advances in radiological diagnosis and antituberculous therapy as people often do not seek care due to poor knowledge of the disease, stigma, or health access barriers ,2,3. Ext unusual . The odd unusual . In thisA 28-year-old male with no known comorbidities presented with complaints of pain in his left knee for one month associated with difficulty in walking for three weeks. He was apparently normal two months back when he had an alleged history of road traffic accident (two-wheeler vs two-wheeler) and sustained an injury to his left knee, following which he was asymptomatic and was able to bear weight. Five weeks following the incident, he developed pain in his left knee along with difficulty in weight bearing. He gave a history of fever going one month back, which settled with antipyretics. He did not have any history of constitutional symptoms such as loss of appetite, loss of weight, evening rise in temperature, cough, or cold. There was a family history of his grandmother having a similar lytic lesion in her left ankle thirty years back. On local examination of the left knee, a swelling of size 5x5cm was found present over the lateral condyle of the femur associated with tenderness; the active and passive range of movement of the knee was 0-60 degrees. Routine laboratory investigations were taken and were within normal limits. Erythrocyte sedimentation rate and C reactive protein values were elevated. Chest X-ray was normal. X-ray of the left knee showed a hypodense lesion in the lateral condyle of the femur Figure .MRI of the left knee further showed a hypoechoic area with erosion in the lateral femoral condyle along the epi-metaphyseal region with areas of cortical break posteriorly with permeative bone destruction, severe marrow edema involving the meta diaphyseal region of lower shaft of femur on lateral aspect extending to epiphysis surrounding the lytic lesion, all features favoring osteomyelitis with lytic lesion in lateral femoral condyle Figure .The patient was taken up for excision biopsy and curettage where through lateral approach skin and soft tissue were dissected, the iliotibial band was also dissected and vastus lateralis was split. The bone site was reached and the lytic lesion was visualized under C-arm guidance. Multiple drill holes were made over the lytic lesion site and curettage was done. A thorough wash was given, antibiotic vancomycin was kept over the curetted lytic lesion region, and the wound was closed in layers Figure .The curetted part of the bone was sent for acid-fast staining, gram staining, and culture sensitivity which turned up to be negative for any growth. Histopathological examination done on the curetted bone sample suggested features of necrotizing epithelioid granulomatous inflammation, showing the possibility of tuberculous etiology. He was hence started on category 1 antitubercular drugs under the Revised National Tuberculosis Control Programme as per revised WHO guidelines and followed up for six months. He was also started on physiotherapy such as static quadriceps exercise, knee bending exercise, and non-weight-bearing walking with walker support, which was gradually converted to partial weight-bearing walking after one week of post operative period. One month postoperative X-ray of the left knee showed a resolving lesion on the lateral condyle of the femur Figure .MRI of the left knee was taken at the end of six months, which showed no new lesions Figure .He has improved symptomatically with the full range of movements of the left knee Figure  and is aTuberculosis infection has one of the highest mortality and morbidity rates in the world. An estimated 10.6 million people are infected with tuberculosis every year among which one in five present with extrapulmonary tuberculosis of which 6% amounts to skeletal tuberculosis . Ten perBaykan et al. have described tuberculous osteomyelitis affecting the femur, tibia, and the bones of hands and feet, having primary foci in the lungs, which may or may not be an active disease, mainly spreading to the epiphyseal region in the pediatric age group , whereasTuberculosis is very common in India but its presentation as a single lytic lesion in the lateral femoral condyle in an adult in the absence of other bone and lung lesions is very unlikely. The likely chance of an orthopedist encountering and treating tuberculosis in atypical sites in long bones warrants the need for suspicion and early diagnosis as the risk of multidrug resistance is on the rise. Our case highlights the high degree of suspicion one must have in diagnosing a lytic lesion of long bones. Error in diagnosis and treatment burdens the medical resources and overall morbidity. Hence, tuberculosis must be kept in mind as one of the differential diagnoses for a lytic lesion in the skeletal system until proven otherwise even if the patient might not present with any constitutional symptoms.


Foreign body ingestion, particularly fishbone, is a prevalent medical complaint in the emergency department. Usually, these foreign substances pass through the gastrointestinal tract without causing any complications. The clinical manifestations of foreign body consumption are non-specific.A 32-year-old male patient presented to our hospital with severe abdominal pain. Physical examination revealed a distended abdomen and tenderness. Plain chest and abdominal X-rays were unremarkable. The performed computed tomography (CT) of the abdominopelvic region showed multiple abscesses. Then, an exploratory laparotomy was decided during which a foreign body, a fishbone, was detected and the affected omental mass was resected, and abscess drainage was done. The resected specimen was sent for histopathological studies. The postoperative period was uneventful.Perforation of the intestinal wall by fishbone ingestion is an unusual entity. The clinical features of intestinal perforation are usually non-specific resulting in delayed diagnosis. Based on individual situations, the treatment strategy can be surgical or non-surgical.Even though ingesting a foreign body is a frequent complaint in clinical practice, its repercussions are extremely rare. Our case presented multiple intra-abdominal abscesses and perforation as a complication of accidental fishbone ingestion. •Foreign body ingestion consequences, as perforation, are extremely rare.•The clinical features of intestinal perforation are usually non-specific resulting in delayed diagnosis.•Computed Tomography is highly sensitive diagnostic tool of intestinal wall perforation.•The gold standard of treatment is surgical techniques to remove foreign objects. Within The risk of intestinal perforation is low and significantly less to be occurred in the large intestine . If perfIt is estimated that 10 to 20 % of patients require endoscopic intervention to remove a foreign body, and surgical intervention is required in less than 1 % of cases ,8.Here we report a 32-year-old gentleman who presented with severe abdominal pain found to be due to ingested foreign body, fishbone, resulting in multiple abscess formation and intestinal obstruction. Our work has been reported in line with the SCARE 2020 criteria .2A 32-year-old male patient, with unremarkable medical or surgical history, presented to our hospital with a ten-day history of severe abdominal pain. This pain was diffused on and off in nature and was associated with vomiting and followed by constipation. Physical examination showed a febrile, paled patient with a distended abdomen with localized tenderness in the left paraumbilical region. No evidence of bleeding or masses was detected in the rectal examination.On admission, the patient was conscious, alert, and oriented to time, place, and person, and Both performed plain chest and abdominal X-rays failed to diagnose the existence of a foreign body .Fig. 1PlThen, abdominal ultrasound was done before hospital admission, showing two large intraperitoneal abscesses in the right lumbar region with a mild subhepatic thick turbid collection.•Multiple encysted fluid collections were seen in the pelvic abdominal region.•Two encysted fluid collections were seen connecting, one was seen in the anterior part of the right lumbar region measuring about 12 × 3 cm, and another one was seen in the umbilical and left lumbar region measuring about 11.6 × 7 cm.•Another large, encysted collection was seen in the pelvic region between the urinary bladder and rectum, compressing the urinary bladder anteriorly and measuring about 12 × 7.6 cm.•Multiple enlarged mesenteric and para-aortic lymph nodes.•Normal appearance of liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and adrenals.•Impression was multiple large, encysted collections most likely to be multiple abscesses in the pelvic abdominal region.At this point, a computed tomography (CT) scan of the abdominal and pelvic region was decided, revealing , Fig. 3:Conservative management was with intravenous fluids and antibiotics initiated, which failed to control the patient's clinical condition. So, a diagnostic laparoscopy was planned . The proThe presence of an inflammatory response indicated healed perforation that was created by the fishbone.Drainage of supra hepatic abscess and inflamed sigmoid colon was also achieved.Multiple attempts were done to assess the perforation and abscess formation sites. These include an air leak test, upper gastrointestinal methylene blue test, and milking test. All tests showed negative results. The patient's abdomen was kept open for abdominal re-evaluation, aiming to detect the perforation site.Three days later, a second look was performed, during which no evidence of free fluid or leak was detected. Running of the small and large bowel was done, and two drains were placed in the left upper quadrant and pelvis. Finally, abdominal skin closure was achieved using skin clips.The resected specimen was sent for histopathological studies .Fig. 5HiA: Inflammation and myofibroblastic proliferation.B: Gram stain inflammation and Bacteria.C: Inflammation and myofibroblastic proliferation.D: Necrosis myofibroblastic proliferation.E: Inflammation giant cell reaction.F: Inflammation and myofibroblastic proliferation.G: Inflammation giant cell reaction.H: Acute inflammation and mesenteric tissue.Grossly, the resected specimen revealed a tan-brown mass measuring 8.5 × 6.5 × 2.5 cm. The cut sections showed a solid yellow surface with hemorrhagic and necrotic areas. Also, the resected mass was a positive Gram stain for bacterial organisms. So, acute and chronic inflammation with myofibroblastic proliferation, ischemic with necrotic changes, and abscess formation of the omental mass was detected.The patient could not recall the time of fish bone ingestion retrospectively. The postoperative period was uneventful, and the patient was discharged on postoperative day 5.3The intestinal wall perforation is commonly encountered in long and