Scalp arteriovenous malformations (AVM) are rare vascular malformations reported only in small case series. Scalp AVMs usually present with symptoms, including headache, tinnitus, epilepsy, cerebral ischemia, and necrosis of the scalp, which can cause functional, cosmetic, and psychological problems. There are many difficulties in the treatment of scalp AVM because of its complex characteristics of vascular anatomy, non-uniform structure, and intracranial-extracranial anastomosis.via direct percutaneous puncture while traditional arterial and venous approaches were not available. In this report, access was obtained through a direct puncture of the enlarged frontal vein. Onyx-18 was injected through a microcatheter to occlude draining veins, fistulous connection, and the feeders. An 18-gauge indwelling needle was inserted into draining veins directly. Postembolization angiography demonstrated complete sAVM occlusion immediately and no non-targeted embolization. At a 1-year follow-up, no procedure-related complications and evidence of recurrence were observed.To illustrate the endovascular treatment of scalp AVM via direct percutaneous puncture approach is safe, rapid, and effective for specific sAVM. Treatment options should be made in terms of size, vascular anatomical characteristics of the lesions, patient's preference, cosmetic factors, and available expertise.The technique of endovascular embolization  Scalp arteriovenous malformations (sAVM), also known as cirsoid aneurysms or scalp arteriovenous fistulas (AFV), are anomalous connections between superficial arteries and veins without capillaries. The pathological mechanism of scalp AVMs is still unclear. These cases are relatively rare and most pediatric cases are congenital.Many factors, such as trauma, craniotomy, hair implantation, infection, and inflammation, are involved with the etiology of scalp AVMs . The AVMvia a direct percutaneous puncture approach.In this article, we reported a case series of scalp AVMs treated with Onyx This study was approved by the Institutional Review Board of Ethics of our hospital. Both patients agreed to be photographed and understood that their identity could be revealed on camera and in the content of the publication. CARE Checklist was implemented in this case report.The first case is a 16-year-old male patient with complaints of progressive enlargement of forehead mass for 10 years. The lesion presented as a soft, pulsatile mass, and the border was not clear. Bowed head and physical exercises could increase the volume of mass. Other neurological symptoms are negative. The patient had no family history of vascular malformations, no history of head trauma, and febrile illness. Local hospital magnetic resonance imaging (MRI) demonstrated a subcutaneous flow void sign in the frontal region, which indicated abnormal vessel mass in the lesion.via endovascular embolization.Cerebral diagnostic digital subtraction angiography (DSA)was performed under local anesthesia after the patient was admitted to our department. DSA confirmed the presence of frontal sAVM with feeding arteries from bilateral frontal branches of STAs and ophthalmic arteries and draining into orbital veins and facial veins . We analThe embolization was performed under general anesthesia. A 5-Fr H1 catheter  was targeted at the right external carotid artery (ECA) as a monitoring catheter through the sheath. In consideration of the location of the sAVM, access was obtained through direct puncture of the enlarged frontal vein with an 18-gauge needle and sutured in place . Next, aThe size of the mass decreased immediately after the embolization and did not present any more pulsation . The lesA 23-year-old female patient presented with a 5-year-history of right occipital tender, pulsatile mass, and continued to enlarge recently. Neurological examination showed no pathological signs. The patient had no history of head trauma, hair transplantation, and other pertinent histories. MRI showed an abnormal vascular mass of the lesion.In our department, super-selective diagnostic DSA was performed. DSA confirmed the diagnosis of high-flow right occipital sAVM and revealed arterial supply from right OA, whereas the temporal and occipital tributaries of the external jugular vein were acting as drainers . Then, wAfter cannulation into the right femoral vein was achieved using a 6-Fr guiding sheath, the 6-Fr Envoy guiding catheter  was positioned within the right external jugular vein (EJV). Two microcatheter (Echelon 10) were advanced and placed in the distal primary targeted vessel assisted with microwire. Angiographic images demonstrated that the microcatheter tip was far from the malformation mass, which could lead to poor Onyx diffusion and microcatheter trapping. Thus, direct percutaneous catheterization under the guidance of the roadmap was performed after the occipital region was sterilized. Contrast injection confirmed an 18-gauge needle was placed in the draining vein. The 18-gauge needle system was flushed with DMSO, and Onyx-18 liquid embolic material (13 ml) was injected to completely occlude the nidus, partial feeding arteries, and draining veins, which was confirmed by post-embolization angiography. Post-embolization angiography showed that the fistula was occluded and no non-targeted embolization , with prThe occipital lesion was wrapped with pressure dressing after the removal of the needle. At the 1-year follow-up visit, complete resolution of the pulsatile mass with no cutaneous necrosis was found.Scalp arteriovenous malformations (sAVM) is an abnormal fistulous connection between arteries and veins without an intervening capillary bed in the subcutaneous layer of the scalp . They usThe sAVM is often detected by physical examination and the diagnosis is proven by computed tomography angiography (CTA) and magnetic resonance angiography (MRA) . Most sAThe sAVM is a kind of intractable vascular disease because of its specific characteristics, including heterogeneous vascular anatomy, high flow shunt, intracranial-extracranial anastomosis, and, probably, cosmetic demands. DSA can reveal whether there is a co-occurrence of intracranial vascular abnormalities and intracranial communication of sAVM, which affect treatment strategies. Besides, preoperative angiographic evaluation can be used for the assessment of feeders, draining pattern, amount of fistular connections, and abnormal shunt blood volume, which contribute to avoiding complications . Thus, DSurgery used to be the first choice in the past years . Howeveren bloc excision without scalp necrosis and massive blood loss (A previous literature review indicated that open surgery is preferred for large cases (>4 cm) with multiple feeding arteries , 16. Theood loss . Possiblood loss .via transvenous approach have been reported  and fewer feeding/draining vessels , 20. It reported .The most frequently used approach to embolization is femoral trans-arterial and transvenous routes. However, direct puncture of the fistular is recommended as an alternative option, while feeding/draining vessels are tortuous , 27. In In this paper, we reported two cases of sAVM embolization by direct percutaneous catheterization of the draining veins. A “plug” is usually made to prevent the regurgitation of embolic agents during the embolization of intracranial vascular malformations (brain AVM or brain AVF). In our cases, Onyx was injected under temporary compression of draining vein by fingers, which retrogradely allowed penetration of the agent into the feeding arteries, nidus, and venous drainage. Due to the short access distance, there was little difficulty in extubation, and the risk of bleeding during extubation was low. The two cases were superficial scalp AVMs with moderate blood flow. The onyx could be injected into nidus effectively. Besides, we did not make the plug-in consideration of cosmetic and economic factors. For cases with high blood flow, the double-lumen balloon catheter and cooker technology could be used . The intvia direct puncture was safe and effective while traditional approaches were not available.There are some limitations to this study. Scalp AVMs are rare lesions and this was a retrospective single-center study with a small number of patients. However, our experience demonstrated that endovascular treatment via a direct percutaneous puncture approach, which indicates that scalp AVM embolization with Onyx is safe and effective. There is still no consensus on the treatment of the scalp AVM. Treatment options should be made in terms of size, vascular anatomical characteristics of the lesions, patient's preference, cosmetic factors, and available expertise.In our series of cases, we reported technical details of scalp AVM endovascular therapy The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the study was approved by the Huashan Hospital Institutional Review Board (HIRB), Fudan University, Shanghai, China. The patients/participants provided their written informed consent to participate in this study.YS and PLiu: conception and design of study, collection and/or assembly of data, data analysis and interpretation, and manuscript writing. YT: conception and design of study and revision and final approval of manuscript. WZ: provision of study and revision and final approval of manuscript. PLi: manuscript writting. YL and ZL: data analysis and colleague. All authors contributed to the article and approved the submitted version.The Outstanding Academic Leaders Program of Shanghai Municipal Commission of Health and Family Planning (No. 21XD1400600 to WZ), National Natural Science Foundation of China (No. 82171311 to WZ), and Clinical Research Plan of SHDC (Nos. SHDC2020CR2034B to WZ and SHDC2020CR4033 to KQ).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Urgent radical nephrectomy and removal of tumor thrombus were performed using atriotomy and inferior vena cava (IVC) endarterectomy under cardiopulmonary bypass. Histopathology revealed CCSK. The patient is tumor-free at 9-year follow-up.Clear cell sarcoma of the kidney (CCSK) is an uncommon renal neoplasm of childhood. Progression of intracaval or cavoatrial thrombosis is extremely rare and mostly asymptomatic, treated with neoadjuvant therapy followed by surgery. However, in an unstable patient, acute radical surgical intervention is the treatment of choice. We present a 2-year-old girl diagnosed as having a large left kidney tumor and acute cardiac decompensation  Clear cell sarcoma of the kidney (CCSK) is an uncommon renal tumor (RT), comprising 2%−5% of all primary renal malignancies in children . TypicalClear cell sarcoma of the kidney has a propensity for aggressive behavior and late relapses . The mosA previously healthy 2-year-old girl was urgently admitted to a county hospital with a 3-week history of intermittent abdominal pain, paleness, and general fatigue. Further, on physical examination, a huge left abdominal mass and hepatomegaly were palpable. Electrocardiogram (ECG) showed a right ventricular strain pattern, and laboratory tests revealed anemia and hematuria.Ultrasonography and computed tomography (CT) revealed a large left heterogeneous RT measuring 80 mm × 95 mm × 67 mm, with a tumor thrombus in the inferior vena cava (IVC) extending into the right atrium . No pulmThe operation was performed simultaneously by the cardiac and pediatric surgical team. After median sternotomy, deep hypothermic cardiopulmonary bypass was initiated with total circulatory arrest. Subsequently, the left radical nephrectomy was performed through the left transverse laparotomy. The renal vein was opened and the tumor thrombus was completely removed, then the renal vein was ligated at the level of the IVC. The next steps were right atriotomy and removal of the tumor thrombus from the right atrium and later from the IVC . As the The patient has received postoperative chemotherapy and radiotherapy, and after 9 years of follow-up, she is in good health and remains tumor-free. Timeline  demonstrIntravascular tumor extension is mainly characteristic of Wilms' tumor (WT) in children , 8. In cMost patients with thrombotic progression are asymptomatic, and the diagnosis is only made by imaging studies . The preGenerally, the UMBRELLA SIOP–RTSG 2016 protocol recommends treating pediatric patients with CCSK with neoadjuvant therapy: vincristine and actinomycin for localized disease, supplement with doxorubicin for metastatic disease . IrrespeThe prognosis of CCSK was originally considered poor and assigned to the “unfavorable histology” category, however, with current intensive treatment including multiagent chemotherapy and radiation therapy, it has improved the 5-year overall survival rate to 73%−86% . Neverthen bloc resection: primary surgery is indicated in an unstable patient, mostly to avoid a potentially fatal tumor embolus ' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.TK and AV contributed to the conception and design of the study. TK, GB, and KR participated in patient care: KR performed the cardiovascular examination, GB