Gastric-type endocervical adenocarcinoma (GAS) is a rare type of cervical adenocarcinoma that is a mucinous adenocarcinoma with a variety of gastral patterns. To date, there are no systematic clinical diagnosis and treatment guidelines.In our case, a 49-year-old woman underwent pelvic magnetic resonance imaging (MRI) due to a pelvic mass, and cervical lesions were unexpectedly found. After receiving relevant surgical treatment, the pathological results showed the particularity of the tumor type—cervical gastric adenocarcinoma with a borderline serous tumor of both appendages and the right ovary.Postoperative routine pathological examination showed mucoepithelial metaplasia accompanied by a borderline serous tumor.After gynecological/urinary ultrasound, blood tests, MRI, cervical biopsy, and uterine curettage, “robot-assisted laparoscopic radical hysterectomy + bilateral salpingectomy-ovariectomy + pelvic lymph node dissection + pelvic adhesiolysis” were performed. After the surgery, the patient was treated with radiotherapy and concurrent chemotherapy.After the operation, radiotherapy, and chemotherapy, the patient had no tumor recurrence and is still in good condition.The diagnosis of GAS is relatively difficult, its clinical manifestations lack specificity, and the pathogenesis has nothing to do with human papillomavirus infection. The patient was misdiagnosed with vaginitis at a local hospital. However, we found that MRI and pathological examination were helpful for the diagnosis of the disease. Although there are no relevant guidelines to explain the treatment principles of GAS, we believe that early surgery is conducive to the prognosis of the disease because GAS has a certain tolerance to radiotherapy and chemotherapy. The incidence of GAS has nothing to do with HPV, and its clinical manifestations are not specific, which poses a challenge to the early diagnosis and treatment of cervical cancer. According to a literature search in PubMed, we found 97 studies related to GAS, but there were no reports of comorbid borderline serous tumors. In this patient, we found a mucoepithelial metaplasia GAS along with a serous borderline tumor, which was diagnosed according to histopathology and immunohistochemistry. This patient was treated for the first time at the Department of Gynecology, Affiliated Hospital of Jining Medical University. The patient provided signed informed consent.Although cervical cancer is the only cancer that can be cured and prevented, it is still the fourth most common cancer among women in the world. The incidence rate of cervical cancer in women is high. In 2018, more than 500,000 new cases of cervical cancer were reported worldwide, and 310,000 women died from cervical cancer.2A 49-year-old patient was admitted to the hospital due to “the discovery of uterine cavity space-occupying and pelvic mass for over 20 days” on August 30, 2020. The patient had regular menstruation at normal times, with the chief complaint of increased vaginal discharge (transparent in color with no odor) with the same volume as that of menstruation over the last 10 years. The patient underwent “hysteroscopic resection of the uterine cavity lesion” 3 years ago due to a “uterine cavity space-occupying mass”, with “adenomyoma” indicated by postoperative pathology, and the patient showed improvement in vaginal discharge symptoms postoperatively. In the last year, the patient experienced symptoms of increased vaginal discharge again with no obvious inducement. The discharge volume was approximately twice that of the normal menstrual volume, and there was occasionally blood in leucorrhea, without odor, accompanied by abdominal distension; no abdominal pain, frequent urination, urgent urination, dysuria, fever, nausea, vomiting, or other discomfort were reported. The patient visited the local hospital many times, received a diagnosis of vaginitis and was provided with drug therapy with poor effects. On August 10, 2020, the patient underwent color Doppler ultrasound in the local hospital with the discovery of an “abnormal echo in the uterine cavity (3.9 cm × 3.4 cm × 1.6 cm) and cystic mass in bilateral adnexa areas”. The local hospital recommended a further examination, and the patient refused due to personal reasons. For further diagnosis and treatment, the patient visited our hospital on August 30, 2020, and was admitted to our hospital due to an “abnormal echo in the uterine cavity, pelvic infection, adnexal tumor, and hydrosalpinx?”. The personal history and family history of the patient were unremarkable. Gynecological examination results were as follows: No abnormality in the development of the vulva; no obstruction in the vagina; an increase in vaginal discharge, which was odorless; cervical congestion; bleeding on touch; tough texture; large size of the uterine body, with normal activity and tenderness pain; and tenderness pain in the bilateral appendages. On July 15, 2020, the detection result of HPV-DNA typing in the cervix was negative; however, there were abnormalities in the ThinPrep Cytology Test. Re-examination by transvaginal ultrasound on August 30, 2020, suggested a mixed-echo mass in the uterine cavity, a bilateral adnexal cystic mass, a left adnexal cystic mass, an isoechoic mass in the right adnexal area (with the possibility of teratoma to be confirmed), multiple cystic nodules of the cervix, and pelvic effusion. Tumor marker detection showed no abnormalities in human epididymis protein 4, carbohydrate antigen 125, the premenopausal ROMA index, carcinoembryonic antigen, alpha fetoprotein, or specific β human chorionic gonadotropin. Furthermore, carbohydrate antigen 199 was measured to be 170.43 U/mL (reference range: 0–37 U/mL). Laparoscopic hysteroscopy was planned. However, considering the presence of a space-occupying lesion in the uterine cavity, a pelvic magnetic resonance imaging (MRI) plain scan and diffusion-weighted imaging were performed on August 31, 2020  gene in the lineage lesions from lobular endocervical glandular hyperplasia and minimal deviation adenocarcinoma of the cervix (MDA) to GAS. This gene is recognized to be a tumor suppressor gene, and its mutation can lead to an incomplete catalytic domain and the loss of kinase activity. At present, STK11/LKB1 is considered to be involved in cell proliferation, cell polarity, cell migration, the DNA damage response, and cell differentiation by regulating the mTOR/AMPK, TGFβ, and/or Wnt signaling pathways. Approximately 50% of sporadic MDA patients have STK11/LKB1 mutations, which are also associated with poor prognosis. However, it should be noted that there is a complex mechanism of STK11/LKB1 mutation in tumorigenesis, which deserves further study.To date, the incidence rate and global distribution of GAS are not known; there are conflicting reports about the proportion of GAS among cervical adenocarcinomas, with 10% in international research MRI was the best choice to show the characteristics of GAS among ultrasound, computed tomography, and MRI. Furthermore, relevant studies,11 indicated that MRI exhibited superiority in reflecting the pathological results of some adenocarcinomas and was the preferred imaging method. In MRI examination of GAS, T1WI may show low signal intensity, and T2WI shows high signal intensity; in addition, there may be multiple solid-signal shadows of mixed cystic components in the cervix, and the cysts may be obviously enhanced after enhancement. In this patient, pelvic MRI showed a thickened posterior wall of the cervix, a mass-like low signal on T1WI and a slightly high signal on T2WI, with the possibility of cervical cancer being identified. These findings suggest that MRI helps to diagnose GAS and avoids missed diagnoses and is therefore worth recommending.Considering the absence of specific symptoms and clinical examination findings in GAS, it is difficult to diagnose with ultrasound, computed tomography, and other imaging techniques. In our patient, transvaginal ultrasound examination showed the existence of multiple cystic nodules in the cervix only, which was not helpful for the diagnosis of GAS. As evidenced by the report of Saida et al, established 3 morphological diagnostic criteria for GAS in 2007: an abundant mucinous cytoplasm; a transparent or slightly eosinophilic cytoplasm; and a clear cell boundary. Furthermore, in 2019, Pirog et al extended the morphological description of GAS to glands composed of small cubic cells or flat cells, papillary glands, goblet cells mixed in the gland, and a thick eosinophilic or foamy cytoplasm. By definition, GAS is a group of tumors with great morphological heterogeneity. Typical MDA has only focal atypia, which is not obvious; visible or non-obvious nucleoli; and occasionally visible mitosis. However, there is serious cytological atypia of GAS with moderate and low differentiation. The case we reported was accompanied by mucoepithelial metaplasia and a borderline serous tumor, which is very rare in the clinical setting. It has been reported that the simultaneous occurrence of mucoepithelial metaplasia and tumors in the female genital tract exhibited an intimate association with gastric-type mucinous lesions, and there might be a certain relationship with GAS; however, the relationship still needs to be further clarified, which would contribute to the early diagnosis of GAS. In addition, the patient in our case report had bilateral borderline serous tumors of the fallopian tubes and clear cell tumors of the right ovary, both of which were accompanied by tumor-like changes at the junction of bilateral adnexa. Nevertheless, no similar report has been published thus far.Kojima et al The mucus secreted by GAS tumor cells is mainly composed of neutral cytoplasmic mucin. The cervical glands of GAS are generally stained red, while those of a normal cervix are purple when stained with alcian blue-periodic acid Schiff. The patient we tested showed negative ER, PR and P16, and positive P53, and the Ki-67 proliferation index of the cervical glands of GAS was 60% to 70% higher than that of normal cervical glands. Clearly, the aforementioned results are basically consistent with those reported in the relevant literature and may be conducive to further clarification of GAS diagnosis.Immunohistochemistry can be an auxiliary tool for the diagnosis of GAS considering its confusing cellular histological features and high risk of missed diagnosis. Immunohistochemically, GAS is generally characterized as follows: negative ER and PR; positive MUC6 and