sharp-edged foreign materials due to the anatomical features and/or restricted angulation of the gastrointestinal tract (GIT). The most prevalent ones are chicken bones, toothpicks, and fish bone, which is the most common etiology of GIT perforation .The clinical features of bowel perforation due to fish bone ingestion are variable ,14. AbdoIn our case, the patient presented with severe abdominal pain and rebound tenderness most likely indicating bowel perforation.Most of the patients failed to correlate foreign body consumption to their medical signs and symptoms, which is expected considering that the median duration from ingestion to the clinical presentation of perforation was 10.4 days, which is compatible with our patient's presentation time ,16. SomeForeign body penetration is a difficult medical situation that is associated with an elevated risk of mortality and morbidity due to late recognition and treatment of the complication ,13.Due to the wide range of perforation locations, the common lack of foreign body ingestion recognition, and multiple clinical signs of perforation, making a diagnosis is frequently challenging . PreoperAccording to reported cases of foreign body perforations, 83 % of these were in the ileocecum, followed by rectosigmoid ,13,14,18A minority of cases of swallowed foreign substances necessitate surgical intervention, while the rest pass through the GI tract without any complications within a week ,4,13. CeThe intestine has a protective mechanism that is activated if the mucosa of the intestine gets punctured by sharp-edged substances, causing localized ischemic areas with significant central convexity forms . At the Fish bones generate pathological alterations that are unique to their sharp point, which grabs the mucous membrane of the wall of the gastrointestinal tract and leads to a necrotic gut, forming a mucosal band around the fish bone that attaches it to the tissue . Also, tThe main risk factor that is related to bowel perforation caused by fishbone ingestion is denture usage ,18. A stPreoperative diagnosis is challenging, mimicking several abdominal pathologies ,6,15. InEven though the role of sonography in the identification and detection of fishbone was mentioned in several studies, its usage is often unreliable ,17. On uThe radiological signs of foreign body perforation on CT scan include pneumoperitoneum, curved foreign substance, fatty strands, intraperitoneal effusion, regional inflammatory alterations, and formation of abscess ,17. The In the current case, a CT scan of the abdominopelvic region showed multiple abscesses that indirectly indicated perforation besides other radiological findings mentioned previously in the case presentation section.Despite the fact that the medical imaging field is advancing, numerous diagnoses of acute abdominal symptoms can be achieved intraoperatively through surgical procedures such as laparoscopy or open laparotomy ,15,20. TA study reported the role of a patient's early presentation can facilitate an efficient endoscopic resolution of such cases . In the Our case was managed operatively by diagnostic laparoscopy that was converted into exploratory laparotomy due to the presence of multiple abscesses. The patient underwent emergent surgery for intraabdominal abscess drainage with foreign body removal. The intraoperative findings were prescribed in the case presentation section.4Despite the rarity of foreign body ingestion complications, like perforation, it is related to high morbidity and mortality rates. The bowel perforation and its consequences, following ingesting the foreign substances, are uncommon life-threatening situations. Imaging modalities aid in the demonstration of characteristics and localization of intra-abdominal signs of perforation. To manage foreign body complications, especially perforation, a surgical approach either by laparoscopy or exploratory laparotomy is a viable treatment option. Our case report emphasizes the diagnostic and surgical challenges of foreign materials perforation.No funding or grant support.Not applicable.Written informed consent was obtained from the patient to publish this case report and accompanying images. On request, a copy of the written consent is available for review by the Editor-in-Chief of this journal.Not applicable.Not commissioned, externally peer reviewed.Athary Saleem: paper writing, editing, picture editing, manuscript drafting.Saqer Alenezi: literature review, paper writing, and editing.Seddeqah Abdulbaqi: Assist in surgery and editing.Anas Saud: picture editing.Nimer Al-Shadidi: performed surgery, paper editing, and supervision.Athary Saleem, D.Pharma., B.Med.Sc., M.D., General surgery department, Al-Adan Hospital, Kuwait.Email: athary.saleem@outlook.comThere are no conflicts of interest to declare by all the authors.


Intestinal adhesions are fibrotic bands of scar tissue that develop intra-abdominally due to serosal or peritoneal irritation caused during surgery or by severe infections. It may also occur congenitally. It can lead to serious complications such as small bowel obstruction, which is then termed adhesive small bowel obstruction. In this scenario, it can constrict the bowel wall and cause ischemia and necrosis of the affected intestinal segment. Computed tomography imaging may show characteristic signs, such as the “whirl sign” or “fat-bridging sign.” Diagnostic laparoscopy or laparotomy can confirm the diagnosis and presence of adhesions. Management of this condition is either conservative or surgical, the latter of which is necessary in the case of intestinal strangulation. While the literature supports the laparoscopic method of adhesiolysis, practically, it may present technical difficulties. Surgeons should employ their clinical judgment in cases where an open procedure may be more beneficial. We present a case of this very occurrence and discuss the risk factors, pathogenesis, diagnostic evaluation, and, finally, the approaches to surgical management of this condition. Intestinal adhesions are fibrotic bands of scar tissue that unusually connect two or more intra-abdominal organs. This scar tissue can form due to tissue irritation or disturbances, such as surgery, significant trauma, or any infectious disease. Although it is a normal phenomenon in the healing phase, it can pose a significant risk in the development of bowel obstruction . PostopeA 35-year-old female patient presented to the emergency department with complaints of sudden, severe, and diffuse abdominal pain for one day, associated with more than twenty episodes of vomiting. The patient denied any changes in bowel movements, such as constipation and obstipation, any fever or chills, or abdominal distension. The patient denied any past history of abdominal pain or any previous hospital admission. Her past surgical history includes an open appendectomy performed 25 years ago. Laboratory investigations were unremarkable. The urine pregnancy test reported negative results. Upon physical examination, the patient looked dehydrated, with diffuse abdominal tenderness on palpation and sluggish bowel sounds on auscultation.An abdominal computed tomography (CT) angiogram revealed long-segment circumferential wall thickening in multiple segments of the distal small bowel  and poor enhancement of these thickened bowel loops with a lack of differentiation of different layers of the bowel wall despite an adequate bolus of intravenous contrast, as seen in Figure The patient was then admitted to the emergency department as a case of intestinal obstruction with intestinal ischemia and immediately posted for diagnostic laparoscopy, during which turbid hemorrhagic fluid was found intra-abdominally and the twisted, dilated gangrenous jejunal and ileal loops were identified. Laparoscopic untwisting of the affected loops was tried but failed due to a lack of intra-abdominal space. In light of these findings, the procedure was subsequently converted to an open laparotomy. A thick adhesion band from the right iliac fossa was found arising from the ileocecal junction to the mid-jejunal mesentery, leading to 360-degree anti-clockwise twisting of distal jejunal and proximal ileal loops, as evidenced in Figure The pathogenesis of adhesion formation is not entirely clear. However, the most widely accepted theory is that a disturbance of the mesothelial surface causes upregulation of the coagulation and inflammation signaling pathways ,5. The pPrevious surgeries are the most common cause of the formation of adhesions, with the most common being laparotomies, as seen in our patient, and few occurrences following laparoscopy. However, it has been reported that with laparoscopic surgery, the risk of developing adhesions has decreased, with the incidence being approximately 5%. The degree of adhesion formation usually corresponds to the severity of intestinal pathology . It shouThese adhesion bands pose a significant risk as they can tighten and constrict the bowel, leading to ischemia and necrosis, as seen in our patient. A preliminary diagnosis of ASBO due to adhesions is made based on the history given by the patient and the physician's clinical judgment . A CT scManagement of ASBO can be either conservative or surgical ,8. Non-oThe risk of ASBO depends on the location of the adhesion, the type of surgery performed, and the various materials used during the procedure, such as sutures, gauze, and even carbon dioxide gas sufflation ,10. LapaSzeliga and colleagues review and discuss the literature comparing the laparoscopic versus open surgical approach to adhesiolysis in the case of ASBO. They summarize that while laparoscopy is more common and recommended, realistically, it presents technical difficulties that might require converting the procedure to an open type, as seen in our case. The restricted view of the intra-abdominal cavity, especially when packed with intestines and adhesions, can be a significant obstacle when performing such diagnostic procedures . They reIntestinal adhesions are a common complication of intra-abdominal surgical procedures that can lead to ASBO. It can develop due to irritation or injury to the peritoneal or serosal surfaces. While the patient's history, clinical features, and CT findings can raise suspicion for ASBO, diagnostic laparoscopy or laparotomy is preferred for confirming and treating ASBO. In those patients without intestinal strangulation, conservative management is preferred. In the presence of intestinal strangulation, operative management is recommended, more specifically a midline laparotomy with adhesiolysis. Surgeons should be mindful of the risk of adhesions developing postoperatively and should employ the recommended prevention strategies to minimize the risk. Notwithstanding these recommendations, there are some cases where the surgeon needs to employ their clinical judgment and consider conversion to open surgery.