performed cardiac surgery, and TK performed the pediatric surgical management of the patient. AV wrote the original draft of this manuscript. TK supervised and revisited this work. All authors have made a substantial, direct, intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Hemangioendotheliomas are highly vascularized lesions, and their intracranial presentation is extremely rare. We present the case of a 65-year-old female patient who was evaluated for cranial deformity, headache, and left hemiplegia. Two bone lesions that were destroying and expanding the bone diploe with intracranial extension were identified in the fronto-temporal and parietal regions. Both lesions were multilobed and showed heterogeneous behavior. Mixed hemangioendotheliomas were identified after the successful resection of both tumors in two separate surgical procedures. The prognosis of this type of tumor with an intracranial location is not well-defined because there are too few reported cases. Hemangioendotheliomas (HE) were first reported in 1982 and were characterized as tumors with a vascular component and an epithelioid appearance that usually occur in soft tissues . IntracrMedical history and physical examinationWe present a 65-year-old woman who has had systemic arterial hypertension for 20 years. She first presented a head lump in the right frontal zone 12 years earlier without receiving any medical treatment, then two other lumps, in the parietal and temporal zones on the same side, appeared after 11 years. Then she started suffering from mild headaches, gait disturbances, left hemiparesis, sensitive loss on the left side of the body, urinary incontinence, and left hemineglect for a year, for which she self-prescribed pain medication without improvement until she was referred to our hospital by her family physician. Physical examination revealed frontal, parietal, and temporal palpable masses greater than 7 cm in diameter, left lower visual field defects, left central facial palsy, and a paretic left gait. There was no evidence of meningism or impaired higher mental functioning.Diagnostic testsMRI scanned two bone lesions that were destroying and expanding the right skull bone with intracranial extension. Both were multilobulated, with cystic and solid components. They showed a hyperintense signal on T2 and FLAIR (fluid-attenuated inversion recovery), consistent with necrosis areas, and a hyperintense signal on T1 and SWI (susceptibility-weighted imaging), compatible with chronic hemorrhage. Enhancement of the solid components was observed after the administration of intravenous contrast media. The largest lesion in the frontal and temporal regions had two lobes and measured 8 cm × 7.7 cm × 7.8 cm, and it was compressing the frontal lobe and the lateral ventricle on the same side. The image also showed surrounding edema with a displacement of the midline brain structures up to 2 cm to the left. The parietal lesion measured 6.8 cm × 6.5 cm × 7.3 cm, and it was displacing the basal nuclei and the ipsilateral mesencephalic peduncle. The orbits, eyeballs, and maxillary sinuses were not affected  34, CD31, factor VIII (FVIII), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF); they were negative for cytokeratins, epithelial membrane antigen (EMA), vimentin, and P53. The Ki67 was 1% (Figure Follow-upFollow-up was carried out by the neurosurgery, radiosurgery, and neuro-oncology services two months later. Thalidomide was prescribed as an adjuvant treatment, along with radiosurgery. The patient presented with significant improvement in left-side strength and no signs of cranial nerve involvement. She reported no more fluctuations in mental functions. The controlled imaging studies did not show tumor progression.Clinically, HE shows malignant behaviors, such as invasion, recurrence, and metastasis. This tumor is considered a borderline brain tumor with a proliferative histopathological appearance and intermediate biological behavior between a hemangioma and an angiosarcoma ,8,9.HE has been described in adults ranging in age from 20 to 74 years. In children, the age reported is between 2 months and 15 years. The ratio between men and women is about 1.2:1 in adults and 3.5:1 in children [The symptoms associated with these tumors depend mainly on their location. They can be related to headaches, seizures, and limb weakness. Within the extracranial location, it is more frequently found in the liver, lungs, or skin. It is important to scan the chest and abdomen because of the possibility of metastasis -12.MRI data in T1 and T2 sequences is consistent with isointense, hyperintense, or heterogeneous signal lesions. In half of the cases, they present perilesional edema . Other cWithin the treatment modalities, surgery is included as the first choice because it is associated with a favorable prognosis without the need for adjuvant therapy. However, when it is required, it is recommended to continue with radiotherapy and chemotherapy ,9,23,24.The prognosis for this type of tumor and its associated intracranial locations is not well established due to its rare presentation and the limited series of cases that exist. The recurrence rate corresponds to 20-24%, and regarding the rate of metastasis, it is estimated that it can occur in 15-20% of all patients ,26. The Adequate identification and approach selection are important since, although HE is a rare tumor with low proliferative activity, it is extremely invasive with a high risk of complications associated with its treatment. This is why a more extensive study must be carried out prior to surgery to rule out a metastatic process and to give a better follow-up due to the possibility of recurrence. Therefore, specific criteria must be established for its maximum resection with embolization support and, if necessary, subsequent adjuvant management with radiosurgery and chemotherapy.


While generally safe, bariatric operations have a variety of possible complications. We present an uncommon complication after gastric bypass revision, namely the creation of an “orphaned” segment of remnant stomach that was left inadvertently in discontinuity, leading to recurrent intra-abdominal abscesses. Sinogram ultimately proved the diagnosis, and the issue was successfully treated using a combination of surgical and endoscopic methods to control the abscess and to allow internal drainage. Obesity is a major public health problem worldwide. It affects quality of life and contributes to many comorbid conditions, including type-II diabetes, hypertension, hyperlipidemia, coronary artery disease, and several cancers . Non-surBariatric surgery offers the best contemporary option for effective and durable weight loss. Different bariatric procedures exist, including restrictive operations such as sleeve gastrectomy and adjustable gastric banding, and combined restrictive and malabsorptive operations such as Roux-en-Y gastric bypass (RGB) and duodenal switch. According to recent data, RGB is the second most commonly performed bariatric operation . RGB hasWhile the expected excess weight loss after RGB ranges from 60–75% at 5 years ,5,6,7, mA 43-year-old woman presented in mid-2020 after a complex past surgical history. She initially had a laparoscopic Roux-en-Y gastric bypass in 2014 for severe obesity, but she had a regain of weight. In late 2019, she had laparoscopic revision, which included reduction of her gastric pouch and redo of her gastrojejunostomy. In doing this, the surgeon resected a portion of her remnant stomach that was densely adherent to the posterior gastrojejunostomy.The patient had a complicated postoperative course and developed intra-abdominal abscesses which were not readily amenable to percutaneous drainage. Therefore, in early 2020, she underwent laparoscopy, which required conversion to open laparotomy for an abdominal washout. At operation, the presumed left upper quadrant fluid collection was judged to be a segment of the remnant stomach.Shortly thereafter, the patient moved to North Carolina and was admitted at a small hospital complaining of abdominal and left shoulder pain. On computerized tomography (CT) scan, a perisplenic fluid collection was noted . She wasThe patient underwent a sinogram that showed the drain was in an apparent abscess cavity. An upper gastrointestinal contrast study  and CT sAfter three weeks, a follow-up sinogram showed no residual cavity, and the drain was removed. However, the patient was admitted shortly thereafter due to severe pain. A repeat CT scan  showed aThe patient was taken to operation and had laparoscopic lysis of adhesions and washout of a purulent cavity at the above-noted site. A surgical drain was left in place . A remnaThe patient was evaluated in clinic 10 days later, at which time her remnant gastrostomy was clamped due to low output. She returned two weeks after that, and a repeat sinogram showed a small fistula between a portion of the remnant stomach and the surgical drain . This arAbout six weeks after her most recent operation, she had retrograde endoscopy through the remnant gastrostomy site, which demonstrated no connection into the “orphaned” portion of stomach that was feeding the fistula . The excSix weeks later, repeat retrograde endoscopy was performed, and the covered stent and pigtail were removed. A 5-mm gastrogastrostomy was noted. Two 7 Fr × 4 cm double pigtail stents were placed to maintain patency of the therapeutic gastro-gastric fistula. The remnant gastrostomy was removed.One month later, the patient reported a 12-pound weight gain and was feeling well. CT scan showed stents in place and no collections .Over the subsequent year, she was referred to colleagues in bariatric medicine due to mild weight regain and patient concerns about excessive weight regain. She had a follow up CT scan after one year that showed the pigtail drains were still in place . She hasAn “orphaned” stomach segment is an unusual complication after revisional gastric surgery that is not well represented in the surgical literature. One similar case was reported after gastric bypass reversal , where aIn the present case report, we have shown that an isolated stomach segment may also occur after revision of a prior bariatric procedure. Both vertical banded gastroplasty and gastric bypass may require revision due to complications or weight regain. Vertical banded gastroplasty can have band erosion or staple line breakdown. RGB can have recurring marginal ulcers, gastrojejunal strictures, pouch dilation, or gastro-gastric fistula from staple line dehiscence. It is important to note that, before the development of the current generation of endostaplers, which divide tissue between rows of staples, bariatric procedures utilized multi-row partitioning staplers that did not divide and separate the stomach segments. Sometimes, such staple lines can recanalize, making revisional procedures necessary.In reoperative cases, the presence of scar and the nature of staple line healing make it very difficult for a surgeon to recognize the location of residual areas of intact pre-existing staple lines. Therefore, during revision gastroplasty, it is possible for a new staple line to inadvertently cross an existing length of intact prior staple line, such that a segment of stomach can have limited or no continuity with the gastric outflow channel.Surgical strategies to limit this risk include use of intraoperative endoscopy, or, if laparoscopic visualization does not allow appreciation of the course of prior staple lines, use of laparotomy to allow tactile benefits. In addition, when one is operating to re-establish gastric restriction after an incomplete staple line dehiscence in the setting of a previously non-divided gastroplasty, it may be prudent to open the stomach and internally divide any residual areas of intact partition (using a linear stapler) prior to forming a new divided gastroplasty.Use of directed transgastric stents is increasingly common for other indications. Mature pancreatic pseudocysts can be internally drained through the posterior stomach with endoscopic and ultrasound guidance ,21,22,23In the present case, EUS was not possible due to the use of a gastrostomy site for access to the remnant stomach. Instead, sinogram under fluoroscopy allowed visualization of the target for stenting and assessment of the tissue bridge to be traversed. Use of retrograde endoscopy via a gastrostomy site has been conducted before ,30,31,32Recurring abscesses after revisional gastric surgery without a leak from the alimentary path should raise suspicion of a gastric fistula arising from an unrecognized leak from the bypassed gastric remnant or, in rare cases, from an “orphaned” segment of stomach. In the case of an isolated stomach segment separate from the proper gastric remnant, multidisciplinary evaluation with interventional radiology, gastroenterology, and bariatric surgery providers can help make the diagnosis and allow consideration of advanced endoscopic techniques for internal drainage without the need for major gastric resection.