HIK1083; CK7, P53, and carcinoembryonic antigen expression; the Ki-67 proliferation index is higher than that of normal cervical glands; and P16 is usually negative or focally positive since GAS is considered to have no relationship with HPV infection. Furthermore, despite an update to the 2019 National Comprehensive Cancer Network guidelines concerning the treatment principles of common cervical adenocarcinoma according to its histopathological classification, it suggests only that fertility-preserving surgery should not be performed for treating patients with GAS. Moreover, it has been reported that GAS has a certain tolerance to radiotherapy and chemotherapy. Consequently, a consensus has been reached in the clinical setting that early diagnosis, clinical stage, and surgical methods significantly affect the prognosis of patients. GAS has an extremely poor prognostic outcome, with a 5-year disease-free survival rate of only 30%. Delayed diagnosis due to HPV negativity and difficulty screening is the major factor contributing to the poor prognosis of GAS. Accordingly, early discovery, early diagnosis, and early treatment, as occurred for this patient, will substantially contribute to improvements in the prognosis and survival rate of patients with GAS.To date, there is no available treatment principle for GAS based on its histopathological types and molecular pathological characteristics. As recommended by the 2015 National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Uterine Neoplasms, the treatment for patients with GAS is similar to that of patients with squamous cell carcinoma at the same stage. In other words, radical hysterectomy is recommended for patients with stage IB1 and stage IIA1 disease, while for patients with stage IB2, IIA2, and IIB–IVa disease, the recommended scheme is platinum-based concurrent chemoradiotherapy.In summary, HPV negativity is one of the main causes of the delayed diagnosis of GAS. However, there are few studies on the pathogenesis and treatment of non-HPV-associated GAS; thus, clinicians face enormous challenges in the diagnosis and treatment of GAS. The significance of this case report lies in the fact that according to the patient's clinical manifestations, a clear diagnosis was possible with the combination of MRI, pathology, immunohistochemistry, and so on. Therefore, it is hoped that the combination of these methods to achieve early detection and early diagnosis as much as possible will eventually facilitate the selection of appropriate treatment to maximize the benefits to patients.The author thanks our hospital colleagues for their support and the patient's dedication.Conceptualization: Yunfei Wang.Data curation: Man Yin, Yunfei Wang.Methodology: Linqing Yang, Yunfei Wang.Writing – original draft: Man Yin.Writing – review & editing: Linqing Yang, Yunfei Wang.


Primary tumors of the appendix, specifically appendicular adenocarcinoma, are a rare malignant neoplasm of the gastrointestinal tract. We present a case of a 64-year-old female who had significant peritoneal adhesions from a previously perforated appendix involving the right ureter, bladder, and anterior abdominal wall after a course of perforated appendicitis, which was managed conservatively with drain placement with interval appendectomy. We are discussing this case in hopes of bringing awareness to the possibility of underlying malignancy in the setting of perforated appendicitis in patients of advanced age. Appendiceal cancers are extremely rare and difficult to diagnose prior to surgical intervention. According to the National Cancer Institute, these cancers make up 0.4% of all gastrointestinal malignancies . The aveWe report a case of a healthy 64-year-old female who originally presented to an outside emergency department with low-grade fever and a two-week history of worsening lower abdominal pain. She denied any nausea, vomiting, loss of appetite, diarrhea, constipation, melena, hematochezia, urinary dysuria, frequency, vaginal bleeding, or discharge. She denied any family history of colon cancer or inflammatory bowel disease. Past surgical history includes tubal ligation, and past medical history includes hypercholesterolemia, hypothyroidism, and lung adenocarcinoma years ago that resulted in a left lobectomy. She reported having a previous colonoscopy many years ago without any signs of polyps or masses.Vitals included height 1.676 m (5' 6"), weight 57 kg (126 lbs.), and BMI 20 kg/m². Physical exam was benign except for the following findings: fever of 38.0°C, moderate-to-severe tenderness with rebound and guarding in the lower abdomen and suprapubic region (right greater than left), and positive McBurney's point. As seen in Figure Once the diagnosis was confirmed clinically and via radiographic imaging, she was transferred for definitive surgical and medical management. On hospital day 1, a percutaneous drain was placed with radiographic assistance with the return of purulent and serosanguineous fluid. Over the following days, her diet was slowly advanced and a repeat CT scan was obtained a few days after the original, as seen in Figure The patient was seen three weeks post inpatient hospitalization to discuss the possible surgical intervention. At that time, the patient was feeling much better and tolerating a normal diet. She had appropriate bowel and bladder function and denied any pain, redness, fever, chills, or gastrointestinal symptoms. On physical exam, the abdomen was soft and supple without any tenderness, distention, or masses present. The patient agreed on obtaining a colonoscopy in four weeks, which aligned with the standard of care of obtaining one 6-8 weeks after an acute perforation of the appendix.Figures Laparoscopic exploration of the abdominal cavity revealed evidence of a grossly inflamed appendix with the adhesion of the appendiceal tip to the anterior abdominal wall, bladder dome, and right ureter. The surgeon performed a partial appendectomy with associated right hemicolectomy for oncological purposes with clip placement at the anterior abdominal wall for future identification of appendicular tip should cancer or positive margins be encountered. A functional anastomosis between the distal ileum and transverse colon was successfully completed. Visualization of the peritoneal cavity during the procedure showed no evidence of carcinomatosis, obvious metastatic disease, or malignant ascites.The patient returned to the office two weeks after the surgery. Pathology from the procedure showed moderately differentiated adenocarcinoma involving the appendix with invasion through the muscularis propria into at least the peri-appendiceal adipose tissue. Carcinoma was present at the mesenteric margin as a solitary tumor deposit, which was felt to be the transected appendiceal tip margin. Perineural and lymphovascular invasion was present. Fifteen lymph nodes were found to be negative for metastatic carcinoma (0/15). Tumor was staged at least a T3 given uncertain involvement of the appendiceal tip and bladder wall. On physical examination, the abdomen was soft, non-tender, non-distended, and had no signs of masses or hernias. The surgical incisions were all clean, dry, and intact without any signs of infection or erythema.The patient's care was then transferred to an outside hospital for evaluation by Surgical Oncology and discussion of further treatment options. A discussion was held to obtain repeat PET/CT imaging in three months to further evaluate the tumor for possible future en bloc resection with or without hyperthermic intraperitoneal chemotherapy (HIPEC).Appendiceal adenocarcinoma comprises about 60% of all appendiceal cancer cases but constitutes less than 0.5% of all gastrointestinal tract neoplasms . AdenocaAcute perforation is one of the complications of appendicitis associated with increased morbidity and mortality. Documented risk factors, especially in the elderly, include male sex, fever ≥ 38°C, diabetes, steroid use, anorexia, and duration of abdominal pain before presentation . Acute pAt the time of diagnosis, appendiceal adenocarcinomas can be localized to the appendix or have spread to other regions, including into the peritoneum. Appendiceal adenocarcinoma represents the most common gastrointestinal neoplasm presenting with perforation with some reports indicating a perforation rate of greater than 45%. This leads to the potential for early dissemination in seemingly non-advanced primary lesions. Patients can present with features of acute appendicitis, right lower quadrant mass, urinary frequency, or intussusception. In this case, the appendiceal mass acted in place of a fecalith to occlude the appendix and acted as the catalyst for an inflammatory process in the vestigial organ . AppendiThe treatment protocol varies based on the progression of disease and subtype. Appendectomy alone may be sufficient therapy for early-stage tumors in all subtypes except for goblet cell adenocarcinoma. For locally advanced adenocarcinoma, staging is recommended, followed by right hemicolectomy, cytoreductive surgery, and systemic chemotherapy as indicated . NiteckiUrological complications are typically inadvertent sequelae that can occur during gynecologic and abdominal surgeries due to the proximity of multiple organs and vessels. If urological complications occur, despite necessary precautions, the assistance of a specialized surgeon should be obtained to effectively repair the complication . In our Appendiceal cancer is a rare but plausible gastrointestinal pathology. Due to their difficult diagnostic criteria, histological examination of all appendectomy specimens is strongly recommended to intraoperatively confirm the presence or absence of any tumors that may have predisposed to appendicitis. This case report highlights the atypical presentation of appendiceal adenocarcinoma caused by a complicated appendiceal perforation and its effect on treatment protocols. Critical decision-making by the medical team of their respective hospital's capabilities and limitations is essential to decreasing complication rates and increasing patient survival rates. The recommended treatment for appendiceal adenocarcinoma is right hemicolectomy due to the increased survival rates compared to appendectomy alone. Following a cancer diagnosis, it is recommended to perform surveillance for any synchronous tumors. Treatment options, such as HIPEC with en bloc resection of residual cancer, may be of benefit when the primary tumor is unable to be removed in its entirety with R0 resection.