Extrahepatic metastasis of hepatocellular carcinoma (HCC) is common. However, pituitary metastasis of HCC is extremely rare. Our case may be helpful to extend the understanding of the disease.A 65-year-old man presented to the outpatient department for unexplained headache and ptosis for 1 month. Brain imaging showed a slight enhancement tumor in the pituitary fossa, and the endocrinological assessment showed normal results. We considered the tumor as a non-functioning pituitary adenoma before surgery. Then, the tumor was resected by an endonasal endoscopic transsphenoidal approach. The histopathological examination results revealed the pituitary metastasis of HCC. Additional abdominal imaging revealed tumors were located in the left and right liver lobes with portal vein invasion and bilateral ilium metastases. After multidisciplinary cooperation, the patient chose chemotherapy.We report a case of HCC metastasis to the pituitary gland that initially presented with neurological symptoms. We should consider the possibility of pituitary metastasis in HCC patients. The most common primary tumors metastasizing to the pituitary gland are breast and lung cancers. The common sites of metastasis for hepatocellular carcinoma (HCC) are the lungs, lymph nodes, and rarely bones . PituitaA 65-year-old man with a headache and left ptosis for 1 month was admitted. He also had a left blurred vision. These symptoms gradually worsened. He declined any symptoms of abdominal pain, nausea, and vomiting. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a mass in the pituitary fossa. He denied discomforts elsewhere. He had hepatitis B antigen-positive for 6 years and did not receive antiviral treatment. His family members did not have a history of liver cirrhosis. Neurological examinations revealed left eyelid ptosis and a small left pupil. Eyeball movements in all directions were normal. The remaining physical examinations were insignificant.The hepatitis B virus test showed a hepatitis B surface antigen level of 2813.00 COI . The liver enzyme test detected a glutamic pyruvic transaminase level of 46 IU/l  and a glutamyl transpeptidase level of 157 IU/l . The results of blood platelet count and coagulation function were normal. An endocrinological test revealed a normal hormone level. The results in the oncology department showed that the level of alpha-fetoprotein was 260 ng/ml .CT showed a pituitary mass with adjacent bone destruction  for the publication of this case report.Conceptualization: SZ, BC. Data curation: FD, QH. Methodology: FD. Resources: BC, SZ. Supervision: SZ, CY. Validation: SZ. Writing—original draft: QH. Writing—review and editing: QH. All authors contributed to the article and approved the submitted version.


Spindle cell lipoma (SCL), an uncommon variant of benign lipomatous tumor, occurs predominantly in the posterior neck or the shoulders. Patients usually present a well-circumscribed and non-aggressive subcutaneous mass. Histopathologically, the mass comprises fat, CD34-positive spindle cells, and ropey collagen on a myxoid matrix. We report a case of left-shoulder SCL in a 45-year-old Saudi male nonsmoker with no known trauma. A soft tissue mass was seen on MRI near the posterior shoulder. It was a 4.5 cm x 3 cm subcutaneous rounded lump with heterogeneous signal intensity. There is no aggressive or invasive feature, and there is no significant fatty content. The mass was surgically excised with no complication. Histological examination revealed a neoplastic lesion constituted of mature adipocyte lobules and proliferation of loosely held bland spindle-shaped cells against a myxoid background. These cells exhibit neither increased mitoses nor nuclear pleomorphism. There were intervening rope collagen bundles. Lipoblasts and atypical stromal cells are also unidentified. At the periphery, a thin capsule was identified. There is no evidence of malignancy. To the best of our knowledge, this is the first reported case in Unaizah, Al Qassim. The correct diagnosis of SCL without a lipogenic component may be made by paying close attention to the clinical setting, histologic characteristics, immunohistochemical profile, and chromosomal abnormalities. Spindle cell lipoma (SCL) is a rare, slow-growing, benign lipoma that was initially documented in 1975 . The comHistory and physical examinationA 45-year-old Saudi man, a nonsmoker with no known medical issues presented a left shoulder swelling that had been increasing without pain throughout a five-year history. The patient, who had no prior history of trauma, noticed the growth by chance. As the swelling grew in size, it became uncomfortable for the patient to wear clothes and drew the attention of others at work and the gym. Lipoma was suggested during the initial investigation. An evaluation of symptoms found that B-symptoms, such as fever, weight loss, and night sweats, were not present. And no family history is present.The patient seemed to be in good health and was cooperative throughout the examination. He was conscious and oriented to time, place, and person. His vital signs were normal, and his neurovascular examination was unimpaired. During the examination of the shoulder, there was a fixed shoulder mass that measured 6 cm by 6 cm: mainly due to his thick skin. This mass was not moving in relation to dimensions and did not pose any restrictions on the patient's range of motion at the shoulder joint. The mass was round in shape with ill-defined borders and an irregular surface. When palpated, the swelling had the consistency of a firm mass. It was on a subcutaneous plane, with the overlying skin remaining undamaged and detached. There was no indication of lymphadenopathy in the regional area. Clinical evidence points to the presence of a lipoma.Pre-operative investigationThe pre-operative MRI revealed the presence of a soft tissue mass near the posterior shoulder. It was a subcutaneous lump that measured 4.5 centimeters long by 3.5 centimeters wide by 2 centimeters depth and had a round shape. The signal intensity was heterogeneous. There was no aggressive nor invasive feature, nor was there a substantial amount of fatty content seen Figures , 1B.Procedure and follow upAfter the risks and benefits of the surgical excision were discussed, a patient's informed consent was obtained for an elective procedure to excise the mass. At first, the area surrounding the skin lesion was prepared and draped in the usual sterile manner and then was anesthetized. Skin incision was made in a linear fashion and lipoma was excised bluntly using small forceps. Hemostasis was assured. The mass was submitted to histopathology for examination under a microscope measuring 5 cm long by 4 cm wide by 2 cm high. After receiving confirmation from the histopathology that the sample did not contain any features indicative of malignancy, the incision was irrigated and then closed in layers. The patient tolerated the procedure well. The patient was discharged one day after the operation, the dressing was changed upon discharge under sterile technique, and six weeks later, when the patient was followed up on, there were no more complaints, the wound was healing, there was no discharge, and there were no new masses.Post-operative investigationsPost-operative microscopic description revealed a neoplastic lesion composed of an admixture of lobules of mature adipocytes and proliferation of loosely held bland spindle-shaped cells against myxoid background. These cells do not show increased mitoses nor nuclear pleomorphism. Intervening rope collagen bundles were seen. Atypical stromal cells and lipoblasts are also not identified. A thin capsule was focally identified at the periphery. There is no evidence of malignancy Figures , 2B.A panel of immunohistochemical stains is performed, and the following reactivity pattern is observed in spindle cells: CD34: Positive; SMA: Positive; Desmin: Negative; and S100: Non-contributory.A common subcutaneous tumor, known as a lipoma, is made up of adipose (fat) cells and is often surrounded by a thin layer of fibrous tissue. Lipomas may occur in both adults and children. In point of fact, these neoplasms make up the majority of those seen by medical professionals. Patients often have symptoms in the cephalic area of the body, particularly in the head, neck, shoulders, and backs of their bodies, according to clinical observations. The subcutaneous tissues of patients are the most prevalent location for tumors to be discovered. Even though the ages at which the masses emerge might vary, doctors almost never need to treat them since they are almost always benign. They are not hazardous to the patient unless they are uncomfortable owing to their position on joints or are developing at an excessive pace, both of which are uncommon for lipomas due to the slow growth rate that is characteristic of lipomas. One of the numerous unusual types of lipomas, which may take many different shapes, is known as SCL .In 1975, Enzinger and Harvey were the ones who made the first discovery of SCL . There iThe lesion that may be seen inside a myxoidstroma is made up of mature adipocytes, very small homogeneous spindle cells, and eosinophilic collagen bundles. According to immunohistochemical labeling, spindle cells are positive for CD34 but negative for S-100 protein. This is in contrast to lipoma cells, which usually only include an adipocyte component and generate a lobular pattern that is embedded in a collagenous matrix. On the other hand, CD34 is not a marker that is only seen in SCLs; rather, it is a signal that may stain positively for various cancers that fall within the lipoma differential diagnostic range. Desmin negativity as well as chromosomal deletions on 12q and/or 16q in SCLs may be helpful in making the diagnosis [The differential diagnosis may include a variety of benign lipomatous tumors made up of mature adipocytes with or without additional components of mesenchymal tissue. Another item that has to be separated is well-differentiated liposarcoma (WDL), which is the most important differential diagnosis. In regions that are analogous to SCL and have boundaries that are difficult to identify, WDL is commonly encountered. Through meticulous histological examination, the features of liposarcoma invasion may be identified. The uniformity of the spindle cell shape, in addition to the lack of lipoblasts, which are not present in SCL, will tip the scales in favor of SCL. It is possible that liposarcoma is present when a “lipoma” that has been excised in the past continues to come back. In contrast to spindle cell lipoma, liposarcoma demands significant broad excision. As a direct consequence of this, we were able to rule out WDL as well as other malignancies. Because WDL very seldom includes spindle-shaped cells that are positive for CD34, the presence of the tumor provided additional evidence for our diagnosis of SCL .SCLs that are fat-free or have a low amount of fat are at one end of a vast range of imaging characteristics created by changes in the ratio of fat to spindle cells. These lipomas are difficult to diagnose with radiological scans because of their overlap and similarities with other soft tissue tumors. In the case that was given, magnetic resonance imaging (MRI) showed that there was a soft tissue mass at the posterior shoulder that was sized 4.5 centimeters by 3 centimeters and had a round appearance beneath the skin. There have not been any invasive or aggressive behaviors, and there was not a considerable amount of fatty content. The advanced age of the patient, the lack of B symptoms, and an intraoperative assessment of a multilobulated fatty projecting mass were all indicators that the patient had a lipoma. Fortunately, a pathological examination determined that the tumor was an SCL, which may be easily treated by removing the affected tissue via an excision.In conclusion, a lipoma with a spindle cell subtype may provide a diagnostic difficulty to radiologists, pathologists, and surgeons since it often presents as a lesion with little or no macroscopic or microscopic fat. SCLs may also have intramuscular extension. Due to the radiographic overlap and similarities with liposarcoma, schwannoma, and other soft tissue tumors in the presence of these characteristics, imaging-based identification of SCLs may be particularly challenging, biopsy followed by surgical removal is suggested. The imaging features of SCLs in the US, CT, PET CT, and MRI may enable the radiologist to suggest this diagnosis prior to biopsy or excision, allowing the physician to avoid unduly aggressive procedures that may result in higher postoperative morbidity.