Omental torsion as a cause of acute abdominal pain is extremely rare and difficult to diagnose preoperatively given the non-specific clinical picture.We report the case of an adult male who went to the emergency room due to abdominal pain, presented clinical symptoms and laboratory findings consistent with acute appendicitis but was diagnosed intraoperatively with omental torsion and associated necrosis, which was successfully treated by laparoscopic omentectomy.It is a rare entity with a low incidence. The symptoms of the cases reported in the literature are usually confused with other abdominal pathologies such as appendicitis or cholecystitis, so preoperative diagnosis continues to be a challenge. The treatment of choice is the laparoscopic approach, since it allows confirming the diagnosis, evaluating the severity of the ischemia, and ruling out other surgical pathologies.It is important to consider omental torsion as another differential diagnosis of acute abdomen, which can be satisfactorily resolved via laparoscopy, thus avoiding the development of complications associated with its natural evolution. •Omental torsion is a rare cause of acute abdominal pain with an incidence of 0.0016% to 0.37%.•The ambiguity of the symptoms makes it a difficult preoperative diagnosis to perform, the probability is from 0.6% to 4.8%.•It has been proposed that in unclear diagnosis or when conservative treatment fails, laparoscopy should be performed.•Laparoscopic omentectomy is the treatment of choice. The ambiguity of the symptoms makes it a difficult and unusual preoperative diagnosis to perform, the estimated probability is from 0.6 % to 4.8 %, and it can easily be confused with other pathologies 23/μL, leukocytes 11.08 103/μL, neutrophils of 66 %, normal coagulation times, normal urinalysis. We performed an abdominal ultrasound that showed: aperistaltic, non-compressible, 6 mm outer diameter appendix, little periappendiceal fluid collection and no other findings , as well as ultrasound (USG), have made it possible to make the diagnosis preoperatively In the USG, peritoneal fluid can be found, as well as an ovoid mass adhered to the anterior abdominal wall. This mass is described as an incompressible hyperechoic lesion with hypoechoic borders that is related to the hypersensitivity of the lesion. On CT, an ovoid mass adhered to the abdominal wall in the umbilical or anterolateral region, in the middle third of the transverse colon, has been described, as well as hardening and strands of omental fat.1.Vascular pedicle sign: the mesenteric vessel is surrounded by multiple turns of the smaller branches of the mesenteric artery.2.Pinwheel sign: cloudy mass of fat with concentric lines, with twisting of blood vessels within the greater omentum. This turns around the central vascular line, this last sign confirms the torsion of the greater omentum Two characteristic signs can be seen:Magnetic resonance shows hypointense linear structures corresponding to low flow in the mesenteric vessels within a hyperintense mass of fat on T1. While in T2, congestion and edema of the greater omentum are observed, as well as a hyperintense tumor There are 2 basic approaches to treating omental torsion: conservative and surgical. When the diagnosis is made with radiological techniques, conservative treatment can be proposed as the first line, with surveillance during the first 24–48 h. Such treatment consists of the administration of oral analgesics, anti-inflammatory drugs and prophylactic antibiotics. Conservative treatment may fail and lead to abscess formation and intra-abdominal adhesions, which can be dangerous for the patient. The main argument against conservative treatment is the failure to identify an inflammatory condition in the appendix, which could expose the patient to complications such as peritonitis and intra-abdominal abscess formation. Therefore, it has been proposed that in the face of an unclear diagnosis or when conservative treatment fails, laparoscopy should be performed With the introduction of laparoscopy and its widespread use, omental torsion or infarction can now be easily seen, and the chances of missing pathology during surgery have decreased significantly. Surgical treatment consists of removing the injured area of the omentum, since there may be necrotic omental tissue, which various authors consider prevents sepsis, as well as allowing a shorter hospital stay. Laparoscopy allows for a confirmatory diagnosis, evaluation of the severity ofdistal ischemia of the omentum due to torsion, as well as omental resection or detorsion of the greater omentum. In most cases, intraoperative conversion to laparotomy is not required since evacuation of the resected specimen can be accomplished through the trocar sites In open surgery, diagnosis is likely to be missed as exploration is difficult through a McBurney-type incision, or any infraumbilical incision, used for standard appendectomy . Laparos4It is important to consider omental torsion as another differential diagnosis of acute abdomen, which can be satisfactorily resolved via laparoscopy, thus avoiding the development ofcomplications associated with its natural evolution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The study is exempt from ethnic approval by the institution.N/A.Writing the paper and assisting in the procedure: Luis Miguel Carrillo, José de Jesús Marín-López.Performing the procedure and assisted in literature search: Luis Miguel Carrillo, José de Jesús Marín-López, Oscar Díaz-Barrera, Jesús Alejandro Olvera-Rodríguez.Assisted in writing manuscript: Luis Miguel Carrillo, José de Jesús Marín-López, Oscar Díaz-Barrera, Jacaranda Herrera-Gutiérrez.Data/evidence collection: Luis Miguel Carrillo, Jesús Alejandro Olvera-Rodríguez, Laura Yazmín Gutiérrez-Gutiérrez.Designed the study: Luis Miguel Carrillo, José de Jesús Marín-López, Jesús Alejandro Olvera-Rodríguez, Laura Yazmín Gutiérrez-Gutiérrez.Review of the manuscript: Luis Miguel Carrillo, José de Jesús Marín-López, Oscar Díaz-Barrera, Jacaranda Herrera-Gutiérrez.Literature Review and guarantor: Luis Miguel Carrillo, José de Jesús Marín-López.Luis Miguel Carrillo.José de Jesús Marín-López.N/A.N/A.


Giant hydronephrosis owing to ureteropelvic junction obstruction is a rare condition characterized by the accumulation of more than 1000 ml of urine in the pyelocaliceal system. It could mimic the other benign cystic kidney disease or other causes of abdominal mass in radiologic images. We reported a 16-year-old female who presented with three months of abdominal pain and gradual abdominal mass ingrowth. Abdominal computed tomography scan showed a giant left cystic mass favored hydronephrosis secondary to ureteropelvic junction obstruction. The patient underwent a left nephrectomy, and more than 12 litters of turbid urine were suctioned from the affected kidney. In conclusion, giant hydronephrosis is an infrequent entity and should be considered in the differential diagnosis of large cystic abdominal masses. The treatment is determined by the underlying cause and the visual appeal of the affected kidney. Giant hydronephrosis as a result of ureteropelvic junction obstruction; is defined as a dilatation of the pelvicalyceal system comprising more than one liter of urine, causing swelling in the hemiabdomen, or crossing the midline with a cover of five vertebral lines . It is cPatient information: a 16-year-old female patient, illiterate, presented to our outpatient urology clinic in May 2021; with progressive abdominal distention started three months ago and was associated with mild to moderate dull pain and fever. The patient had a history of right renal pelvic stone that underwent double J stent insertion and extracorporeal shock wave lithotripsy five months ago. At that time, the patient family was informed about the left renal ureteropelvic junction obstruction.Clinical findings: the patients' vital sign was stable . The oral temperature was 38.5°C. The total body weight was 52 kg. She was pale, and the abdomen was distended with everted umbilicus and mild abdominal tenderness . Other blood investigation tests, such as liver function tests, were normal. According to her signs and symptoms, ultrasonography was requested that showed massive multicystic lesions of the left kidney with severe hydronephrosis. Abdominal computed tomography scan with intravenous contrast revealed a huge left cystic mass (20x17 cm) with severe hydronephrosis and the renal cortical thickness of about 3 mm and the inferior border of mass reaching the pelvis with no obvious contrast material in the ureter or left renal arteries and caused pressure effects on other peritoneal organs  (st 11kg) . She wasPatient's perspective: the patient was happy with the successful outcome of the surgery.Informed consent: a written informed consent was obtained from the patient for participation in our study.Giant hydronephrosis is an infrequent problem that affects patients of all ages and is described as more than 1000 ml of urine in the pelvicalyceal system. Despite numerous cases of massive hydronephrosis described in the literature, just a few patients presented with more than 2 liters of urine in the pelvicalyceal system . In the et al. reported a case of giant hydronephrosis having five litters of urine in the pelvicalyceal system [et al. described a case of giant hydronephrosis containing more than 15 kg [et al. reported the giant hydronephrotic kidney in 1746, containing 115 liters of urine [et al. and Para et al. reported recent cases of giant hydronephrosis in a 62-year-old man and 19-year-old girl containing 80 liters and 13.5 liters of urine, respectively [Regarding previous reports, Chiang and associations reported 4 cases of giant hydronephrosis containing between 1.9 to 3.4 litter . Turgut l system . Schradean 15 kg . Additioan 15 kg . Glass eectively ,11. The These patients' clinical symptoms are not specific, but they commonly include increased abdominal girth and distended abdomen. Other manifestations include flank pain, hematuria, chronic abdominal pain, and repeated urinary tract infections . Even wiThe treatment modality described in published articles includes percutaneous nephrostomy insertion, reconstructive surgery such as ureterocalicostomy, dismembered pyeloplasty, calycovesicostomy, and boari flap with calycovesicostomy, and laparoscopic and open simple nephrectomy. The treatment option is deepened on patient condition, renal functional status, and surgeon experiences . In a paGiant hydronephrosis is a rare condition that must be included in the differential diagnosis of giant abdominal masses. Simple nephrectomy provides a suitable option, such as in our case.