Capillary hemangioma can be found in many organs, but rarely in pleura. Previously, only localized pleural capillary hemangioma cases have been reported. Corticosteroids are the most commonly recommended drugs in capillary hemangioma.Here, we present a case of a young woman with recurrent hemorrhagic pleural effusion. Despite repeatedly thoracentesis, the routine examinations, including chest computed tomography (CT) scan, pleural effusion biochemical test, and cytology all failed to make a definite diagnosis. Thus, single port video-assisted thoracoscopy (VATS) was then performed. Numerous nodules arising from the parietal pleura were found, and biopsies showed multifocal pleural capillary. However, recurrent pleural effusion was successfully managed by oral azathioprine, after failure of dexamethasone treatment.To our knowledge, this is the first case of a patient with recurrent hemorrhagic pleural effusion masquerading as malignant pleurisy, but in fact caused by multifocal pleural capillary hemangioma. Capillary hemangioma is a neoplasm of vascular proliferation, which is benign but may be multifocal. Capillary hemangioma is commonly found in facial skin, subcutaneous tissue and oral mucosa, although it can be found in any organs , 2. In tWe report the case of a 32-year-old non-smoker female, who presented with mild dyspnea for two weeks. She denied cough, hemoptysis, fever and weight loss. Serologic tumor markers, including carcinoembryonic antigen (CEA) and α-fetoprotein (AFP), did not reveal any abnormalities. Tuberculin purified protein derivative (PPD) test of the patient was negative. A computed tomography scan (CT) of the chest revealed left pleural effusion, and there was no evidence of mediastinal lymphadenopathy and the lung fields were clear Fig. a, b. AltCapillary hemangioma is an even rare congenital disease, which is thought to be associated with the imbalance between proangiogenic factors and angiogenesis inhibitors , 4. PleuMultifocal pleural capillary hemangioma is more like a localized capillary hemangioma with multiple lesions, which was different from the diffuse neonatal hemangiomatosis . Most prDiagnosis of hemangioma mainly depends on imaging and pathological examinations. Multifocal capillary hemangiomas may present numerous nodules on the pleural surface with pleural thickening on CT scan . HoweverThe majority of hemangiomas are harmless cutaneous lesions, but approximately 10% of hemangiomas need a therapeutic approach because of their location, size, or behavior . The treSteroid hormones are most commonly used in the treatment of hemangioma, which may promote regression of the proliferating hemangioma by inhibition of cytokines, regulating of hemangioma proliferation and involution . High doTo conclude, capillary hemangioma in the pleura is extremely rare, for recurrent hemorrhagic pleural effusion, the possibility of benign tumor such as hemangioma should be considered. Thoracoscopy is an important method for diagnosis. Due to the rarity of multifocal plural capillary hemangioma, the treatment still needs to be further explored. In addition to corticosteroids, immunosuppressive agents may also be potential therapeutic drugs. Hence, reporting of our case and sharing the treatment experiences may be helpful to improve for clinical therapeutic strategy.


Large ovarian tumours are rare. Various diagnostic modalities are used to help in confirming the size and type of ovarian tumours. Laparotomy in a lateral decubitus position under general anaesthesia is the most common treatment approach. Here we present a case of a 17-year-old unmarried girl from whom a 13 kg ovarian tumor was resected. We highlight in this case report the mental stress that a patient goes through when accused of having an extramarital pregnancy by the community in a conservative society like ours. Furthermore, the importance of psychological support and counselling is paramount. The presentation of large abdominal masses is rarely seen in clinical practice as early access to medical investigations and imaging is readily accessible . This paA 17-year-old unmarried female presented to our resource-constrained clinic in a remote part of northern Pakistan, with a history of painless and progressive abdominal distension. Over the past four months, the patient’s abdomen had progressed to a diameter of 130 cm, restricting her ability to breathe and causing shortness of breath on exertion and on lying down. There was no significant personal or family history.Socioeconomic factors such as lack of healthcare access and poor health literacy led to a delay in presentation. Also, it was important to acknowledge the sociocultural factors involved that affected the patient and her family. Community allegations of extramarital pregnancy had resulted in ostracization of the family and significant psychological distress to the patient, who appeared with a flat affect, depressed mood, poor eye contact, and reported frequent suicidal ideation due to the social pressure.On examination, the patient was hemodynamically stable but dehydrated and pale. The abdomen was massively distended (130 cm), tense, non-tender, and prominent veins were seen on the anterior abdominal wall. However, the huge mass was palpable due to its sheer size the upper and lower limits could not be defined. Chest examination revealed symmetrical expansion with adequate air entry bilaterally, however, the patient was unable to take deep breaths because of likely splintage of the diaphragm.Chest X-ray revealed rib crowding and elevation of the diaphragm to T5 . Abdominal ultrasound revealed a huge cystic and lobulated mass with internal septations occupying the whole abdominal cavity, most likely arising from the right ovary, along with a mild amount of fluid in the peritoneal cavity. An abdominal CT scan and CA-125 were also offered but rejected by the family due to cost restrictions as these investigations could not be performed locally.Surgical excision was planned under regional anaesthesia due to the impact of the abdominal mass restricting respiration and lung capacity relatively contraindicating general anaesthesia. Incision extended from xiphisternum to symphysis pubis. A huge mass was seen originating from the right ovary with flimsy adhesions between mass and intestine/omentum which were easily freed. It was removed in total, sparing ipsilateral fallopian tube and ovary. Surrounding viscera were found to be uninvaded, which favoured the benign nature of the lesion. Furthermore, no metastases were observed in any organ. Due to pressure effects, the posterior aspect of the anterior abdominal wall was very hyperaemic. Two drains were placed in the peritoneal cavity that were removed on the third post-operative day. The patient’s recovery was uneventful, and she was discharged on the seventh post-operative day with suture removal and good wound healing observed on the 14th post-operative day. The patient and family were extremely satisfied and relieved. During pre-operative work, the father had mentioned several times that the patient had developed suicidal thoughts due to social stress. There has been no recurrence of tumour growth at four months follow-up.Macroscopic examination revealed a 13 kg specimen (30 cm x 30 cm x 26 cm), however, histopathology was refused by the family who instead requested to take the specimen home to demonstrate as evidence to their family and community members to prove that her abdominal distention was secondary to a tumour and not a foetus (Figures Some of the largest ovarian tumours in literature to date are a 148.6 kg mass as reported by Spohn in 1922 and a 79.4 kg mass as reported by Symmonds in 1963 , inaccesOvarian neoplasms are divided into germ cell, stromal, and surface epithelial. Surface epithelial tumours comprise 50% of all ovarian tumours and are categorised into benign and malignant types. Benign serous tumours include surface papillomas, adenofibromas, cystadenofibromas, and cystadenomas. Furthermore, grossly they are quite large, unilateral, and ovoid or spherical in shape , as seenA variety of diagnostic approaches can be taken to diagnose the type of tumour. Ultrasonography  and compVarious treatment approaches have been discussed in literature and usually include laparoscopy and laparotomy. Laparotomy under general anaesthesia is by far the most common approach taken -5, 7, wiFurthermore, every case that we analysed had a total abdominal hysterectomy and salpingo-oophorectomy performed -4, 7, hoIn addition to medical and surgical treatment, it is also important to assess the psychosocial impact of an ovarian tumour. Patients may report anxieties regarding their diagnosis, their appearance, the surgeries required, and the risks of malignant pathologies. Psychosomatic stress disorder related to ovarian tumours has been acknowledged only in two case reports , 5 and wOvarian tumours are relatively common, however, large sizes are rarely seen. Various diagnostic modalities are used to help in confirming the type of ovarian tumour. Laparotomy in a lateral decubitus position under general anaesthesia is the most common treatment approach. It is fundamental to consider the psychosocial impact of abdominal mass in conservative communities with limited health care access.