Foreign body aspiration (FBA) is infrequently encountered in the adult population, with major risk factors including advancing age, intoxication, and disorders of the central nervous system. Here, we present a case of FBA in an adult undergoing routine lung cancer screening to review imaging findings and highlight potential pitfalls for the practicing radiologist. A low-dose chest computed tomography (CT) scan was performed for lung cancer screening in a 57-year-old male with a one-month history of worsening dyspnea and cough. An endobronchial lesion was identified in the right bronchus intermedius. A follow-up 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) revealed hypermetabolic activity in the region of interest, raising concern for malignancy. Bronchoscopy was performed, revealing a nodular mass adjacent to a foreign body in the bronchus intermedius. Histopathologic analysis of the tissue sample revealed the presence of an aspirated foreign body with squamous metaplasia of the respiratory epithelium. Adult FBA is an uncommon clinical entity that may be incidentally observed on a screening chest CT. Relevant multimodality imaging findings are discussed here, along with a review of the accompanying pathologic changes seen with chronic airway impaction. Foreign body aspiration (FBA) is typically encountered in the pediatric population . Given iInitial presentation A 57-year-old man with a history of HIV, hypertension, chronic obstructive pulmonary disease (COPD), and a 25-pack-year active smoking history presented for an annual lung cancer screening appointment. The patient reported a recent one-month history of shortness of breath and a non-productive cough. He also described the feeling that "no air was going into the right side of my lungs". He denied hemoptysis, weight loss, fatigue, fevers, chills, night sweats, chest pain, or palpitations.On physical exam, the patient’s vital signs revealed hypoxia with an oxygen saturation (SpO2) of 93% and mild bilateral rhonchi on chest auscultation.ImagingA low-dose screening computed tomography (CT) of the chest was performed as a part of lung cancer screening and demonstrated a 1.2 cm nodular endobronchial lesion in the distal bronchus intermedius  was performed to evaluate the metabolic activity of the lesion. A 1.2 x 1.7 cm hypermetabolic focus with a standardized uptake value (SUVmax) of 7.2 was identified in the right hemithorax, corresponding to an endobronchial soft tissue nodule in the right bronchus intermedius Figures , 6. FindBronchoscopyFlexible bronchoscopy with endobronchial ultrasound was then performed, revealing an ovoid soft tissue mass within the bronchus intermedius measuring up to 0.8 cm Figures -9. Biops PathologyHistopathologic analysis of the endobronchial mass revealed benign squamous metaplasia and hyperplasia with stromal fibrosis. Tissue samples of the surrounding mucosa demonstrated benign squamous metaplasia with mild chronic inflammatory changes. No malignant cells were identified. The curved, reddish-brown foreign body removed from the bronchus intermedius was grossly examined and identified as a pistachio shell. Clinical follow-upOn follow-up examination, the patient reported "feeling like a new man". He stated his cough and shortness of breath resolved following the bronchoscopic intervention. A follow-up CT of the chest was obtained, which revealed the interval removal of the right bronchus intermedius lesion seen in prior studies. A small, irregular soft tissue nodule measuring up to 0.3 cm was seen, suggesting residual inflammatory change at the procedural site Figure .Foreign body aspiration (FBA) is a relatively uncommon phenomenon in the adult population. Indeed, a large recent retrospective study by Ulas et al. determined that only 11.7% of FBA cases were seen in adult patients (>18 years old) . DespiteThe most common symptoms associated with FBA in adults include a sudden onset of choking, coughing, dyspnea, fever, hemoptysis, and wheezing ,6,7. TheThe diagnosis of FBA is typically achieved with a combination of detailed history-taking, diagnostic imaging, and bronchoscopy. Standard chest radiography is the initial imaging modality of choice in cases of suspected aspiration. However, the variable radiopacity of aspirated objects results in the inconsistent sensitivity reported in the literature, ranging from 8% to 80% . SecondaA chest CT may be performed following initial radiography to identify radiolucent foreign bodies not seen on X-ray as well as to provide anatomic detail for procedural planning. Interestingly, the patient in the case presented here underwent routine annual cancer screening CT for lung cancer, which is when the aspirated foreign body was incidentally discovered. Jang et al. found that CT studies reliably identify tracheobronchial foreign bodies when compared to standard radiography, with greater than 60% sensitivity [Radiologic evaluation for patients with suspected FBA does not typically involve nuclear imaging. However, in the case presented here, FDG PET-CT was performed due to a suspicion of malignancy. A single hypermetabolic focus was identified in the bronchus intermedius, which raised further suspicion for neoplasm in this patient within the "intermediate risk" category when risk-stratified using the PLCOM2012 model described by Tammemagi et al . An incrHistopathologic analysis of the tissue samples obtained in our case similarly demonstrated sequela of chronic inflammatory changes; these findings include lymphocyte and plasma cell infiltration, fibrosis, and the formation of foreign body giant cells and granulomas . These cRespiratory pseudostratified columnar epithelium normally lines the conducting airways of the respiratory tract. Metaplastic change to the squamous epithelium is classically seen as secondary to the toxic insult of the airways as a precursor to the development of squamous cell carcinoma. This phenomenon has been widely documented to occur in the bronchial tissue of smokers, with squamous metaplastic cells expressing increased levels of carcinoembryonic antigen . AdditioOnce FBA is identified or suspected with corroborative clinical history and imaging findings, bronchoscopy is the next step in management for foreign body removal. Flexible bronchoscopy is the favored procedure in the adult population as it produces less patient discomfort, may be performed under light sedation, and uniquely allows access to the distal and peripheral airways . HoweverFBA is relatively uncommon in the adult population, particularly in the absence of known risk factors such as trauma, intoxication, or primary neurologic disorders. Here, we present a unique case of an aspirated foreign body incidentally identified on low-dose chest CT to highlight a potential pitfall for the interpreting radiologist. As updated recommendations for lung cancer screening result in a broader population now eligible for low-dose chest CT, it is important for radiologists to recognize alternative entities that may mimic malignancy on traditional and hybrid imaging modalities. This case also highlights the context-dependent nature of diagnostic radiology, as the search for occult malignancy on this screening CT proved to obfuscate the correct diagnosis.