Duodenum inversum is a rare congenital anomaly of unknown aetiology characterised by the proximal duodenum travelling posteriorly and superiorly prior to crossing midline. Clinical presentations include epigastric pain, nausea, and abdominal distension. It can be associated with duodenitis, acute pancreatitis, peptic ulcer disease and functional biliary obstruction. In this case report, we discuss a 77-year-old male who presented with hematemesis and epigastric pain secondary to duodenitis, for which he had a CT scan of the abdomen which demonstrated duodenum inversum. Despite the rarity of the condition and its common omission from differential diagnoses, the ability to recognise duodenum inversum is important for radiologists, especially considering its implications in clinical management. If not diagnosed correctly, it may result in unnecessary hospital admissions, dietary restrictions, and perhaps even unnecessary surgery. In this case, the radiological diagnosis of duodenum inversum using CT allowed for conservative medical management and prevented surgical intervention. He had a history of hypertension, bilateral hip and knee replacements and chronic history of non-steroidal anti-inflammatory and aspirin use. Vital signs upon arrival at the emergency department were within normal limits with a blood pressure of 104/63  mmHg, heart rate of 71 beats per minute, oxygen saturation of 95% while breathing ambient air, temperature of 37°C, and respiratory rate of 16 respirations per minute. Abdominal examination revealed a non-distended abdomen with tenderness in the epigastrium. There was no guarding, rebound tenderness, pulsatile, or palpable mass. Laboratory results were unremarkable with a lipase of 50 [0–60 U l−1) and no cystic thickening of the duodenal wall, fibrous tissue within the pancreaticoduodenal groove or common bile duct dilatation on imaging. Given the significant stranding in the region of the proximal duodenum and pancreatic head, further evaluation with MRI was performed to exclude a pancreatic head lesion and this was negative. The patient also underwent an emergent upper gastrointestinal endoscopy which confirmed duodenitis.Contrast-enhanced CT abdomen showed inflammatory stranding surrounding the D2 and D3 segments of the duodenum consistent with duodenitis. Close review of the duodenum showed an abnormal course with the proximal duodenum travelling posteriorly and superiorly prior to the D3 segment crossing midline in an abnormally high position, in keeping with duodenum inversum . Groove Intestinal malrotation: absence of a retromesenteric  D3 segment of the duodenum, abnormal SMA –SMV relationship and large bowel predominantly on the left and small bowel predominantly on the right. These features are not present in duodenum inversum, as other than the abnormal course of the proximal duodenum, the large/ small bowel and SMA/ SMV’s anatomic relations remain preserved.1Redundant duodenum: elongated duodenal loop with normal position of the DJ flexure.The patient was given an intravenous bolus of 80 mg of pantoprazole whilst awaiting endoscopic and radiological investigations, followed by regular oral 40 mg pantoprazole twice a day for 3 months.The patient’s symptoms improved during admission. Repeat upper gastrointestinal endoscopic ultrasound 2 months later showed no significant sonographic signs of pathology in the pancreas and a benign-appearing intrinsic mild stenosis at the junction of the D1 and D2 segments of the duodenum.2 The incidence is rare (0.07%), with less than 20 cases reported since 1950.3,4 This anomaly appears to occur more commonly in males, with a 4:1 ratio reported.3 Aetiology is unknown, but it is hypothesised to be a result of the persistence of the dorsal mesentery resulting in a mobile duodenum.3,5 It can be complicated by duodenitis, acute pancreatitis, peptic ulcer disease and functional biliary obstruction.3 Associated conditions include malrotation, incomplete rotation, annular pancreas and pancreas divisum.6Duodenum inversum is a congenital malformation where the proximal duodenum travels posterosuperiorly prior to crossing the midline in an abnormally high position.7 However, the value of this, or any classification system, is limited by small numbers and a lack of correlation between specific anatomic variants and clinical presentation.2Feldman and Morrison described four types of duodenum inversum: Type 1 is characterised by complete inversion of the duodenum with an absence of the duodenal curve; Type 2 is defined by the presence of the duodenal curve; Type 3 has a duodenal curve with marked redundancy of the duodenum; and Type 4 is defined as duodenum inversum associated with malrotation.4,8Apart from CT and MRI, fluoroscopic upper gastrointestinal (GI) series with barium contrast have been used to illustrate multiple reported cases of duodenum inversum. Classic findings on upper GI series include: the return of contrast from the second part of the duodenum back into the first and then into the bulb; stasis in the duodenum; and rapid passage of contrast through the third part of the duodenum.Duodenum inversum is a rare condition that may be unfamiliar to many radiologists. However, the recognition of duodenum inversum is important especially because it usually responds well to conservative management and an accurate diagnosis will prevent unnecessary surgical investigations.Duodenum inversum is a rare congenital anomaly that is important to recognise and diagnose to avoid unnecessary surgical intervention.Diagnosis is established on fluoroscopy, CT or MRI based on characteristic abnormal course of the duodenum.3It can be associated with duodenitis, acute pancreatitis, peptic ulcer disease and functional biliary obstruction.2,3,9Treatment of symptomatic duodenum inversum is usually medical therapy with proton pump inhibitors for patients with associated duodenitis or ulcers.


An 86-year-old man sustained progressive motor weakness in the left lower extremity for 1 month. Cranial computed tomography (CT) revealed an isodense mass in the right parietal lobe, with a smooth-contoured focal erosion in the adjacent parietal bone. The extra-axial tumor appeared isointense on T1- and hyperintense on T2-weighted magnetic resonance imaging with intense enhancement. On three-dimensional CT angiography, the ectatic left occipital artery coursed into the right parietal foramina and connected with a dilated meningeal vessel supplying the tumor. The focal erosion formed in the inner parietal bone was located adjacent to the feeding vessel. A total tumor resection was achieved. The microscopic findings of the resected specimen were consistent with a World Health Organization grade III hemangiopericytoma (HPC). Bone erosion and peripheral feeding vessels may be characteristic findings of intracranial solitary fibrous tumor (SFT)/HPC. Careful interpretation of neuroimages could help detect clues for distinguishing an SFT/HPC masquerading as a meningioma from a true meningioma. Meningiomas are a frequent brain tumor of the central nervous system. However, a variety of tumors can radiologically mimic meningiomas, which can cause confusion in presurgical diagnosis After branching from the external carotid artery, the occipital artery initially courses deep sites from its origin to the arch formed by the trapezius and sternocleidomastoid muscles. The artery then becomes superficial while ascending to the vertex, where it occasionally penetrates the fine bony canal(s), parietal foramen, or foramina that are typically located in the parasagittal region, just anterior to the rhomboid suture, and anastomoses with the meningeal vessels Here, we report a unique case of SFT/HPC accompanying bone erosion that was fed by the transcranial blood supply from the contralateral occipital artery.An 86-year-old man sustained progressive motor weakness in the lower extremity for one month. At presentation, the patient was well oriented and presented with monoparesis  in the left lower extremity. Cranial computed tomography (CT) revealed an isodense mass in the right parietal lobe with smooth-contoured focal erosion in the adjacent inner table. Neither intralesional calcification nor hyperostosis was observed in the adjacent skull . The comThe prevalence of lesions mimicking meningiomas is estimated to be not negligible, suggesting the necessity of assuming a wide range of pathologies for varying prognoses and treatment strategies The present SFT/HPC was a high-grade tumor that was likely to have a low overall prognosis due to a high risk of local recurrence and extracranial metastasis. In contrast, the patient was at an advanced age. Furthermore, a total resection was achieved by the initial surgery. Therefore, it was considered reasonable for the patient to be placed under observation without immediate adjuvant radiotherapy.In conclusion, bone erosion and peripheral feeding vessels may be characteristic findings of intracranial SFT/HPCs. Careful interpretation of neuroimages could provide clues for differentiating an SFT/HPC masquerading as a meningioma from a true meningioma.All the authors contributed equally to this study.