Solitary plasmacytoma (SP) is a malignant tumor caused by the monoclonal proliferation of plasma cells, representing less than 5% of plasma cell tumors. SP can be categorized into two groups: solitary bone plasmacytoma (SBP) and solitary extramedullary plasmacytoma (SEP). SEP most commonly occurs in the head and neck and is rarely located in the reproductive system. Here, we report a case of a 77-year-old woman with SEP in the cervix who had a 7-day history of vaginal bleeding. Ultrasonography and magnetic resonance imaging (MRI) showed an oval mass in the cervix, which was initially considered as neoplastic lesions and highly suspected to be cervical cancer, but cervical leiomyoma and other benign tumors cannot be completely excluded. Subsequently, cervical biopsy showed that the tumor was SEP, and then the patient underwent surgery. The postoperative pathological diagnosis was also SEP, which confirmed the radiologist’s misjudgment. In conclusion, SEP that occurs in the cervix is remarkably rare, and only nine cases have been reported in the cervix. No case reports to date have described in detail the imaging findings of cervical SEP. This study demonstrates the MRI imaging characteristics of a patient with SEP of the cervix and reviews the imaging findings of SEP reported in the previous literature, in order to provide more extensive insights for radiologists to consider the differential diagnosis of cervical lesions. On MRI, the mass was homogeneous, slightly hyperintense on the T2-weighted images , and isointense on the T1-weighted images . Decreased apparent diffusion coefficient (ADC) value were detected in the cervical lesion . Post-contrast enhancement images showed mild to moderate heterogeneous enhancement and pronounced peripheral rim enhancement . According to the patient’s age, clinical manifestations and imaging features, the radiologist’s initial consideration was neoplastic lesions and the possibility of cervical cancer was high. The possibility of cervical leiomyoma cannot be fully ruled out, however. The patient accepted colposcopic examination and underwent cervical biopsy and endocervical curettage under colposcopic guidance. The biopsy specimens revealed SEP on microscopic examination. Additionally, bone scan revealed no abnormal skeletal uptake, and no abnormal plasma cells were found in the bone marrow, which excluded the diagnosis of multiple myeloma (MM). Following discussion, the clinicians decided that the best treatment strategy was surgery with postoperative radiotherapy. Then, the patient underwent a laparoscopic extensive hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. The resected mass size was about 3.0×2.0 cm. The result of histopathological examination revealed a SEP of cervix. Immunohistochemical staining was positive with CD38, CD138, Kappa  and negative with Lambda. The Ki-67 proliferation index was low (5%). The patient received radiotherapy after surgery and remains well through follow-up.A 77-year-old female patient was admitted to hospital because of a 7-day history of abnormal vaginal bleeding, with no abdominal pain or distention. Gynecological examination revealed cervical atrophy, and the normal shape of the cervix disappeared. There was no contact bleeding of the cervix and no tenderness of the posterior fornix. She had no other symptoms, and the results of the laboratory examinations were normal. Ultrasonography showed hypoechoic nodule in the cervix. The pelvic magnetic resonance imaging (MRI) scan found a well-defined oval mass of size 2.3×1.8×2.8 cm in the cervix, which destroyed the continuity of the cervical stroma SEP can occur in any part of the extramedullary sites but predominantly in the head and neck, particularly in the nasal cavity, sinuses, nasopharynx, and larynx . Other c/slight hypo-intensity on the T1-weighted images, medium hyper/hyper-intensity on the T2-weighted images, and obvious high signal on DWI with a corresponding low signal on ADC maps. The malignant progression of cervical cancer can spread to the vagina, parauterine tissues, adjacent organs, and distant metastasis. Of note, cervical cancer is a hypervascular tumor, in which the most significant imaging feature is early and obvious enhancement on the dynamic contrast enhanced MRI (DCE-MRI), but the late enhancement is lower than the normal cervical stroma . The abscess cavity contains a fluid component and is surrounded by edema . The absSEP is usually a localized low-grade malignant tumor, and the therapeutic purpose is mainly local control . BecauseThe progression of SP includes the appearance of new plasmacytoma or the progression to MM. SBP is more likely to progress to MM than SEP . Risk faIn conclusion, we present an extremely rare case of SEP in the cervix and its characterization on MRI. SEP should be considered in the differential diagnosis of cervical lesions without a history of multiple myeloma.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the patient for the publication of this case report.JW and LJ: manuscript writing. TL: pathological review. XM, XC, and HL: manuscript revision. SL: conception and critical review. All authors contributed to the article and approved the submitted version.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.