Ulnar longitudinal deficiency (ULD) is a rare skeletal condition marked by the partial or complete failure of the formation of the ulna. This rare condition is often associated with fixed flexion deformity, radial head subluxation, complex carpal, metacarpal, and digital abnormalities. Most presentations are male-preponderant and right-sided. Different classifications have described ULD. Usually, the condition is not associated with systemic findings; however, detailed physical examination and radiologic evaluations are crucial for assessing and managing affected patients. We report a rare case of ULD in an 11-month-old female infant with congenital absence of the left ulna, four digits, and a postaxial hypoplastic finger. Ulnar longitudinal deficiency (ULD), also known as "congenital ulnar hemimelia," "postaxial longitudinal deficiency of the upper limb," "ulnar club hand," or "ulnar ray deficiency," is a rare sporadic skeletal condition marked by a partial or complete failure of formation of the ulna bone. ULD is a part of congenital longitudinal deficiencies, a spectrum of abnormalities that affect the upper extremities, with radial longitudinal deficiency being more common than others. Radial longitudinal deficiency affects 1:30,000 live births, while ULD affects one to two in 100,000 children .We present an 11-month-old female infant, a recent immigrant from Colombia, delivered small for gestational age with congenital absence of the left ulna bone at 37 weeks gestational age through emergency cesarean section due to maternal preeclampsia and hemolysis, elevated liver enzyme, low platelet count (HELLP) syndrome. There was no history of teratogenic medication ingestions during the perinatal period but a previous miscarriage from an unknown etiology.Our patient presented to the ambulatory clinic for a health supervision visit at five months of age. Her anthropometric parameters  and developmental milestones were appropriate for her age, and her immunizations were up-to-date. At that visit, her physical examination was pertinent for candidal diaper rash and a deformed, hypoplastic left upper extremity (LUE) with four digits and a postaxial hypoplastic finger. Her mother noted no history of abnormal bleeding, cardiac problems, recurrent infections, or delayed wound healing since birth. There was no family history of genetic disorders, skeletal abnormalities, or physical findings of VACTERL  association. However, routine immigrant screening showed a positive tuberculin skin test of 20 mm (reference range: <5 mm), but she was without any signs and symptoms of active tuberculosis. There was no exposure to contacts with chronic cough or tuberculosis; there was no fever, cough, poor feeding, growth faltering, or palpable enlarged lymph node swellings. Chest, shoulder, humeral, and hip X-rays were normal. The left upper limb X-ray was significant for a small ovoid bone in the location of the ulna and fifth metatarsal with moderate bowing of the radius Figures , 2. OtheSonic Hedgehog gene pathway responsible for the development of ulnar-sided forearm structures and four ulnar-sided digits. This Sonic Hedgehog gene deficiency explains the thumb abnormalities that occasionally accompany ulna dysplasias [ULD is a rare sporadic skeletal condition. It is characterized by a longitudinal deficiency at the posterior axis of the upper limb where the ulna bone is situated. Its etiology is frequently related to the deficiency of the splasias -5.ULD is usually isolated and not commonly associated with any systemic conditions. However, specific syndromes like limb/pelvis hypoplasia/aplasia syndrome, Weyer's oligodactyly syndrome, and ulnar-mammary syndrome have ULD as an associated feature . It is fDifferent classifications have described ULD depending on several factors. Ogden et al. classified the anomalies based on the severity of the ulnar deformity. Bayne classification has been widely used and classifies ULD into four types  . Our patTreatment of ULD depends on the severity of the malformation and targets improvement of limb function and overall quality of life. Management involves a clinical geneticist consultation and referral to the orthopedic and plastic surgical teams for evaluation and surgery if required. Treatment would be either operative or nonoperative, depending on the elbow and forearm anomalies classification. Nonoperative treatments include early stretching and splinting at a young age. Surgical treatments are recommended after the second year of life, including tissue distractions, syndactyly releases, deepening of first web space, opponensplasty, metacarpal rotational osteotomies, and pollicization ,7.ULD is a rare form of congenital longitudinal deficiency associated with digital abnormalities, as presented in our case report of an 11-month-old female infant with ULD type 3 according to Bayne classification with associated oligodactyly and postaxial hypoplastic finger. Therefore, prompt diagnosis by detailed history, complete physical examination, and early referral to the surgical teams are paramount when these patients are encountered to prevent complications such as contractures, improve functionality, and avoid secondary psychological disruption to the patients and their families.


Neuroendocrine tumors (NETs) are a rather uncommon cause of chronic non-bloody diarrhea and are therefore often left undiagnosed for prolonged periods of time. In this case, a 46-year-old man was inappropriately treated with antibiotics for months by various doctors, and by the time the diagnosis of NET was made, the tumor had already metastasized to the entire skeleton. The patient refused surgery and was started on octreotide, which resolved his diarrhea. Neuroendocrine tumors (NETs) are derived from neurosecretory cells located in various parts of the body. These are rare tumors and occur mostly in the lungs, appendix, small intestine, rectum, and pancreas. They can be functional (produce their own hormones) and non-functional (do not produce any hormones). The diagnosis and treatment of these tumors depend on the size, the extent of the tumor, its location, how aggressive it is, and whether it produces hormones or not. NETs are a rare cause of chronic diarrhea. Due to this, it becomes difficult to diagnose them on time in patients, and this can have severe life-threatening consequences for the patients . In thisA 46-year-old man presented to the emergency room of the hospital with complaints of multiple episodes of diarrhea, generalized body weakness, malaise, and nausea. He denied having any emesis. His personal history was significant for coronary artery disease for which he was taking medication as prescribed by his cardiologist. He denied any history of smoking, alcohol, or substance abuse. His family history was unremarkable. He also stated that he had been having similar episodes of non-bloody diarrhea on and off for the last eight months, but every time it used to resolve on its own after taking a course of antibiotics.Blood samples and arterial blood gas (ABG) analysis were ordered for him. The tests revealed a slightly reduced sodium level (132 mmol/L) and metabolic acidosis (pH: 7.1 and bicarbonate: 6 mEq/L). C-reactive peptide (CRP) and total leucocyte count were within normal limits. During the period of his stay in the hospital, a contrast-enhanced CT (CECT) scan was ordered, which revealed a small lesion (~2 x 2 cm) in the pancreatic head region.Suspecting a potential malignancy, a gastrointestinal (GI) surgery referral was ordered, and the patient underwent an endoscopic ultrasound, which corroborated the CT findings. Later on, a fine needle aspiration cytology (FNAC) was done from the lesion, which revealed cells with round nuclei, granular cytoplasm, positive staining for chromogranin A (CgA), and staining negatively for CD56, revealing the diagnosis to be a pancreatic NET. Serum chromogranin levels were only marginally elevated but given the fact that the patient was taking proton pump inhibitors (PPI) for his gastric reflux, these values seemed less reliable.A 68Ga-DOTANOC PET-CT was done to stage the disease and decide on the course of treatment. The scan revealed a DOTANOC-avid pancreatic head lesion and multiple DOTANOC-avid sclerotic metastatic skeletal lesions Figures , 2. No lThis case report is meant to highlight the role that 68Ga-DOTANOC PET-CT plays in the work-up of metastatic NET as well as the role of somatostatin analogs in the management of these hormonal symptoms in these patients ,3. NETs Despite being rare tumors, NETs must always be suspected in a patient with complaints of chronic non-bloody diarrhea. Adequate imaging, including 68Ga-DOTANOC PET-CT for metastatic work-up, should be conducted in all patients with a suspicion of NET and somatostatin should be prescribed to all symptomatic patients to avoid other life-threatening consequences.