Embolic events play an important role in clinical everyday practice. Malignant arterial embolism is a rare nevertheless often fatal entity for cardiac, cerebral or systemic ischemia, requiring immediate diagnosis and treatment.This is a case report of a 65 years‐old female, suffering from pulmonal adenocarcinoma, who was hospitalized due to neurological deficits caused by an acute ischemic stroke, followed by anterior myocardial infarction within 3 days. Diagnostic work‐up revealed metastasis of the pulmonal adenocarcinoma in the right atrium and a patent foramen ovale. Histopathological examination of the coronary embolus verified paradoxical arterial embolism of the pulmonal adenocarcinoma into a coronary vessel and consequently cerebral arteries.The present case underlines the need for (i), consideration of malignant embolism, (ii) histopathological examination of the embolus to determine its etiology, and (iii) interdisciplinary discussion of individual therapeutic and prevention strategies in cancer patients with cerebral, cardiac or systemic embolic events. Besides thromboembolic causes of systemic ischemic diseases, rare entities like malignant arterial embolism may be underestimated. These diagnostic errors often result in improper treatment with oral anticoagulants, ignoring the malignant nature of the embolus, demanding surgical or interventional embolectomy,2A 65 years‐old female was admitted to neurological emergency unit with acute onset of aphasia and brachiofacial hemiparesis of the right side . Cerebral magnetic resonance imaging (MRI) displayed an acute Middle cerebral artery (MCA) infarction (left side), Figure . Pulsed Histological examination of the LAD‐embolus revealed coagulated poorly differentiated adenocarcinoma. Immunohistochemical analysis yielded a TTF‐1 negative, CK7 positive and PD‐L1 positive (TP‐Score of 90%) tumor cell staining result, corresponding to the primary TTF‐1 negative pulmonary adenocarcinoma with typical lepidic growth pattern . During chemotherapeutical treatment and checkpoint inhibition with Nivolumab, a dedifferentiation and upregulation of PD‐L1 presumably took place. A complementary transesophageal echocardiography discovered a large patent foramen ovale (PFO) and a tumor mass floating in the right atrium with two tumor plugs inserting in the fossa ovalis  interdisciplinary discussion, (ii) consideration of malignant embolism, (iii) histopathological examination of the embolus to determine its etiology, and (iv) individual therapeutic and prevention strategy, based on all available information in cancer patients with cerebral or systemic embolic events.R.B. has received Honoria for Lectures and advisory boards from AbbVie, Amgen, AstraZeneca, Bayer, BMS, Boehringer‐Ingelheim, Illumina, Lilly, Merck‐Serono, MSD, Novartis, Qiagen, Pfizer, Roche, Targos Mol Path. R.B. is a co‐founder and CSO for Targos Mol Path, Kassel (Germany). All other authors have nothing to disclose.Conceptualization, B.J.W., H.‐P.H., A.J.H., R.B.; Methodology, B.J.W., H.‐P.H., A.J.H., M.G.; Investigation, B.J.W., H.‐P.H., R.B.; Formal Analysis, B.J.W.; Resources, B.J.W.; Writing—Original Draft, B.J.W., H.‐P.H., R.B.; Writing—Review & Editing, B.J.W., H.‐P.H., A.J.H., L.K.H., M.G., N.M., R.B.; Visualization, B.J.W., A.J.H., L.K.H., N.M.; Supervision, B.J.W., H.‐P.H., L.K.H.; Data Curation, B.J.W., H.‐P.H., L.K.H., M.G., N.M., R.B.; Project Administration, B.J.W., R.B.; Validation, H.‐P.H., L.K.H., M.G., N.M., R.B.All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Informed consent was obtained from the spouse, as the legal representative of the patient of this case report, to publish the patient data, including potentially identifying individual information in this study.


Necrotising fasciitis (NF) is a rapidly progressive infection of soft tissue and fascia. Early diagnosis and prompt extensive surgical debridement decrease mortality. This remains a challenge for rural surgeons who have limited experience with the disease, in a setting where patient transfers to tertiary centres are lengthy and often delayed. To assist clinical decision making in this setting, a case series of five NF presentations in a rural Australian hospital were retrospectively analysed for presentation, investigation, treatment and clinical outcomes. Three underwent abdominal wall debridement and two underwent below knee amputation. Results demonstrate early recognition of NF and the extent of surgical intervention prior to acute transfer are key to successful outcomes. Expedient diagnosis and early extensive debridement at the initial contact reduce mortality and should be the goal of management in this setting. Necrotising fasciitis (NF) is a rapidly progressive infection causing destruction of soft tissue and fascia. Cases are rare with an incidence of 1 per 100 000 . The majin situ and driving ongoing sepsis during the transfer process. Limited literature exists describing the experience of NF in a rural setting to assist surgeons in this decision-making process. This case series set in rural Australia demonstrates successful outcomes of NF can be achieved through early diagnosis and aggressive surgical treatment prior to definitive transfer.Delay to diagnosis and surgical intervention increases the mortality of NF , 9. It fFive consecutive cases of NF admitted to a rural Australian hospital within the last 12 months are presented below. Three involved the abdominal wall and two the lower limb. Clinical presentation and surgical outcomes are summarized in A 62-year-old male presented with 2 weeks of left lower limb erythema and an ulcerated, necrotic great toe wound, initially treated as gout by his primary care provider. Computed tomography (CT) demonstrated features of NF to the level of mid-tibia and he underwent a left below knee amputation (BKA). He required only one further debridement following tertiary transfer and was transferred back for local rehabilitation 11 days later.A 76-year-old male presented with 5 days of an increasingly painful, erythematous left foot, initially thought to be a superimposed superficial infection of gout. An X-ray demonstrated NF and he was taken to theatre for a left BKA. No further debridements occurred at the tertiary centre. He was transferred back for ongoing wound care and rehabilitation 23 days later.A 70-year-old female presented with a 3-week history of lower abdominal pain. Given clinically well with minimal symptoms, she was initially discharged home; however, represented 2 days later with sepsis and extensive necrosis of her abdominal wall. She was taken urgently for debridement and transferred to a tertiary centre. Five further debridements took place and she was transferred back for ongoing vacuum-assisted closure (VAC) dressings 45 days later.A 60-year-old male presented with an abdominal wall abscess, having previously been reviewed and discharged 1 week prior for vague abdominal pain associated with minor skin erythema. Initially, incision and drainage were performed under local anaesthesia. He became systemically unwell and a CT demonstrated abdominal wall NF. He proceeded to theatre for debridement. Primary closure occurred 1 month later and he was discharged directly home.A 51-year-old male presented to the ED with increasing abdominal wall erythema and pain following incision and drainage of a lower abdominal abscess 1 day prior in the surgical outpatient department. Although clinical suspicion for NF was low, a CT demonstrated abdominal wall NF and he was taken to theatre for debridement. The abdominal wall defect underwent primary closure 5 days later and he was discharged directly home Day 10 after presentation.NF is a serious, rapidly progressive soft tissue infection with Australian mortality rates as high as 18% . Our revDelayed recognition of NF significantly increases mortality , 15, 16.In an attempt to improve outcomes of NF, a recent study investigated delays to diagnosis and treatment using data from The Australian and New Zealand Audit of Surgical Mortality . They foFor ambivalent cases, imaging and surgical cut down with urgent gram stain may assist diagnosis . CT featOnce the diagnosis of NF is made, the decision of timing and extent of operative debridement remains difficult. Many surgeons have limited experience with NF and although the temptation exists to transfer cases to tertiary centres for specialist intervention, delay to operative debridement increases mortality , 16, 20.Once the decision has been made to operate locally on suspected NF, rural surgeons must avoid being cautious when it comes to the degree of surgical debridement. Prompt and extensive initial debridement remains the cornerstone of treatment and should be the aim of the primary operation . Early eAdditionally, early intervention may reduce the need for tertiary transfer. Case 5 had few symptoms to suggest NF at presentation; however, early CT was performed allowing expedient diagnosis and time to operative intervention. Urgent initial surgery meant infection was limited and debridement was not required to be as extensive. He avoided transfer to a tertiary centre and further debridements, allowing primary closure of his abdominal wall and discharged only 10 days after his initial presentation.NF remains a challenging condition for surgical teams in the rural setting. Lack of recognition, the dilemma surrounding local versus tertiary operative intervention and the extent of debridement are especially difficult for surgeons inexperienced with the disease. However, as this case series demonstrates, limb and lifesaving interventions can be performed in the rural setting with good outcomes and limited mortality. Supported by the literature, early diagnosis and expedient extensive debridement prior to transfer should be the goal of management in this context. Ultimately, this case series serves as a reminder that NF remains a clinical diagnosis and surgical teams must have a high index of suspicion with a low threshold for urgent, extensive surgical debridement to reduce morbidity and mortality rates in the rural setting.