Ventriculoperitoneal (VP) shunt is often placed as a treatment for hydrocephalus. Additionally, it is also not uncommon to perform laparoscopic surgery for colon cancer with a VP shunt in place. It is very rare for colorectal cancer to metastasize to an implanted VP shunt. We report a case of VP shunt-related metastasis of the ascending colon that was successfully resected.A 79-year-old man who had a VP shunt for hydrocephalus two years earlier underwent laparoscopic right colectomy for ascending colon cancer. Six months after the colectomy, imaging examinations showed mass formation in the subcutaneous tissue of the abdominal wall along the VP shunt. Because of the possible metastasis of colorectal cancer and the fact that it was a solitary lesion, a tumor resection with replacement of the VP shunt was performed. Histopathological examination revealed that the mass was a metastasis of colon cancer.This case involves the metastasis of colorectal cancer in the subcutaneous tissue of the abdominal wall after laparoscopic surgery, and since the tumor had reached the serosa, the possibility of metastasis by pneumoperitoneum was considered. Careful intraoperative manipulation is considered to be important for prevention.Metastasis of colorectal cancer to the VP shunt is extremely rare, but possible. In such cases, intraoperative prevention and careful postoperative follow-up are required. It has been reported that brain tumors can sometimes metastasize into the abdominal cavity via VP shunt, riding the drainage flow from the lateral ventricle. Very rarely, malignant tumors of intra-abdominal organs have been reported to result in abdominal wall metastases along the VP shunt. It is not uncommon for patients with VP shunts to develop colorectal cancer, and several cases of colorectal cancer surgery have been reported. However, to our knowledge, there are no reported cases of VP shunt-related subcutaneous tissue metastasis of colorectal cancer.We herein report a case of solitary metastatic ascending colon cancer that metastasized along the VP shunt after the primary tumor resection.This study has been presented in line with SCARE criteria .2A 79-year-old man was referred to our hospital after a positive fecal occult blood test. He had developed a subarachnoid hemorrhage two years ago and later developed hydrocephalus and had a VP shunt implanted.A total colonoscopy showed a tumor in the ascending colon , and the18F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG-PET/CT) scan showed FDG accumulation coincident with the mass  level was elevated from 3.5 to 42.7. Computed tomography (CT) showed the formation of a mass in the subcutaneous tissue of the abdominal wall along the VP shunt, which was implanted on the left side of the abdomen . Furtherthe mass , suggestSince it was a single metastasis without other distant metastasis, we performed a resection of the abdominal wall tumor. A spindle-shaped incision was made in the skin directly above the tumor and the subcutaneous tissue was incised with a margin. The catheter of the VP shunt was disconnected from the connection and removed with the tumor. A new catheter was placed into the abdominal cavity by a different route and connected by neurosurgeons. The operative time was 85 min and the intraoperative blood loss was 18 mL.The resection specimen contained a white, 13 mm nodular tumor surrounding the VP shunt . The his3Implantation of a VP shunt is a commonly performed procedure for ventricular drainage of hydrocephalus. Although there are some reports of tumor metastases related to the VP shunt in the literature, due to the nature of the drainage of cerebrospinal fluid from the ventricles to the abdominal cavity, most reports are of intraperitoneal metastases of brain tumors .Reports of VP shunt-related metastasis due to malignancy of intra-abdominal organs are extremely rare. There are only four cases reported in the literature, which are metastases of pancreatic carcinoma , ovarianTo our knowledge, this is the first case of VP shunt-related subcutaneous tissue metastasis of colorectal cancer to be reported. It is also the first case of an intraperitoneal primary malignancy metastasizing to a VP shunt that was radically resectable.This case was a metastasis after laparoscopic colon resection, and since the primary tumor had invaded the serosa, it is highly likely that the malignant cells were dispersed in the pneumoperitoneum during the laparoscopic surgery and deposited around the shunt. Another possibility is the presence of tumor cells in the small amount of ascites fluid, which may have attached to the VP shunt and grown. Neale et al. reported that if the pneumoperitoneum pressure did not exceed 80 mmHg, no cerebrospinal fluid reflux occurs in the VP shunt . Therefo2 leakage [In this case, cytological examination of cerebrospinal fluid was also performed, but no malignant cells were detected. The fact that the tumor did not grow in the lumen of the VP shunt catheter, but on the outside, suggests that the tumor did not enter the cerebrospinal fluid but rather adhered to the outside of the catheter. It is thought to be a form of metastasis similar to port site metastasis in that it is caused by pneumoperitoneum etc. and metastasizes to the subcutaneous tissue of the abdominal wall. The rate of port site metastasis in colorectal cancer surgery has been reported to be around 1%, and studies have shown that there is no significant difference in wound metastasis of open surgery . As for  leakage ,13. AlthIn the literature, all cases of VP shunt-related metastases are highly advanced and have had a poor prognosis, but we think that they could be cured if they are resected without remnants. Although the incidence is rare, palpation or imaging confirmation of the appearance of nodules in the VP shunt after laparoscopic surgery may lead to early detection of such metastases.4Although metastasis to the VP shunt after colorectal cancer surgery is rare, it is possible, as in this case. A possible cause of metastasis is that tumor cells exposed on the serosa may have migrated to the VP shunt by pneumoperitoneum. To prevent the development of such metastases, careful intraoperative manipulation is considered essential, and careful postoperative follow-up should be performed.None of the contributing authors have any conflicts of interest.All authors have no funding of research.This study is exempt from ethical approval in our institution.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.Masahiro Kataoka: Writing original graft.Hiroka Kondo: Reviewing.Yasumitsu Hirano: Supervision, review and editing.Not applicable.Masahiro Kataoka.Not commissioned, externally peer-reviewed.


Benign tumors of the proximal fibula are clinically notable, often resulting in pain, cosmetic defects, and potential neurovascular compromise. These symptomatic lesions warrant surgical consultation, but specific procedure selection remains a topic of ongoing discussion. The fibula is widely considered an expendable bone, which permits a greater variety of surgical options relative to other skeletal locations. As a result, some authors suggested en bloc resections without reconstruction as a viable first-line option to decrease tumor recurrence risk. However, wide resections may still result in diminished postoperative functionality compared with the standard intralesional and marginal approaches. Thus, surgical management remains a multifactorial decision, and often orthopaedic surgeons rely on past clinical experience or surgical preference within this unique tumor location. This detailed review will summarize the published literature and discuss the outcomes and indications of various surgical approaches for benign tumors of the proximal fibula. Emphasis will be placed on balancing tumor recurrence risk and postoperative functionality within the context of histologic diagnoses and surgical approaches. Clinical comparisons of these procedures have been described in the literature with varying outcomes.Benign tumors of the proximal fibula are clinically notable, potentially causing severe pain, neurovascular compromise, or cosmetic defects that necessitate surgical attention.9 As a result, establishing local tumor control and minimizing joint disturbance can pose a challenge for the orthopaedic surgeon.10 The ideal surgical outcome maximizes postoperative limb functionality and minimizes the risk of tumor recurrence. Classic thinking has favored minimally invasive excisions over wide resections in the fibula for this purpose, although categorical indications for deciding among procedures have not been established because of a paucity of large-scale comparisons.12 Accordingly, surgeons frequently rely on clinical experience and preference to steer treatment recommendations.12Although the proximal fibula contributes minimally to weight-bearing, this anatomic region still presents a surgical risk because of its closeness, proximity to the peroneal nerve, anterior tibial artery, and lateral collateral ligament (LCL) attachment site.In this review, we will briefly discuss the clinical significance of benign tumors of the proximal fibula and examine the available options for surgical management within this unique anatomic location. Importantly, we will highlight the risks and postoperative complications surgeons should consider when deciding between specific surgical approaches.11 Accordingly, few large-scale epidemiologic studies have thoroughly examined fibula tumor characteristics such as grade, subtype, and anatomic location. To date, one of the most comprehensive analyses was performed by Arikan et al, which included 264 fibular tumors stratified by the Enneking staging system.14 Of these, most  were benign, ranging from stages 1 to 3. The median age of patients with benign tumors was 17 years, with a female predominance of 59%. The proximal third of the fibula was the most common site for benign lesions (67.5%), followed by the diaphysis (24.9%), and the distal third (8.2%). The most frequent benign fibular lesions were osteochondromas, enchondromas, and aneurysmal bone cysts (ABC). In this