Echinococcus granulosus. Intraosseous involvement is observed in 3% of cases, of which only 2-6% are in the maxillofacial region. A scientific literature search revealed only seven cases involving the mandible. We report a rare case in a 16-year-old female patient who presented with facial asymmetry and well-defined radiolucency of the ramus. Our findings will help in understanding the diagnostic issues caused by non-specific presentation and difficulties in suspecting such a rare diagnosis as echinococcosis of the oral or maxillofacial region. A thorough systemic investigation is essential as 20-30% of these cases show multiorgan involvement.Parasitic infections rarely involve the oral and maxillofacial regions and pose a diagnostic challenge when they do. Hydatid cysts are parasitic cysts caused by  Fortunately, intraosseous involvement is sporadic, accounting for only 3% of all cases. Mandibular involvement is infrequent, with seven cases reported in the literature to date.2Hydatid cysts, also known as human cystic echinococcosis, have been reported since time immemorial. The word “Hydatid” in Greek translates to “a drop of water”.A 16-year-old female patient visited our institute with a chief complaint of swelling on the left side of her face for 1 month. The swelling presented gradual and slow growth and became more evident over the last month. Medications prescribed by a local facility did not resolve the swelling. The patient denied any history of trauma.Extraoral examination revealed non-tender and diffuse expansile swelling on the left side of the face, extending from the outer canthus of the eye to the lower border of the mandible and from the malar region to the posterior border of the mandible on the left side. The patient had a mouth opening of 5 mm. Intraorally, obliteration of the buccal vestibule was noted in relation to left mandibular molar region. A draining sinus with pus discharge was evident at the left mandibular third molar region , and 1B.OPG revealed well-defined radiolucency along the left mandibular ramus . CT axiaBased on the clinical and radiological features, a provisional diagnosis of an infected odontogenic keratocyst, orthokeratinized odontogenic cyst, and unilocular ameloblastoma was made.An incisional biopsy, along with the extraction of the left mandibular third molar, was performed under local anesthesia.Gross examination of the incised specimen revealed multiple bits of whitish to yellowish-white, soft, membranous gelatinous tissue resembling tender coconut meat of varying sizes .On histopathological examination, the H&E-stained sections showed multiple acellular, avascular, and eosinophilic lamellated structures consistent with chitin. These structures were lined with a germinal membrane from which the brood capsules developed. Detached germinal membrane with protoscolices of parasite form the “hydatid sand” was evident, which is pathognomonic of hydatid cyst , and 4C.The patient underwent further investigation to rule out multiorgan involvement. The abdominal and pelvic USG revealed a well-defined hyperechoic lesion measuring 8 × 9 mm in segment VIII of the right hepatic lobe, consistent with “calcified granuloma.” Other abdominal organs appeared normal. Echinococcus IgG ELISA was performed, which was reported to be equivocal. Casoni's intradermal test revealed positive findings. The patient was referred to a general surgeon for the management of liver hydatidosis.Once the diagnosis was established, the patient was started on scolicidal therapy with albendazole 400 mg twice daily, with a scheduled treatment course for 2 years. The definitive surgical treatment comprised cystectomy through an intraoral approach under local anesthesia, and the remaining cyst tissue was removed. The incision healed without any dehiscence. The patient was followed up at regular intervals of 1 month, 3 months, 6 months, and 1 year, with no clinical symptoms. After a 1-year follow-up, OPG revealed a healing lesion with well-defined bony trabeculae formation and no evidence of recurrence .Echinococcus granulosus. The incubation period is highly variable. Infection is most likely to occur during childhood and manifest clinically at later stages of life.3 The clinical and radiographic presentation is non-specific and depends upon the involved organ, size, and its effect on the surrounding tissues.4 Men and women are equally affected.3Hydatid cysts are benign, asymptomatic cystic lesions caused by the parasite 7 Similarly, the present case did not show pericysts because of intraosseous involvement.Microscopic examination revealed three layers. The innermost layer (endocyst) and intermediate layer (exocyst) are parasitic layers composed of protoscolices and hooklets in the hydatid sand and avascular eosinophilic lamellated structures, respectively. The outermost layer (pericyst) is the host layer, consisting of fibrous tissue and chronic inflammatory cell infiltrates. 8 On inquiry, the patient reported a history of raising goats at home. The larval form of the parasite is mostly transmitted through ingesting contaminated food. Inside the body, the larva breaks down and releases an embryo that settles in the organs. Six to ten days after settling, the embryo becomes vacuolated. Intraosseous involvement is predominantly secondary to primary infection due to the seeding of the embryo on the bone. Subsequently, they produce microvesicles by exogenous budding and spread along the path of least resistance, where the daughter vesicles invade the bone and replace the medullary tissue. Ischemia and direct local pressure play an important role in bone destruction. Intraosseous cysts generally do not calcify. Over time, subsequent destruction of the bone cortex occurs with the dissemination of the disease to the surrounding tissues.4Dogs and cattle are the primary and intermediate hosts, respectively. Humans are accidental hosts of this parasite. It is known to commonly affect the cattle-raising population.8 Intraosseous involvement is seen in <3% of cases. Furthermore, 2-6% of the total intraosseous cases affect the maxillofacial region.2 Hence, along with an ultrasound examination of the liver, chest radiography and MRI of the abdomen and brain are necessary to exclude the involvement of other organs. Serological investigations include IgG ELISA, indirect hemagglutination, latex agglutination, and immunoelectrophoresis.3 However, these tests have a high chance of false-negative results in intraosseous involvement and calcified cysts.2 The present case showed indefinite results in IgG ELISA, likely due to intraosseous involvement in the mandible and calcified granuloma in the liver.Overall, 20-30% of patients with hydatid cysts show multiorgan involvement. The liver (50-70%) is the most commonly affected organ, followed by the lungs (20-30%), spleen (0.7- 8%), kidney (7%), muscles (4%), central nervous system (0.2-3%), and heart (0.2-2%).9 Surgical manipulation of the cyst must be performed carefully, as spillage of the cyst contents may cause anaphylactic shock.10Intraosseous hydatid cysts are confirmed only by biopsy, particularly if there is no evidence of the involvement of other organs. Once the histopathological diagnosis is confirmed, the treatment of choice for hydatid cysts of the maxillofacial region is surgical excision of the entire cyst in combination with scolicidal therapy with albendazole.11 first reported a hydatid cyst involving the mandible.11 Our literature search revealed only seven cases involving the mandible. A summary of the cases reported till date is presented in ShukerThe oral cavity is the gateway and mirror of overall health and well-being. Many systemic diseases have initial clinical manifestations in the oral and maxillofacial areas. Although the clinical and radiographic features of echinococcosis in the oral and maxillofacial regions are non-specific, often leading to misdiagnosis, histopathology should be considered the gold standard for diagnosis.


Primary cutaneous follicle center lymphoma (PCFCL) differs from follicular lymphoma in biological behavior and molecular profile and is treated as a distinct entity, according to the 5th edition of the World Health Organization classification of hematolymphoid tumors. It is an uncommon cutaneous B-cell lymphoma that is considerably rare in children and adolescents. To date, only 13 cases of individuals younger than 20 years of age have been reported in the literature. The lack of relevant clinical epidemiological data in this population has hampered the investigation of its clinical and diagnostic aspects. Here we report the case of a 17-year-old male with PCFCL, who may be the first PCFCL patient under 20 years of age reported in China. He was admitted to the hospital with a solitary nodule on his face. After complete surgical excision, the patient’s facial mass was histologically identified as PCFCL. The patient’s prognosis was favorable, with no recurrence at 17 months of follow-up after the surgical resection. We present a case of an adolescent PCFCL patient and systematically review the literature with a view to increase the awareness of the disease and inform the diagnosis and treatment of this age group. It is confined to the skin and rarely involves the lymph nodes or other extra nodal organs –10. In t2An Asian male aged 17 was admitted to our hospital in March 2022 due to “a facial nodule found for about 6 months.” A right temporal mass, initially the size of a peanut, was accidentally discovered in September 2021. The patient was previously healthy; the lump seemed to increase in size over time, and he visited our dermatology center in January 2022. An examination revealed a right temporal mass of approximately 2 cm in diameter; it was tough, with good mobility, clear borders, and a smooth surface. When the mass was imaged using ultrasound, a 2.2 cm ×1.9 cm ×1.1 cm very hypoechoic nodule with a regular shape, distinct borders, and uneven internal echogenicity was detected in the fatty layer of the right temporal region  and the results of immunohistochemistry and Ig gene rearrangement tests, we considered a diagnosis of PCFCL.The patient was hospitalized in our department for oral and maxillofacial surgery on February 9, 2022. The ECOG score was 0. No significant abnormalities were observed on routine blood tests. The lactate dehydrogenase was 188.7 U/L . It might be difficult to distinguish between benign and malignant skin cancers without a biopsy. On February 11, 2022, the patient underwent a right temporal mass resection and adjacent flap transfer repair under general anesthesia, during which the mass was completely removed, and the postoperative specimen was sent for pathological examination. The pathology showed multiple pieces of grayish-white disorganized tissue, totaling 2.3 cm ×1.8 cm ×0.7 cm. Hematoxylin and eosin (H&E) staining revealed lymphocyte infiltration with a follicular growth pattern. The follicular structure was atypical and lacked distinct mantle zones. Infiltrating cells comprised mainly follicular centrocytes and centroblasts, along with several histiocytes , PCFCL, primary cutaneous diffuse large B-cell lymphoma, leg type (PCDLBCL-LT), intravascular large B-cell lymphoma, and EBV-positive mucocutaneous ulcer-provisional .Clinically, PCFCL is more common in middle-aged men (>50 years old), with a preference for the head, neck, and back, and it typically presents as painless or pruritic. They can manifest morphologically as isolated or numerous plaques, nodules, papules, or masses . HoweverAccording to histology, centroblast and follicle center cells make up the majority of tumor cells in PCFCL. Tumor cells show three growth patterns: follicular, diffuse, and follicular diffuse. Tumor cells were immunohistochemically tested positive for B-cell markers, such as CD20, CD79a, PAX5, and Bcl-6, but negative for CD5 and CD43 and mostly negative for MUM1. The expression of CD10 and bcl-2 varied, and their co-expression indicated a higher chance of skin recurrence . The strP = 0.001) , and either a CT or PET-CT scan. The necessity of bone marrow aspiration and biopsy remains a subject of debate. The TNMB staging system, originally designed for mycosis fungoides (MF) and Se’zary syndrome (SS), is not applicable to other primary cutaneous lymphomas. Consequently, the International Society for Cutaneous Lymphomas (ISCL) has recommended using an alternative TNMB staging system. A new TNM staging system was proposed by ISCL and EORTC for primary cutaneous lymphomas other than MF/SS , 18. The= 0.001) . In addi= 0.001) .The preferred treatments are complete surgical resection or field radiation therapy, both of which have a complete remission rate of nearly 100% . In thisIn conclusion, PCFCL is relatively rare in the pediatric and adolescent populations. The diagnosis of the disease is challenging due to the paucity of relevant studies and the lack of awareness of the disease, which may lead to underdiagnosis or misdiagnosis of the disease. Here we report a rare case of PCFCL in an adolescent in China and its multidisciplinary collaborative diagnostic and treatment process, which we hope will further raise awareness of the disease. In the future, as more prospective studies are conducted, the clinical and biological characteristics of PCFCL in pediatric and adolescent populations will be further elucidated.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.The studies involving humans were approved by the ethics committee review board of The Affiliated Hospital of Qingdao University. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin. Written informed consent was obtained from the minor(s)’ legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.W-YN: Data curation, Writing – original draft, Writing – review & editing. JD: Supervision, Writing – review & editing. X-SY: Writing – original draft. HQ: Writing – original draft. Y-JS: Writing – original draft. H-YG: Resources, Visualization. G-LL: Supervision, Methodology. Z-GC: Supervision, Methodology.