Herein, we will describe our experience of posterolateral epidural supra-C2-root approach (PESCA) for biopsy of retro-odontoid lesions in one surgical session after occipitocervical fixation and decompression in a patient with CDS and massive brainstem compression.A 70-year-old woman presented to our department with a 4-week history of progressive walking impairment, neck pain, neck rigidity, fever, dizziness, slight palsy of the left hand, and multiple fall episodes. Magnetic resonance imaging (MRI) of the craniovertebral junction (CVJ) and cervical spine revealed a lesion of the odontoid process and the retro-odontoid region with mainly solid components, as well as small cystic components, and brainstem compression and displacement. In first step, fusion surgery of the CVJ C0–C4 was performed with occiptocervical decompression. After fusion and decompression the lower lateral part of the C1 arc and the lateral superior part of the left side of the C2 arc were removed. The entry point was located directly above the superior part of the C2 root. A biopsy of the lateral portions of the lesions was obtained by bioptic forceps under microscope guidance. Pathologic examination of the mass revealed deposition of birefringent crystals compatible with calcium pyrophosphate. In addition to the clinical symptoms , the diagnosis of CDS was made. Non-steroidal inflammatory drugs (NSAIDs) and colchicine (and later magnesium) were started. At follow-up examination 6 months after surgery, an MRI scan of the cervical spine revealed regression of the pannus and the cyst with replacement of the brainstem, clinical improvement of walking, and increased strength of the left hand.This study demonstrates that PESCA can be used to obtain tissue for pathological analysis in one surgical sitting after fusion and decompression and that fusion, decompression, and PESCA (in the same session) together with subsequent conservative management could be a good alternative for the treatment of CDS. Retro-odontoid pseudotumors are defined  as soft Joyce et al.  pointed Retro-odontoid pannus may develop in the spinal canal , may cauCrystal deposition diseases comprise a group of metabolic diseases, such as CPPD or hydroxyapatite crystal deposition (HAD), in which crystals are deposited in and around the joints and create inflammatory and destructive lesions .While CPPD is the third most common inflammatory arthritis, characterized by acute (formerly known as pseudogout ) or chroIn 1985, Bouvet et al. , 11), whIn a previous publication, we advocated for the posterolateral epidural supra-C2-root approach (PESCA) for biopsy of lesions of the odontoid process (OP) in one surgical session after occipitocervical fixation and decompression, which might be a good alternative to classical approaches .Herein, we will describe our experience of PESCA for biopsy of retro-odontoid lesions in one surgical session after occipitocervical fixation and decompression in a patient with CDS and massive brainstem compression.To best of our knowledge this is the first case of CDS which had been managed by this concept.A 70-year-old woman presented to our department with a 4-week history of progressive walking impairment, neck pain, neck rigidity, fever, dizziness, slight palsy of the left hand, and multiple fall episodes.Magnetic resonance imaging (MRI) of the craniovertebral junction (CVJ) and cervical spine revealed a lesion of the OP and the retro-odontoid region  with maiThe patient had a history of Saethre–Chotzen syndrome (SCS)  and diabetes mellitus with diabetic nephropathy. MRI also revealed a fusion of the cervical vertebral bodies C3 to C6 due to Saethre-Chotzen syndrome .Owing to brainstem compression and displacement caused by pannus grade 4, cervical instability, and progressive walking impairment, we decided to perform surgery. Our goal was to stabilize the CVJ, decompress the foramen magnum and spinal canal at the C1 level, and perform biopsy of the periodontoid lesion for pathological analysis in a single surgical session.Preoperative planning included a thin slice CT image of the cervical spine and CVJ for spinal neuronavigation, CT angiography (CTA) for analysis of the V3 segment of the vertebral artery, which revealed a “normal” anatomy, and a three-dimensional model print .Cefuroxime was administered for perioperative surgical prophylaxis. The patient was placed in a prone position under general anesthesia, and radiography was performed after positioning to verify anatomical alignment. Intraoperative monitoring (IOM) included motor-evoked potentials and sensory-evoked potentials of the upper and lower extremities.A midline incision was made and the inion, posterior wall of the posterior cranial fossa, C1 arc, and C2, C3, and C4 laminae were exposed.Fusion surgery of the CVJ C0–C4 was performed with an OC plate  under spinal neuronavigation (Brainlab).After fusion, the foramen magnum was enlarged under microscope  examination. Laminectomy of the medial C1 arc and the lower lateral part of the C1 arc , removal of the left superior part of the left side of the C2 arc, and flavectomy were performed . DopplerDifferent landmarks such as the C2 root and remains of the C1 arc, C2 arc, and dural sac were identified. Then, PESCA, which we described in a previous publication, was performed .The window between the remains of the C2 arc and the C2 root was used in our approach. The entry point was located directly above the superior part of the C2 root. The trajectory was located medial to the pedicle of C2, medial to the C1–C2 facet joint, and medial to the tubercle for the transverse ligament of the atlas.A bioptic instrument was inserted under microscope guidance . Owing tA postoperative CT scan showed proper positioning of the screws and sufficient decompression of the spinal cord at the level of the CVJ . The patPathologic examination of the mass revealed fibrous connective tissue with deposition of birefringent crystals compatible with calcium pyrophosphate (CPP) due to CPPD disease . In addiAt follow-up examination 3 months after surgery, the patient did not manifest any neurological symptoms, and the CT scan of the CVJ did not reveal large regression of the pannus. Therefore, NSAIDs (diclofenac), steroids (prednisolone), and magnesium were administered.At follow-up examination 6 months after surgery, an MRI scan of the cervical spine revealed regression of the pannus and the cyst with replacement of the brainstem , clinicaOka et al.  summarizThe precise diagnosis of CDS might be challenging –19, as tDifferent authors concluded that CT of the CVJ is the gold standard for the diagnosis of CDS , 17. TheJain et al.  concludeGrob et al.  describeDifferent types of pannus have been classified in the literature such as hypervascular, hypovascular, and fibrous pannus .Many authors , 20 presChondrocytes generate “pericellular exosome-sized vesicles,” also termed as “articular cartilage vesicles,” which are one of the important sites of crystal formation in cartilage; furthermore, they produce extracellular inorganic phosphates, which are essential to the formation of CPP crystals .Zünkeler et al.  hypothesOnce located in the joint, CPP crystals may contribute to further mechanical damage  of the Moreover, a number of comorbidities correlate with CPPD . DiffereMost authors have recommended treatment with NSAIDs and/or steroids  , 24, 25.Lee et al.  pointed Oka et al.  reportedDifferent authors , 17 alsoJain et al.  advocateAs shown in the present case and in some cases, treatment of pannus by conservative methods may take months. During this time, the patient is already at a high risk of further impairment, especially in the presence of brainstem compression.Even if conservative therapy is indicated in most cases of CDS, surgery is also indicated in a few cases . Fiani eBaysal et al.  reportedAccording to most authors and to our opinion, surgery is necessary in case of massive brainstem compression, myelopathy, dramatic progression of neurological symptoms, unclear diagnosis  and instability. In our case, the patient had a massive brainstem compression and displacement and progressive walking impairment. Therefore, surgery was performed.PESCA might be a good alternative and is easier to perform in periodontoid lesions than in odontoid lesions because the trajectory is not as deep. Even if the window of PESCA is small, the surgical path is narrow, and the working angle is oriented up, performing surgery in one session is a huge advantage for the patient . To bestTWIST1 gene  , 33 seve35 used in the removal of OP, retro-odontoid lesions  or extending lesions in and around the OP (such as chordomas).A number of authors –36 descrOne risk of transcondylar and trans-atlas approaches is instability . AnotherOya et al.  describeSrivastava et al.  describeThe posteriolateral transpedicular approach to C2 has a narrow trajectory (because of the diameter and angle of the pedicles); therefore, the reachable targets are limited and in most cases, the upper part of the OP is not reachable. This approach has been used mainly for biopsy.pars interarticularis and the inferior articular atlas was used as a guide to expose the atlanto-occipital joint ways. Mobilization of VA could be necessary to enlarge the surgical window  together with subsequent conservative management could be a good alternative for the treatment of CDS.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of the University Hospital Tübingen, Germany; reference number 478/2020BO. The patients/participants provided their written informed consent to participate in this study.PH: performed analyses, performed 3D-print, and critical revision. T-KH, KK, MS, and MT: performed analyses and critical revision. SA: idea and development of PESCA, performed surgery, performed analyses, wrote the article, and critical revision. All authors listed have made substantial, direct, and intellectual contribution to the work and approved it for publications.We acknowledge support by Deutsche Forschungsgemeinschaft and Open Access Publishing Fund of the University of Tübingen.