study, giant cell tumors (GCT) were less commonly reported relative to other smaller scale retrospective analyses . Resection of these tissues off of the proximal fibula can permit varus joint laxity and potentially result in knee instability.18 Although debated, the role of the proximal fibula in direct weight-bearing seems minimal, leading to its general classification as an expendable bone.20 Cadaveric analyses demonstrate that only 7.12% of weight from the knee is transferred through the fibula, which drops to less than 1% when the fibular head is resected.21 However, through its contribution to the proximal tibiofibular joint, the fibula dissipates torsional stress at the ankle and alleviates lateral bending of the tibia, and resections of the fibular head may compromise joint stability.22-24The proximal fibula is surrounded by neurovascular and anatomical structures, which necessitate careful surgical attention.25 Of the osteoid-forming lesions, osteoid osteomas are the most common variant in the proximal fibula  osteoid-forming, (2) cartilage-forming, and (3) vascular and connective tissue differentiation. osteoid-29 Some neoplasms such as GCTs of bone do not correspond to a general pathologic classification. GCTs of bone are poorly differentiated benign aggressive tumors characterized by multinucleated osteoclast-like cells. Although they are classified as benign, GCTs of bone may rarely metastasize to the lungs.30 By recognizing the unique pathologies of common benign fibula tumors, surgeons can better tailor a management plan for optimal control.ABCs are common fibular lesions composed of vascular tissue and blood-filled cysts. These tumors are locally destructive but do not undergo malignant transformation.1 In a cohort of 44 patients, Sun et al4 reported that the frequency of a palpable mass (56.8%) and the duration of symptoms (11.7 months) were greater in benign proximal tumors compared with malignant lesions, although statistical significance was not reported. The authors also concluded pain as nonpredicative factor for benign or malignant lesions (P = 0.971). Both of the aforementioned studies may be limited by only including patients who were managed surgically; asymptomatic patients were possibly underrepresented.In a review of 120 patients diagnosed with a benign proximal fibula tumor and managed surgically, localized pain (94%) was the most frequent presenting symptom, with a palpable mass (39%), pathologic fracture (17%), or peroneal nerve compression (12%) representing other complaints.31 Characteristic manifestations may be seen in select tumors, for example, osteoid osteomas present with nocturnal pain relieved by NSAIDs, and osteochondromas can be associated with limb deformities.25The extent of benign tumor symptoms typically correlates with their Enneking stage progression; stage 1 tumors are often asymptomatic and incidentally discovered while stage 2 through stage 3 lesions present according to their extent of tissue involvement.33 The nonaggressive benign lesions typically demonstrate a sharp transition zone, a well-defined sclerotic border, and a lack of cortical destruction.33 By contrast, various aggressive benign tumors such as GCTs of bones may mimic malignant lesions on plain radiography and require magnetic resonance or CT imaging to aid in diagnosis.34 If a specific lesion still cannot be identified, a biopsy is generally required to make a definitive histologic diagnosis.34 Care must be taken to avoid the peroneal nerve.35Many benign tumors have characteristic features, and often plain radiographs in multiple planes are sufficient to establish a diagnosis.36Benign tumors of the proximal fibula can undergo multiple surgical treatments, each with varying risks. The LCL and surrounding neurovascular structures represent surgical considerations when trying to achieve a low recurrence rate and optimal functional outcome.13 Given the paucity of current guidelines or algorithms for this anatomic location, surgical management is largely reserved for certain symptomatic, benign aggressive, and low-grade tumors.13 For example, enchondromas represent the most frequent Enneking stage 1 tumor of the proximal fibula, and these often asymptomatic lesions are initially managed with observation and serial radiographs.25 Surgical intervention through curettage is classically indicated on the onset of symptoms, increased tumor growth, pathologic fractures, or evidence of a chondrosarcoma.25 Similarly, osteoid osteomas have similar clinical outcomes when treated with either NSAIDs or surgical resection, and approximately 50% of tumors spontaneously regress with conservative management.38 Although excision or radiofrequency ablation of the nidus proves curative and is routinely practiced in other anatomic locations, the increased risk of peroneal nerve involvement makes these invasive procedures less desirable within the proximal fibula.38-40 Although nonsurgical interventions are a viable initial treatment for select latent lesions, surgical interventions serve the primary role in definitive tumor management in some cases of the proximal fibula.41The fibula's general classification as an expendable bone has resulted in expanded options for surgical management; however, most asymptomatic benign tumors of the proximal fibula are treated nonsurgically.42 Each procedure permits limb salvage, and they are differentiated by the extent of tissue resected. Intralesional excisions dissect a portion of the tumor, leaving potentially microscopic neoplastic cells in situ. This technique can be done through curettage, and the tumor cavity is typically filled with bone graft or substitute.31 Adjuvant therapies are routinely pursued, particularly for aggressive benign tumors, in an attempt to decrease local recurrence. Cement, such as polymethylmethacrylate, is considered a useful tool to achieve local tumor control through heat generation combined with structural stability.43-45 Argon laser, phenol, liquid nitrogen, and other cytotoxic agents are also used and have shown efficacy in decreasing the recurrence rates in the literature.45464748 Marginal excisions cut through the pseudocapsule, potentially leaving microscopic disease, but generally carry less recurrence risk than intralesional procedures.49Four fundamental tumor removal techniques have been described in the proximal fibula: intralesional excision, marginal excision, Malawer type I en bloc resection, and Malawer type II en bloc resection.41 The type I procedure involves a complete resection of the proximal head of the fibula with 2 to 3 cm of healthy proximal diaphysis .12Generally, type I resections Figure  have bee21 Guo et al21 retrospectively analyzed 44 patients with benign proximal fibula tumors who underwent either intralesional excision or a type I resection and identified potential risk factors for local recurrence. One GCT of bone managed by a type I resection was the only recurrence within the benign tumor cohort, and there was no statistical difference in recurrence rate between the intralesional and type I treatment groups. When the investigation was expanded to include eight additional patients with malignant proximal fibular neoplasms, univariate testing demonstrated peroneal nerve palsy on presentation and malignant status as the only variables associated with tumor recurrence (P < 0.01). In addition, when the patient variables were independently controlled for in a multivariate analysis, including the method of surgical management and tumor type, peroneal nerve palsy on initial presentation was the only predictive variable for tumor recurrence (P < 0.01). Although statistically significant, this study was potentially limited by a small sample size and a lack of stratification between pathologic subtypes.For most benign tumors of the proximal fibula, intralesional and marginal excision procedures have shown similar postoperative tumor recurrence rates as en bloc resections Table .1,21 Guo1 conducted the largest study directly comparing recurrence rate by the surgical technique. Their study included 121 benign tumors (120 patients) of the proximal fibula, which were managed by intralesional curettage, marginal excision, or type I resection. Overall, the recurrence rate was 8% (n = 10), with recurrence statistically more frequent in the intralesional curettage group compared with the en bloc group (23% versus 5% P = 0.029). However, when stratified by tumor pathology, GCTs of bone and ABCs made up most tumor recurrences (70%).To date, Abdel et alP = 0.08). In addition, all patients with an ABC who were managed through intralesional curettage experienced tumor recurrence, whereas none of those treated with en bloc resection had recurrence . Accordingly, Abdel et al1 concluded that although many tumors can be appropriately managed with intralesional excision, GCT and ABC warrant consideration for en bloc resection.Within the GCT of bone group, patients treated with intralesional excision experienced a higher recurrence rate compared with those managed by an en bloc resection  compared with the intralesional group  and type I resection group . In general, osteochondromas demonstrate low recurrence rates of less than 2% after surgical intervention.51 In addition, the marginal excision group did not include GCT of bone nor any cases of ABC, both benign aggressive tumors with a higher risk of recurrence. Thus, it is likely that the recurrence results within the marginal cohort of this study were aided by a relatively favorable distribution of tumor histology; this remains a notable limitation when attempting to directly compare the efficacy of different surgical techniques.Although there were zero recurrences in the marginal resection group in the study of Abdel et al,21 Accordingly, if surgery is the desired management choice for stable nonaggressive tumors in this anatomic location, the intralesional approach is a recommended initial surgical intervention.31 Dahlin et al52 reported on 30 cases including chondroblastoma with a cure rate of 90%, with the remaining recurrences adequately treated by revision curettage and no noted surgical