The incidence of hepatolithiasis is variable. Globalization has additionally altered disease dynamics globally. A multi‐disciplinary team approach is deemed necessary for the timely diagnosis, safe, affordable treatment, and good prognosis. Rest of the systemic examination was normal. Contrast enhanced computed tomography (CECT) revealed multiple hypodense/hyperdense lesion in segment 3 of liver. Magnetic resonance imaging (MRI) showed hypo‐hyperdense focal lesions with conglomerate appearance on segment 3 of liver suggestive of hepatolithiasis (Figure A 59‐year‐old South Asian female presented with the complain of pain upper abdomen and recurrent fever for 1 year. There was no history of vomiting, jaundice, anorexia, or weight loss. Family history was unsupportive of diagnosis. On laboratory examination, alkaline phosphatase was elevated by two times. Serum bilirubin was normal, and her leukocytes count was 11,200/mmThe incidence of hepatolithiasis is variable. It is highly prevalent in parts of Asia, such as China, Japan, and South Korea, with a reported incidence between 3.1% and 21.2%.Low socio‐economic status of our patient could have been the attributing factor. Also, unilobar hepatolithiasis and particularly that on the left was the main indication for left lateral segmental hepatectomy in our case. With this image, we would like to recommend that the differential diagnosis of hepatolithiasis should be thought in the back of mind if an elderly person from endemic region presents with the complain of pain upper abdomen and recurrent fever. Surgical intervention is deemed necessary with the aforementioned indications, and it can provide good prognosis to the patient with an excellent stone clearances.Narendra Pandit: Conceptualization; data curation; investigation; methodology; resources; supervision; writing – original draft; writing – review and editing. Durga Neupane: Conceptualization; data curation; investigation; methodology; resources; supervision; writing – original draft; writing – review and editing.None.None.Written informed consent was obtained from the patient for the accompanying images.


Paragangliomas are mostly benign, slow-growing, hypervascular tumors originating from neural crest derivatives. Head and neck (H&N) paragangliomas represent <1% of all H&N tumors and <5% are malignant. They are mostly non-secreting tumors that originate from autonomous parasympathetic paraganglia. We present a case of right middle ear jugulotympanic paraganglioma, a subtype of H&N paragangliomas, which had been misdiagnosed as otosclerosis for about 10 years. The patient was suffering from worsening tinnitus along with hearing impairment. High clinical suspicion of jugular paraganglioma prevented us from taking a biopsy. Complete surgical excision after preoperative embolization was decided. Embolization resulted in facial nerve paralysis, however, facial nerve rerouting was performed during the complete surgical excision of the tumor. The patient remains disease-free three years postoperatively, with House-Brackmann III facial nerve paralysis. Paragangliomas are usually benign and slow-growing tumors that originate from neural crest derivatives . When ocA 53-year-old female patient presented to our Ear Nose and Throat outpatient department complaining of a 10-year hearing impairment of the right ear. She also mentioned pulsatile tinnitus and ear fullness, progressively worsening through these 10 years. She had been primarily diagnosed with otosclerosis in the past and had been treated conservatively with monitoring in another medical setting. The patient’s medical history was otherwise normal.A thorough physical examination was performed. Otomicroscopy revealed a bluish mass partially covered by the epidermis, which was occupying the right external auditory meatus. The tympanic membrane could not be visualized. Neck palpation was unremarkable. No cranial nerve deficits were observed. Both Rinne and Weber tests were indicative of conductive hearing loss on the affected side. Pure-tone audiometry confirmed a right ear conductive hearing loss . The patient underwent contrast-enhanced petrous bone computed tomography (CT) and magnetic resonance imaging (MRI). The imaging tests revealed an enhancing heterogeneous soft tissue lesion filling the right jugular foramen, which was depicted as eroded and dilated. The mass was expanding, through the jugular foramen, in the middle ear via its floor, occupying the ossicles, and toward the right external auditory canal. It was also adjoining the sigmoid sinus and the proximal internal jugular vein, presenting intracranial extension with pressure to the right cerebellar hemisphere. Dimensions were approximately 2.5x2x4 cm Figures , 1b, 1c.The appropriate treatment for the patient was decided to be surgical removal after selective preoperative embolization. After embolization, the patient developed facial nerve paralysis (House Brackmann III) of her right face. Radical mastoidectomy under general anesthesia was performed, with complete tumor resection and facial nerve rerouting. In this procedure, the temporal part of the facial nerve and the middle ear content prevents the wide exposure of the jugular foramen area. Subsequently, to widely expose the jugular foramen and the apex of the temporal bone, the middle ear contents must be removed, and the facial nerve must be rerouted. Then, the facial nerve is mobilized along its entire mastoid and tympanic course up to the geniculate ganglion (long anterior rerouting technique). This technique is indicated for paragangliomas Figure .The cavity was filled with fat tissue, along with external auditory meatus obliteration.Following the operation, the surgical specimen was sent for histopathological examination, which confirmed the diagnosis. Round neoplastic cells with smooth nuclear membranes and abundant eosinophilic cytoplasm forming solid nests  and trabeculae were described. Fibrovascular stroma and fibrotic areas, along with embolization-related alterations were also noticed. Paraganglioma cells were diffusely positive to synaptophysin, focally positive to chromogranin A, and positive to S-100 immunohistochemical stains. The proliferation index (Ki-67) was low at 1-2%. During the postoperative period, the patient was disease free, with House Brackmann III facial nerve paralysis. At the three-year follow-up a few weeks ago, she remains disease free with facial nerve paralysis and adequate closure of the eye Figures , 3b, 3c.Paragangliomas are rare, mostly benign, slow-growing, catecholamine-secreting, hypervascular neuroendocrine tumors. They occur during neural crest migration and they are divided into sympathetic and parasympathetic tumors . Their nParagangliomas represent mostly solitary tumors but also multiple lesions have been described in 11-22% of cases ,6. They Regarding treatment, although surgical excision is recommended for large tumors, primary radiotherapy, stereotactic radiosurgery, and radiologic surveillance are also considered effective treatments. The choice depends on the patient’s health and comorbidities, tumor size and location, as well as the biological activity of the tumor ,6. PreopOtolaryngologists should always include jugulotympanic paragangliomas in the differential diagnosis of tinnitus, hearing loss, and/or ear fullness. A misleading diagnosis of otosclerosis for conductive hearing loss could lead to negligence of the underlying cause. Imaging is of paramount importance for pulsatile tinnitus or unilateral symptoms while biopsy should be avoided when there is high clinical suspicion for paragangliomas. Treatment remains challenging, as adjacent structures may be affected .