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Aim: To assess urologists’ proficiency in the interpretation of multiparametric magnetic resonance imaging (mpMRI). Materials and Methods: Twelve mpMRIs were shown to 73 urologists from seven Italian institutions. Responders were asked to identify the site of the suspicious nodule (SN) but not to assign a PIRADS score. We set an a priori cut-off of 75% correct identification of SN as a threshold for proficiency in mpMRI reading. Data were analyzed according to urologists’ hierarchy  and previous experience in fusion prostate biopsies . Additionally, we tested for differences between non-proficient vs. proficient mpMRI readers. Multivariable logistic regression analyses (MVLRA) tested potential predictors of proficiency in mpMRI reading. Results: The median (IQR) number of correct identifications was 8 (6–8). Anterior nodules  represented the most likely prone to misinterpretation. Overall, 34 (47%) participants achieved the 75% cut-off. When comparing consultants vs. residents, we found no differences in terms of E-fPB (p = 0.9) or in correct identification rates (p = 0.6). We recorded higher identification rates in urologists with E-fBP vs. their no E-fBP counterparts . At MVLRA, only E- fPB reached the status of independent predictor of proficiency in mpMRI reading  after adjusting for UH and type of institution. Conclusions: Despite urologists becoming more familiar with interpretation of mpMRI, their results are still far from proficient. E-fPB enhances the proficiency in mpMRI interpretation. Multiparametric magnetic resonance imaging (mpMRI) of the prostate has become the gold standard imaging modality for suspicious prostate cancer (PCa) ,2. ThroumpMRI represents a mandatory step in the flowchart of PCa diagnosis as well as a useful tool for staging and preoperative planning of PCa treatment ,5,6. TheThe interpretation of mpMRI is challenging even in the hands of experienced radiologists as it implies understanding of different MRI sequences, how to manipulate the images and how to assign suspicion scores. Although urologists are not required to have the same skills and precision required as radiologists, the “best practice” requires that the surgeon has adequate skills to read the imaging autonomously and to obtain the basic information for accurate prostate biopsies and treatment delivery . RecentlSuspicious mpMRI images of 12 patients were selected by an expert uro-radiologist (G.C.), whose interpretation was considered as the gold standard, and shown to urologists from seven institutions (five academic and two non-academic) from August 2019 to November 2020.Case 1: 59 years old, PSA 5.5 ng/mL, no previous biopsies, PIRADS 4, posterior—apical lesion.Case 2: 80 years old, PSA 7.2 ng/mL, no previous biopsies, PIRADS 4, posterior—median lesion.Case 3: 74 years old, PSA 5.4 ng/mL, no previous biopsies, PIRADS 4, anterior—median lesion.Case 4: 77 years old, PSA 5.7 ng/mL, previous negative biopsy, PIRADS 4, anterior—median lesion.Case 5: 73 years old, PSA 5.5 ng/mL, no previous biopsies, PIRADS 5, posterior—apical lesion.Case 6: 59 years old, PSA 5.2 ng/mL, previous negative biopsy, PIRADS 4, anterior—apical lesion.Case 7: 73 years old, PSA 6.5 ng/mL, previous negative biopsy, PIRADS 5, posterior—basal lesion.Case 8: 73 years old, PSA 4.5 ng/mL, previous negative biopsy, PIRADS 4, posterior—median lesion.Case 9: 75 years old, PSA 7.6 ng/mL, no previous biopsies, PIRADS 5, posterior—median lesion.Case 10: 67 years old, PSA 7.9 ng/mL, no previous biopsies, PIRADS 3, posterior—basal lesion.Case 11: 69 years old, PSA 7.8 ng/mL, no previous biopsies, PIRADS 3, anterior—median lesion.Case 12: 67 years old, PSA 5.4 ng/mL, no previous biopsies, PIRADS 4, posterior—median lesion.All the selected scans were attained with a 1.5-T mpMRI study  with a phased-array surface coil and an endorectal coil . All 12 cases presented a PIRADS ≥ 3 lesion  Figure , in detaThe mpMRIs were administered using the RadiAnt DICOM Viewer 4.0.1 software . Every participant had a maximum of 10 min to evaluate each mpMRI. Four sequences were shown at the same time in loop: T2 weighted image (T2), diffusion weighted imaging (DWI), apparent diffusion coefficient (ADC), contrast enhancement (CE).First, each participant answered an anonymous survey see  with demContinuous variables were summarized as medians and interquartile ranges (IQR) and categorical variables as the number of subjects and percentage values.Statistical analyses were based on two steps. First, data were analyzed according to urologists’ hierarchy (resident vs. consultant) as well as according to previous experience in performing fusion prostate biopsies  . AdditioSecond, we aimed to assess potential predictors of proficiency in mpMRI reading. For this purpose, we relied on multivariable logistic regression models. Covariates consisted of type of Institution (academic vs. non-academic), previous experience in fPB and urologists’ hierarchy (resident vs. consultant).p < 0.05.For all statistical analyses, R software environment for statistical computing and graphics  was used. All tests were 2 sided with a level of significance set at Overall, we collected complete data of 73 urologists. Of these, 36 (49%) and 37 (51%) were, respectively, residents and consultants A; 54 (74Forty-nine participants (67%) were already out of their learning curve for fPB. Similarly, 43 (59%) and 31 (42%) responders came from institutions with more than 300 referrals for PCa and more than 200 prostatectomies per year, respectively.Overall, 81%, 71%, 38%, 51%, 79%, 42%, 68%, 62%, 77%, 41%, 73%, and 60% of participants correctly identified the lesions from 1 to 12, respectively. When summing up the number of correct responses, 34 (47%) participants achieved the 75% cut-off.p = 0.9). Similarly, no differences were recorded in the percentage of correctly identified lesions (p = 0.6). Only in case number 10, a statistically significant difference was recorded among consultants (59% of correct answers) vs. residents .In our cohort of responders, we found no differences in experience in fPB between consultants vs. residents (p = 0.004). Specifically, the former correctly identified more frequently the lesion of cases 1, 3 and 6 . In the comparison according to experience in fPB B, we recp = 0.016). Furthermore, a statistically significantly greater percentage of proficient responders correctly identified the lesions.When analyzing proficient vs. non-proficient readers C, we idep = 0.02) after adjusting for urologists’ hierarchy and type of institution  of prostate cancer on mpMRI, using artificial intelligence (AI) in order to reduce missed cancers and unnecessary biopsies and increase inter-observer agreement between clinicians . HoweverTo date, several studies have tested the proficiency of radiologists in mpMRI interpretation, also addressing the impact of different learning tools advocated to enhance their reading skills ,25. ContFirst, it is worrisome that only 47% of responders achieved our a priori standard of proficiency (75% correct answers). In light of these results, surgeons should still consult radiologists during surgical planning. It is of utmost importance that urological surgeons receive formal training in mpMRI reading.Second, the least correctly identified lesions were numbers 3, 4, 6 and 10; it is of note that all those nodules were anterior lesions, except for case 10, which was a PIRADS 3 posterior basal lesion. Interestingly, even when responders reached the 75% cut-off of proficiency reading, those lesions were less frequently correctly identified. It can be therefore postulated that anterior and low-PIRADS lesions represent a challenge even for more experienced eyes.p > 0.9). However, it is of note that consultants correctly identified the only PIRADS 3 lesion included in the study (case 10) almost twice as frequently as residents.Third, we did not record differences in identifying correct lesions between residents vs. consultants. These results can be justified by the same exposure to fusion prostate biopsy between the two groups . Moreover, urologists exposed to fPB were more likely to identify anterior lesions . Additionally, among those who reached proficiency cut-off, 47% had experience in fPB compared to only 21% of non-proficient readers (p = 0.02). This result was further confirmed by MVA analyses, where experience in fPB was the only independent predictor of correct mpMRI reading  after adjusting for urologists’ hierarchy and type of institution.Finally, and foremost, experience in fPB seems to play the leading role in achieving proficiency in mpMRI reading. Indeed, when comparing experienced vs. non-experienced, correct responses were recorded in 75% vs. 67%, respectively . Moreover, we feel that radiologists, as well as urologists, should be provided with a short patient summary to help with the correct interpretation of mpMRI sequences.Third, the study is limited by the lack of a training intervention to see whether the accuracy can be improved with an educational program.Finally, participants of our study all came from Italian institutions. Despite the effect of including academic vs. non-academic, high vs. low-volume centers and residents vs. consultants, we are not able to conclude that our results are generalizable to other European and non-European settings.Our results suggest that experience in fusion prostate biopsies enhances the ability of correctly identify suspicious nodules at mpMRI. Moreover, anterior lesions may be more challenging to locate.


Teaching Point: Extramedullary acute myeloid leukemia tumor belongs to the differential diagnosis when a tumor develops in a patient with a history of leukemia, and magnetic resonance imaging is of diagnostic value by demonstrating iso-intensity and hyperintensity compared to skeletal muscle respectively on T1- and T2-weighted images and homogeneous contrast enhancement. This pathological nerve tissue was hyperintense on fat-suppressed T2-weighted images (FS-T2WI), isointense to skeletal muscle on T1-weighted images (T1WI), and exhibited avid contrast-enhancement (T1Gd). A triangular perineural zone with similar signal characteristics  infiltrated the surrounding brachial muscle (*) and brachioradialis muscle (#). Ultrasound-guided biopsy confirmed the presence of an extramedullary acute myeloid leukemia tumor (eAML). A consecutively performed bone marrow biopsy confirmed relapse of the underlying intramedullary/systemic leukemia.A 32-year-old woman presented with right elbow pain accompanied by loss of strength and sensory disturbances in the forearm. The medical history mentioned a bone marrow transplantation one year prior for acute myeloid leukemia (AML), without current therapy due to assumed remission. Clinical examination revealed hypoesthesia dorsally at digits 1–3, paresis of the hand dorsiflexors, and a pressure-sensitive zone in the upper arm. An electromyogram signalized mononeuropathy of the right radial nerve. Radiographs were negative for osseous/articular elbow lesions. Ultrasound demonstrated a thickened hyporeflective radial nerve in the distal upper arm proximally to the elbow joint. MRI confirmed radial nerve thickening (An eAML presents with extramedullary masses comprised of immature myeloid cells . An eAML


Duplication of the urethra is a rare congenital malformation in dogs, whose resolution is mainly surgical, but this type of solution is not free from complications. In a case report regarding a young dog, an alternative approach based on diode laser cauterization was tried. Unfortunately, since this method did not provide the desired results, the need for surgery was inevitable.Duplication of the urethra is a rare congenital malformation. A 14-month-old, sexually intact, male, Lagotto dog with complete Y-type urethral duplication was subjected to accessory urethra treatment for cystoscopic guided laser cauterization, with a 10-Watt diode laser with 550-micron fiber and 2.3 Fr outer diameter. The laser cauterization, that was repeated every 14 days for a total of three times, was performed by inserting the instrument from the accessory urethra outlet in the perianal area until it could be seen by the urethroscope, inside the ischial urethra. Nevertheless, this technique that proved to be non-invasive, less expensive than surgery, of short duration, and safe, did not allow the complete closure of the abnormal urethral tract. Therefore, the subsequent surgical removal of the accessory urethra was carried out. To the authors’ knowledge this is the first report on the use of cystoscopic guided diode laser cauterization for accessory urethra treatment. Duplication of the urethra is a rare congenital malformation observed in humans, dogs, cats, heifers, goats, and llamas ,2,3, usuExcision of the accessory urethra is described as the elective therapeutic option when the orthotopic urethra is patent. In this paper, cystoscopic guided laser cauterization is proposed in a dog with complete Y-type urethral duplication, a technique that has never been utilized before.A 14-month-old, sexually intact, male, Lagotto breed dog was referred to the Veterinary Teaching Hospital of University