complications. Similarly, in a study by Bauer et al,53 enchondromas demonstrated a recurrence rate of 4% after intralesional curettage. As discussed previously, adjuvant therapies can be used for the benign nonaggressive tumors in this anatomical region to further control recurrence risk.45464748 Given the low reported recurrence rates, intralesional and marginal excisions provide the added benefit of decreased risk of iatrogenic neurovascular and anatomical compromise in this sensitive region.10 En bloc type I resections have been described for benign nonaggressive tumors of the proximal fibula but are typically reserved for rapidly growing, locally destructive lesions with potential for malignant transformation.54Benign nonaggressive tumors within the proximal fibula, such as osteochondromas, enchondromas, simple bone cysts, and chondroblastomas, demonstrate a low risk of recurrence after intralesional and marginal excisions Table .1,21 Acc55 Inatani et al55 concluded a 50% recurrence rate after intralesional curettage in four patients with GCT of bone in the proximal fibula. By contrast, smaller case series of patients with fibular GCT of bone managed with intralesional excision reported no recurrences.56 In addition, novel tumor curettage techniques in the fibula have resulted in decreased healthy tissue removal while avoiding an increase in recurrence rates of GCT of bone.57 These techniques use posterior surgical windows and precise endoscopic curettage with cementation and argon plasma coagulation, respectively, and warrant further clinical consideration.57Most authors acknowledged en bloc resection as an effective management option for fibular GCT of bone, whereas others asserted intralesional excision with adjuvant therapy as viable alternatives. Those advocating for en bloc resection of the proximal fibula for GCT's of bone cited both the aggressive nature of the tumor and the high recurrence rates as indications because they outweigh the potential risk of neurovascular or functional complications.59 Because of the potentially high recurrence rate, some authors cited the expendable nature of the fibula as an indication for en bloc resection. Vergel De Dios et al60 examined 238 patients with ABC in varying skeletal locations; there were zero recurrences in those treated with en bloc resection, compared with 19% with intralesional curettage. These findings are agreeable with Abdel et al1 and Campanacci et al61 who similarly found zero recurrences with en bloc resection. By contrast, small-scale studies and case reports advocate for less invasive strategies. Lampasi et al62 and Jesudason et al3 concluded zero recurrences of fibular ABC's after intralesional curettage, although sample size was limited to six patients and one patient, respectively. Mavrogenis et al63 reported a successful ABC embolization in the proximal fibula with rapid pain relief and no tumor recurrence. Rossi et al64 reported on 36 patients and found no recurrence in 97% of patients treated with embolization.Like GCTs of bone, the preferred treatment strategy for ABCs of the proximal fibula remains under discussion. ABCs in nonexpendable anatomical locations, such as the femur, are classically managed with curettage and bone grafting, although recurrence can vary between 10% and 59%.most benign tumors of the proximal fibula, with GCT of bone and ABC being the exception. Although evidence is mixed, larger scale studies support type I en bloc resection of the proximal fibula as the preferred surgical treatment of GCT of bone and ABC, if the goal is to diminish recurrence rates.29 However, achieving treatment success remains multifactorial, including surgical skill, use of adjuvant therapies, and extent of the lesion.10Overall, the available evidence implies limited recurrence risk differences between intralesional/marginal tumor removal and en bloc resections for Although the risk of tumor recurrence remains a key surgical consideration, notable clinical attention should also be given to achieving adequate postoperative mobility, function, and joint stability. Consideration of postoperative functional limitations may influence selection between procedures with similar recurrence rates.8-55 Kundu et al10 demonstrated this by using the Musculoskeletal Tumor Society (MSTS) scoring system in their analysis of 46 patients with a proximal fibula tumor treated with an en bloc resection. The authors concluded that those with a concomitant peroneal nerve resection had a significantly lower average MSTS score compared with patients with no nerve involvement . Inatani et al55 demonstrated an even greater disparity in postoperative function within their cohort because those with a peroneal nerve resection had a mean MSTS score of 65% compared with 96% without involvement (P < 0.05), although the analysis may be limited by small sample size (n = 12). Dieckmann et al8 and Erler et al9 demonstrated analogous results because patients with peroneal nerve involvement resulted in lower functional scores. Even before surgical intervention, patients with evidence of peroneal nerve palsy on initial presentation have a higher risk of wound healing complications including infection.21 Thus, it is imperative for the orthopaedic surgeon to weigh the risk of peroneal nerve involvement for each surgical procedure.The peroneal nerve plays a major role in postoperative function, and its involvement is associated with inferior outcomes.1 Although studies providing direct comparisons between procedures remain limited, en bloc resections show a tendency of greater risk of peroneal nerve involvement.1 In type I resections, the peroneal nerve is typically protected by mobilizing it from the peroneus longus through sacrifice of the articular branch; nerve traction during surgical retraction is a common source of injury.31 In the analysis of Abdel et al on 120 patients with benign proximal fibula tumors, 9 (7.5%) reported a postoperative peroneal nerve palsy. The type I resection group resulted in six palsies , and the remaining three originated from the intralesional/marginal excision group ; statistical significance was not reported. Similarly, the authors cited peroneal nerve palsy as a common complication after a type I resection, whereas nerve injury is rarely reported after an intralesional excision.66 Spontaneous peroneal nerve recovery within a year of surgery has been reported because of traction injury.66The rate of iatrogenic peroneal nerve injury during tumor removal ranges from 3% to 57%.66Surgical detachment of the LCL and BFT can provide an additional source of impaired postoperative function, and evidence demonstrates that reattachment after an en bloc resection improves functional outcomes.66 reported on 19 patients who had a type I resection and compared lateral knee stability and MSTS function scores in patients who either underwent, or did not undergo, subsequent LCL and BFT reattachment to the tibial metaphysis. In their study, the reattachment group was associated with significantly higher rates of lateral knee stability  and higher scores on MSTS function surveys . Similarly, Bickels and Wittig31 reported on 15 patients who underwent a type I resection and tibial LCL reattachment; 14 had complete lateral knee stability with only one patient reporting a grade 1 instability , although no control group was included.Zhao et al36 analyzed six patients who underwent type I resection with LCL and BFT reattachment to the surrounding soft-tissue structures, rather than the tibial metaphysis, and all patients recorded some level of knee instability, varying from grade 1 to grade 2. Agarwal et al67 concluded similar rates of instability after LCL reattachment to soft-tissue structures.Arikan et al66Overall, the relative procedural simplicity and lack of adverse events have led to the recommendation that LCL and BFT reattachment should be practiced, preferably through anchoring to the tibial metaphysis, after type I en bloc resections of proximal tibia.66 This deficiency is largely attributed to the decreased LCL and BFT stump length  and the extent of tissue removed compared with type I resections.42 An inability to reattach the ligamentous structures further contributes to the instability of the proximal tibiofibular joint, which may also produce secondary deficiencies in ankle mobility.24 Accordingly, type II resections are rarely indicated for benign lesions of the proximal fibula, unless extended tumor involvement of adjacent anatomical structures commands a widespread resection.Multiple studies have demonstrated that type II resections are associated with markedly higher rates of knee instability and inferior MSTS scores compared with type I resections.Benign tumors of the proximal fibula are uncommon and can be clinically notable causes of morbidity. The choice of surgical management of these lesions is a multifactorial decision, with recurrence risks, functional outcomes, and patient goals guiding selection.Intralesional and marginal excision procedures are effective at treating benign nonaggressive tumors of the proximal fibula and are the preferred initial surgical option. These procedures have decreased postoperative functional limitations and no discernible differences in recurrence rates compared with en bloc resections.By contrast, Malawer type I en bloc resections are the preferred treatment for benign aggressive tumors, such as ABCs and GCTs of bone. Recurrence rates are lower compared with intralesional/marginal excisions, but the invasive nature of this procedure increases the risk of postoperative functional limitations. LCL and BFT reattachment to the tibial metaphysis should be done to improve postoperative joint stability. In patients who desire a more active lifestyle after surgery and find the functional risks unacceptable, intralesional or marginal excisions may be considered an appropriate initial therapy, although recurrence should be closely monitored. All options should be collaboratively discussed with the patient, and the surgical management plan that best balances the oncological and functional outcomes should be selected.