In this paper, we describe the case of a 40-year-old patient with an expanding and symptomatic complex liver cyst. Despite comprehensive diagnostics, including labs, imaging and biopsy, a clear etiology could not be determined. As a result, a partial liver resection was performed. The histopathological examination revealed evidence of schistosomas. We postulate that the displacement of the portal fields created a pseudocyst and that the resultant ischemia was the root cause of the patient’s discomfort. Postoperatively, the patient received an antihelmintic therapy with praziquantel with which she was able to fully recover. Schistosomiasis is one of the most prevalent parasitoses, with an overall prevalence of ~240 million patients worldwide. Though preventative measures in the last 20 years have been able to significantly reduce the incidence by almost 60% , ~700 million people reside in the endemic regions of sub-Saharan Africa, South America and parts of Asia .Due to increasing globalization, however, cases in western Europe have also become more common . In factParasitosis is caused by infection from blood flukes. As a miracidium, they multiply and mature in fresh water snails to cercariae, who, in turn, swim to penetrate their human host. Afterwards, they enter the blood stream and complete maturation within the portal vasculature. Finally, paired adult schistosomas travel to target organs, the mesenteric venules of the bowel or the venous plexus of the bladder where they then lay their eggs .Clinical presentation is varied and depends on the type and localization of the schistosoma. With hepatic manifestation, patients present with hepatomegaly and periportal fibrosis that may lead, depending on the degree of fibrosis, to portal hypertension. Ultrasound studies show a broadening of the periportal border zones. An increase in serum transaminases or other liver function parameters is not generally observed .~26 years. Initially, the patient presented to her general practitioner with upper right quadrant pain. An ultrasound study (~0.8 × 0.9 cm. Follow-up studies showed an expanding lesion with newer hyperechoic portions. In 2020 a liver specific magnetic resonance imaging (MRI) (The presenting patient was a 40-year-old Brazilian native who had lived in Europe for nd study  showed ang (MRI)  was perfDue to persistent pain, the decision was made to perform a laparoscopic cyst deroofing. In an intraoperatively performed ultra sound , howeverUnfortunately, histopathological examination showed only chronic inflammation with fibrosis. No evidence of malignant transformation was noted. Even in the postoperatively performed follow-up MRI, no malignant criteria could be identified. However, as a result of the extreme discomfort felt by the patient as well as the still unclear nature of the lesion, the decision was made to perform a partial en bloc liver resection of segments V, VI and VII.The histopathological work-up revealed the already described macroscopic cystic lesion . More pr~18% [Due to the increasing frequency of imaging diagnostics, the number of incidentally diagnosed liver cysts has increased greatly . Studies~18% . AffecteIn addition to simple cysts, further cystic lesions include biliary cystadenomas/adenocarcinomas, polycystic liver diseases, caroli syndrome or echincoccus can be identified by radiologic imaging.From a therapeutic stand point, simple asymptomatic cysts require no intervention. Symptomatic cysts, by contrast, can generally be adequately treated with laparoscopic deroofing, thereby minimizing the need for resection . Indeed,The case we describe here presents yet another differential diagnosis. We would, however, like to point out, that during the course of our research no other cases of cystic liver lesions due to a Schistosoma’s infection were identified. The diagnosis of schistosomas is possible through a variety of means, so that surgical resection would not generally be necessary. For example, diagnosis can be secured through urine or stool samples, as well as point-of-care tests searching for circulating antibodies (POC-CCA/CCA) from urine or serum.Schistosoma mansoni and hepatocellular cancer is probable [Schistosomiasis is usually treated with a short course of oral antihelmintic therapy, usually praziquantel for 1–3 days. Avital parasite eggs, however, will still be excreted over a period of several months. Therefore, follow-up tests after 6, 12 and 24 months are recommended [probable .


An angiomatous nasal polyp is a rare subtype of sinonasal polyp that is commonly found in the middle meatus and characterized by the presence of blood vessels within polyp tissue. It is a benign lesion but is prone to misdiagnosis as a malignant tumor because it typically grows larger and is more vascular than other types of polyps. In this report, a 16-year-old male with no significant past medical history presents with a six-month history of epistaxis and progressive nasal obstruction. Examination of the oral cavity showed a centrally located soft palate mass. CT maxillofacial with contrast showed a hypervascular 3.4 x 4.7 x 6.1 cm mass in the nasal cavity extending through the nasal choanae and down to the level of the tongue. MRI showed a heterogenous polypoid mass originating from the left middle meatus vs. nasal cavity, with characteristics favoring an aggressive tumor. The patient was taken for interventional radiology (IR) embolization and nasal endoscopy. Biopsy showed the left nasal mass contained granulation tissue and the palatal mass consisted of necrotic tissue. He was taken for second-stage endoscopic sinus surgery with plans for extensive reconstruction if necessary. Extensive polyposis was found without gross evidence of an aggressive tumor. The anterior polyposis was debulked and the polyp was cut at its root to allow for removal of the nasopharyngeal/oropharyngeal portion through the mouth. He was able to be discharged on the same day and his postoperative recovery was uncomplicated. Angiomatous nasal polyps are uncommon, share features of aggressive tumors on imaging, and require angiography and biopsy to safely rule out malignancy. Endoscopic surgical resection typically results in good outcomes and low recurrence rates. Angiomatous nasal polyps (ANPs) are a rare subtype of sinonasal polyps characterized by vascular proliferation within the polyp. They comprise 4%-5% of all sinonasal polyps and likely develop from secondary changes of sinonasal polyps as they grow and develop vascular compromise with subsequent neovascularization ,2. The mA 16-year-old male with no significant past medical history presents with a six-month history of epistaxis and nasal obstruction. Three months ago, the bleeding became severe enough that the patient was withdrawn from school. He was originally seen at another institution and given antibiotics for foul-smelling nasal discharge. He also reports an eight lb. weight loss over the last month. On exam, the patient was noted to be solely mouth-breathing due to nasal obstruction. His nose was normal externally without septal deviation, with bilateral polyposis and abundant drainage noted. The oral cavity exhibited a centrally located soft palate mass which pressed the soft palate inferiorly, pointing the uvula anteriorly Figures -1C. The CT with contrast showed a hypervascular 3.4 x 4.7 x 6.1 cm mass that extended from the nasal cavity to the oropharynx Figures -2F. The MRI of the face and neck revealed a large, heterogeneously enhancing polypoid mass that appeared to arise from the left nasal mucosa or left maxillary sinus and extend into the nasopharynx and oropharynx Figures -3D. AbnoAn arteriogram performed under awake orotracheal intubation revealed hyperemic nasal mucosal and a tumor blush from branches of the distal left internal maxillary artery (IMAX) Figures -4E. The ANPs are an uncommon nasopharyngeal soft tissue mass, most frequently diagnosed in children and young adults . The polBiopsy can be used to distinguish malignant tumors from ANP, and angiography is generally required to distinguish JNA and ANP . The parThis report demonstrates the diagnostic approach to ANP and characteristic radiological findings, while also featuring several uncommon characteristics. First, MRI demonstrated erosion of the medial wall of the maxillary sinus, a feature which has only rarely occurred in benign lesions and is more typical of malignant tumors . Also, tANPs are a rare variant of sinonasal polyps that are characterized by their distinctive histopathological features and findings on angiography. They typically present with symptoms of nasal obstruction, rhinorrhea, and anosmia, and are often misdiagnosed as other benign or malignant sinonasal tumors. This case of an ANP demonstrated several features atypical of the diagnosis, including a chief complaint of epistaxis, a large polyp extending into the oropharynx, and erosion of the medial wall of the maxillary sinus. The patient underwent successful excision of the nasal polyp endoscopically and recovered without complications. This report highlights the size to which ANP may grow and the possibility for ANP to present with epistaxis as the chief complaint. Providers should keep ANP on the differential for patients with similar presentations while cautiously evaluating for malignant tumors and JNA.


The use of prosthetic implants and metallic materials is widespread in modern orthopedic surgery. Generally, these materials are non-toxic and inert. Nevertheless, a few cases of malignancy associated with certain implants have been documented in the literature. It has been reported that some components of these implants have carcinogenic properties. In most cases, these tumors are high-grade sarcomas that occur in the bone or soft tissue adjacent to the implant site. Here we present the case of a 53-year-old patient who underwent intramedullary nailing of the tibia and developed a pleomorphic sarcoma at the implant site 18 years later. Prosthetic implants and metallic hardware are widely used in modern orthopedic surgery. They have significantly improved patient outcomes. These materials are relatively inert and non-toxic. Nevertheless, some of their constituents may have a neoplastic potential . FurtherA 53-year-old man presented to our orthopedic department with two rapidly growing, ulcerated masses on the left leg. The patient reported that these masses had been developing for 2 months and were painless. He also reported a progressive weight loss of 5 kg and intermittent fever.The patient’s medical history included a left tibial fracture surgically treated with intramedullary nailing 18 years ago. Upon physical examination, the first mass measured 10 cm in the anterior aspect of the upper leg, with no inflammatory signs opposite. However, the second mass measured 15 cm and was ulcerated with necrosis on the inferomedial aspect of the leg . The lymAnteroposterior and lateral radiographs of the left leg showed a nail intramedullary in the left tibia, and multiple osteolytic lesions, heterogeneous, poorly limited with permeative destruction of the cortical bone . The metBased on the past history, clinical, imaging and histologic findings, the diagnosis of high-grade undifferentiated pleomorphic sarcoma with bone involvement in association with an implanted orthopedic hardware was retained. Consequently, our multidisciplinary team of orthopedists, oncologists and pathologists discussed the different treatment options and, after obtaining the patient’s consent, we opted for radical treatment  and adjuvant chemotherapy for metastasis. After receiving the first dose of chemotherapy, the patient was discharged from the hospital. The follow-up was initially scheduled every 3 months for 1 year, then every year after that. At 6 months follow-up, the patient tolerated the prosthesis well and responded favorably to chemotherapy. Three years later, he is alive and there are no distant metastases and no local recurrences.The occurrence of malignancy associated with implanted orthopedic prosthesis or hardware is extremely rare. Until now, approximately 50 cases of sarcoma associated with orthopedic implants have been reported in the literature . As compImplant-associated sarcomas were seen in patients of widely varying ages 11–87 years, with a mean age of 50 years [High-grade undifferentiated pleomorphic sarcoma, formerly known as malignant fibrous histiocytoma, is a rare malignancy. It is usually seen in the 6th and 7th decades. About 75% of these tumors occur in the soft tissues of the extremities mainly in the lower limbs . TypicalLastly, it is extremely rare for a malignant tumor to develop in association with an orthopedic implant. Nevertheless, physicians should be aware of this possibility, especially if new symptoms occur related to orthopedic implants.