of Parma  with a history of urinary incontinence, with urine coming from the perianal region, as well as from the urethra, during micturition. The dog presented normal urination from the primary urethra (orthotopic), without urine stream alteration, straining or hematuria, pain manifestation or dysuria. The owner reports that the dog maintained a female-like posture during urination until the age of one year, and only since then started lifting the hind limb for urination; the owner also noticed urine leaking occasionally from the perianal region. Physical examination of the dog showed normothermia, no lymph node involvement, inspection-palpation of hair coat layers showed no urine-induced burns and genital organs appeared anatomically normal. Complete blood count and biochemistry were within normal limits. Urine had a specific gravity of 1.046, a pH of 6.5, protein level of 23.4 mg/dL, and PU/CU of 0.08. The urine culture yielded was sterile for aerobes, anaerobes, and enrichment. After clipping perineal hair, a pinpoint opening was found in the median perineal raphe, approximately 4.5 cm ventral on the left side of the anus . There wAn abdominal ultrasound was performed, and no anomalies were found. Under general anesthesia, the penile urethra was catheterized, highlighting that the orthotopic urethra was functional. The retrograde hydropropulsion confirmed the access between the perineal orifice and the orthotopic urethra. To determine the extent of the accessory channel, a contrasted retrograde urethrocystography was performed. The post-administration LLDx projection of 5 mL of radiographic contrast medium iopamidol , diluted with physiological solution 1:3 allowed for the highlighting of a stripe superimposed on the ischium and in the soft tissues of the perineum, with a length of 6.2 cm and a thickness of approximately 0.32 cm in the craniocaudal direction, originating from the membranous urethra placed between the prostatic portion of the organ and the ischial curvature, and terminating in the perineum, enabling the diagnosis of a complete Y-shaped urethral duplication . During the cystoscopic examination performed with a 2.5 mm HugeMed Video-ureteroscope, the penile urethra and ischial curvature appeared normal, with a wide and regular lumen, and free from uroliths and stenotic processes. The mucosa, that appeared regular and normochromic, showed a normal thickness. In the intrapelvic tract of the urethra, between the prostate and the ischial curvature, the outlet of a urethral path was observed . By inseUnder general anesthesia, a cystoscopic guided laser cauterization with 10-Watt diode laser with 550 micron fiber and 2.3 Fr outer diameter  was performed; the diode laser fiber was inserted from the urethral outlet in the perianal area until it was viewed through the urethroscope, inside the ischial urethra. The cauterization was performed at the starting point of the splitting, using a power of 3 Watts with a continuous pulse, and subsequently proceeding with a spiral movement for the entire length of the abnormal urethral tract, moving back to the outlet on the skin. After 2 weeks, a second treatment was carried out after checking the urethral tract by endoscopic vision. Compared to the previous session, the caliber of the lumen of the path was reduced by half at the starting point of the orthotopic urethra. The therapeutic path was completed with a third intervention 2 weeks later. Upon inspection, the lumen diameter of ostium of the fistula on the urethral wall almost corresponded to the previous treatment, while the cutaneous outlet on the perianal area was almost completely healed, still presenting a flow of urine, although largely decreased.Given the lack of complete obliteration of the lumen in the abnormal urethral tract, it was decided to proceed with surgery, consisting of legating the origin of the abnormal tract and removing it in its entirety.The patient was positioned in a sternal decubitus. After a trichotomy of the perianal region and the ventral portion of the abdomen, a purse string suture was performed on the anus. A 2.6-mm urethral catheter was placed in the orthotopic urethra and connected with a closed system to a urine collection bag. Subsequently the perineal ostium of the abnormal urethral tract was catheterized with a 1.3-mm, semi-rigid, urinary catheter. The abnormal urethral tract was delicately isolated, then its resection was performed. The excised portion was sent to the pathological anatomy laboratory for histological examination a–c, whicOnly seven cases of urethral duplication have been described in dog to date ,7,8,9,10Excision of the accessory urethra is described as the elective therapeutic option when the orthotopic urethra is accessible and surgical reconstruction of canine urethral defects involves invasive approaches ,16,17,18Interventional urology refers to minimally invasive procedures for the treatment of congenital, acquired, and neoplastic conditions, where endoscopes, fluoroscopy, and other instruments are used to access, under direct visualization, structures inside the urinary tract. Access is most commonly achieved through natural orifices and the procedures are executed internally, with or without minimal external incisions for various diagnostic and therapeutic endeavors . In the Cauterization is a medical procedure which consists of the therapeutic destruction of tissues using heat or caustic substances. Medical lasers are currently employed in veterinary medicine and surgery, and the laser cautery procedure is a viable option in various clinical situations ,24. LaseAlthough diode lasers have been available for a long time, their clinical applications are still limited in dogs . The dio


Enchondroma is a benign cartilaginous tumor composed of mature hyaline cartilage. Cartilaginous tumors are detected in a small percentage of cases in the craniofacial region. These tumors may have diverse presentations ranging from a simple enchondroma to a high-grade osteo or chondrosarcoma. In the maxilla, only 1 case of enchondroma has been reported in the literature to date, to the best of the authors' knowledge. Tumor's membranous development attributes to its occurrence usually in the cartilage-bearing areas of the jaws, like the condylar process of the mandible (Meckel’s cartilage). This case report intends to present one case of enchondroma involving the left maxilla, which has no primary cartilage of its own. Enchondroma is a benign cartilaginous tumor composed of mature hyaline cartilage . CartilaA benign growth of mature hyaline cartilage known as a chondroma is mainly seen in the extremities (96%), with 72% in the upper limb, 24% in the lower limb, 2% in the head and neck and 2% in the trunk .Depending on their locations, chondromas can be classified as enchondromas which originate from the marrow in the medullary cavity of the bony skeleton, juxtacortical or periosteal chondromas, which originate adjacent to the periosteum below the cortical surface and extra-skeletal or soft tissue chondromas .Enchondromas or central chondromas account for 0.32% of all entities in the craniofacial region, making it quite uncommon [A 52-year-old female patient reported to our institute with a complaint of swelling in the upper front tooth region for five months and also complains of forwardly displaced upper front teeth. The patient noticed a mild gap in the upper front teeth (canine-premolar) region three years ago, which gradually increased in the following years to the present size. The patient started developing swelling in the upper front tooth region in November 2021, which gradually increased to 3x2cm in size. She also gives a history of displacement of upper front teeth due to the swelling. The swelling was not associated with any local discharge or paresthesia. The medical history was non-contributory.On clinical examination, there was a mild diffuse swelling present on the left side of the face below the ala of the nose. Figure  OverlyinSince the lesion was a firm, painless, well-circumscribed swelling fibrous dysplasia, ameloblastic fibro-odontoma, complex odontoma, and chondroma were considered differential diagnoses.Incisional biopsy was performed from the periapical region of 24 and the labial aspect of 22 and 23 under local anesthesia. Hard tissue specimens measuring 0.2 cm and 0.4 cm were obtained, respectively. Histopathological sections showed small cartilaginous fragments displaying a cellular lesion in small lobules comprising of chondrocytes with small bland chondroid cells in lacunar spaces, uniform staining nuclei, no pleomorphism, anaplasia, mitosis, hyperchromasia and multinucleated giant cells. Hence the lesion was diagnosed as enchondroma of the left anterior maxilla.The lesion was planned for an en-bloc resection with respect to left maxilla extending from 21 to 25 region with 1 cm peripheral margins under general anesthesia using intra- oral crevicular incision extending from 13 to 27 followed by primary closure using the buccal pad of fat and mucosa Figures . HistopaThe case is on continuous follow-up for eight months to check for any reoccurrence and is currently undergoing prosthetic rehabilitation Figure .The benign, cartilaginous enchondromas, first coined by Muller in 1838, are slow-growing and asymptomatic tumors found in the medullary cavity of the bone. Having equal sex predilection most frequently affects long bone and short tubular bones of the hand, and it most frequently occurs in the third or fourth decades of life . MaxillaIn a review of 8542 bone tumors conducted by Dahlin and Unni, chondromas account for 2.8% of all tumors and 12% of benign tumors. These tumors' occurrence in non-cartilaginous jaw regions has led some authors to refer to them as hamartomatous growth . HoweverEnchondromas usually present as painless, slow-growing, and well-confined tumors with an ovoid or a variable convexity. The lesion rarely involves overlying mucosa, and tooth mobility and root resorption are possible . It exhiThe radiographic findings of chondromas are not typical. It is possible to see a mottled, amorphous mass that is radiolucent and radiopaque. The lack of cortical damage and soft tissue extension favors a benign diagnosis . A lobulThe distinction between chondroma and chondrosarcoma may be difficult because of overlapping histologic features . DistingTherefore, it has been argued that all symptomatic cartilaginous lesions should be classified as chondrosarcomas and treated accordingly. Many pathologists believe that the presence of a chondroma indicates a potential chondrosarcoma. Due to the possible clinical and histological overlap and consideration that twenty percent (20%) of head and neck chondrosarcomas may be initially diagnosed as benign, the treatment of the enchondroma is a wide, although not radical, excision. The resection with a margin of normal soft tissue and bone is preferred. In a considerable proportion of cases, curettage has led to local recurrence . As the Long-term follow-up is crucial. The initial diagnosis should be re-evaluated if recurrence occurs to rule out the possibility of low-grade malignancy .Due to the dearth of available literature, it is imperative to report such cases. Extreme vigilance should be used from the time of diagnosis to rule out enchondroma due to the potential clinical overlap with fibro-osseous lesions and other benign lesions of the jaws. Enchondroma leads to disruption of structure, compromising the aesthetics and function. Long-term clinical and radiological follow-up is required because of its high propensity for recurrence, as well as the likelihood of malignant change.