Methamphetamine is the second most commonly abused drug worldwide. It is a sympathomimetic agent that works by inhibiting the reuptake of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin. Methamphetamine use is associated with early mortality, and cardiovascular complications are the leading cause of increased mortality. We discuss the case of a 41-year-old man who presented to the emergency department with a sudden abdominal pain of eight hours' duration. The pain was located in the epigastric area with radiation to the back. Upon examination, the patient appeared agitated and diaphoretic. His pupils were dilated bilaterally. His vital signs included tachycardia (120 bpm), tachypnea (24 bpm), hypertension (150/90 mmHg), and normal temperature (36.9 ℃). Abdominal examination revealed a soft and lax abdomen with no tenderness. His bowel sounds were normal. Given the physical signs, a toxicology screen was conducted and was positive for methamphetamine use. The patient reported that he used recreational drugs occasionally and admitted that the abdominal pain developed a few hours following methamphetamine use. The patient was treated with fluid resuscitation, analgesic, antihypertension medications, and anticoagulant therapy. The patient had significant improvement in his condition within 48 hours with complete resolution of the abdominal pain. Isolated superior mesenteric artery dissection is a very rare clinical condition. This case report highlights the importance of recognizing the cardiovascular adverse effects that may develop after methamphetamine use. Methamphetamine is the second most commonly abused drug worldwide, after cannabis . It is eOur patient was a 41-year-old man who presented to the emergency department with a sudden abdominal pain of eight hours' duration. The pain was located in the epigastric area with radiation to the back. The pain was constant and was stabbing in nature, and it was associated with nausea and vomiting. He reported that the pain worsened when lying flat on his back and was partially relieved when he leaned forward. Before the onset of his pain, the patient had been feeling well. There was no history of anorexia, weight loss, fever, or change in bowel or urinary habits. The past medical history of the patient was remarkable for well-controlled hypertension and diabetes mellitus. His medication included amlodipine 5 mg and metformin 1000 mg, and he reported good compliance with his medications. He had not undergone any previous surgery. He had a smoking history of 20 pack-years and reported no alcohol consumption. The family history was significant for ischemic heart disease.Upon examination, the patient appeared agitated and diaphoretic. His pupils were dilated bilaterally. His vital signs included tachycardia 120 bpm), tachypnea (24 bpm), hypertension (150/90 mmHg), and normal temperature (36.9 ℃). His oxygen saturation was 99% on room air. Abdominal examination revealed a soft and lax abdomen with no tenderness. His bowel sounds were normal. Cardiorespiratory examinations were also normal. Initial laboratory investigations revealed a hemoglobin level of 14.5 g/dL, leukocytes count of 11,000/μL, and platelets count of 375,000/μL. Both serum amylase and lipase were within the normal limits. The biochemical investigation, including hepatic and renal profiles, was normal (Table 20 bpm, tInitial abdominal radiograph revealed normal findings Figure . The patWe reported the case of a middle-aged man with isolated superior mesenteric artery dissection presenting with acute abdominal pain. To the best of our knowledge, this is the first reported case of superior mesenteric artery dissection in association with methamphetamine use. Isolated superior mesenteric artery dissection is a very rare condition with few reported cases in the literature. The first case of isolated superior mesenteric artery dissection was reported by Bauersfeld in 1947 . Since tWhile no pathological cause is identified in most cases with isolated superior mesenteric artery dissection, the reported risk factors include atherosclerosis, cystic medial degeneration, fibromuscular dysplasia, and trauma . In the As in our case, the diagnosis of isolated superior mesenteric artery dissection can be reached by an abdominal CT angiography scan. It is crucial to evaluate the patency of the dissected artery and the presence of complications, including hematoma and bowel ischemia . In the Given its rarity, there are no available treatment guidelines for an isolated superior mesenteric artery dissection. A retrospective review by Gobble et al.  revealedIsolated superior mesenteric artery dissection is a very rare clinical condition. This case report highlights the importance of recognizing the cardiovascular adverse effects that may develop after methamphetamine use. CT angiography can make the diagnosis accurately. If no evidence of complications is present, patients may be managed conservatively with bowel rest and anticoagulation with close observation.


Small bowel obstruction can occur due to multiple etiologies, including intra-abdominal adhesions, hernias, strictures, Crohn's disease, and malignancies. An infrequent cause of small bowel obstruction can be seed bezoars. We present a case of a 72-year-old male who presented to the emergency department with a clinical picture of small bowel obstruction without any apparent risk factors for this condition. After thorough questioning, it was revealed that he had consumed a large number of sunflower seeds prior to the onset of symptoms. This eventually was proved to be the cause of his symptoms. The case is presented with the intent to highlight the necessity of acquiring dietary history in patients with high suspicion for bowel obstruction without any predisposing risk factors. Phytobezoars are formed due to the consumption of unshelled sunflower or pumpkin seeds, fruits with seeds, or kernels. When they occur, they can lead to constipation, obstruction, and ulcers as a result of intestinal mucosal damage . Most reA 72-year-old male with a history of essential hypertension and without any history of abdominal surgeries presented to the emergency department with several hours of acute onset severe abdominal pain. The pain was colicky, non-radiating, and localized to the periumbilical area. He tried bismuth subsalicylate at home with no relief of symptoms. He had not passed any flatus and had no bowel movements since the onset of symptoms. He denied any fever, chills, diarrhea, nausea, or vomiting. He denied any past occurrences of similar episodes. On further questioning, he admitted to eating a large amount of fried, unshelled sunflower seeds the day before the symptoms started. He had a colonoscopy ten years ago which revealed a tortuous colon but no polyps or diverticulosis. There was no history of colon cancer or inflammatory bowel disease in the family. On presentation, vital signs were within normal limits. The abdominal exam revealed decreased bowel sounds, tenderness in the periumbilical area and right lower quadrant, no rebound tenderness was noted, and McBurney's sign was negative. All laboratory investigations, including a complete blood count, comprehensive metabolic panel, and lipase, were within normal limits. A CT of the abdomen was pertinent for a transition zone in the terminal ileum with wall thickening, fat stranding, and dilation of the bowel proximal to the transition zone Figure . These fThe next morning, the patient had two large volume bowel movements, after which his abdominal pain significantly improved. Colonoscopy was performed and showed nonspecific ulceration proximal to the ileocecal valve, suggestive of trauma, possibly from ingestion of a large number of sunflower seeds Figure .At this point, early Crohn's disease was still in the differential. The pathology report showed focal surface epithelial erosion and florid lymphoplasmacytic and neutrophilic infiltrates. No granulomas were seen in the tissue Figure . These fSunflower seeds are a popular dietary item for many people. There are several reported cases of children with small and large intestinal obstruction by phytobezoars containing rhubarb, raisins, or unshelled sunflower seeds. However, cases of complete or partial small bowel obstruction in adults are extremely rare . AccordiOur patient had a partial small bowel obstruction caused by unshelled sunflower seeds, which resolved with conservative management. This case demonstrates that obtaining dietary history can aid in timely and accurate diagnosis in patients presenting with a clinical picture of bowel obstruction. Furthermore, educating patients about limiting the consumption of indigestible foods is essential as a prophylactic measure against such conditions.


MSH2. Sarcomas are not common on the LS tumor spectrum, and sarcomas associated with MTS are extremely rare.Muir–Torre syndrome (MTS), which accounts for a small subset (1–3 %) of Lynch syndrome (LS), is an autosomal dominant genetic disorder characterized by sebaceous gland or keratoacanthoma associated with visceral malignancies. Most families with MTS have pathogenic germline variants (PGV) in MLH1 PGV.Here we report a myxofibrosarcoma of the abdominal wall in a 73-year-old man with a sebaceoma that occurred synchronically, leading to a diagnosis of MTS. The loss of MLH1 and PMS2 protein expression was detected in immunohistochemistry, and high-frequency microsatellite instability (MSI-H) was also confirmed. A germline genetic analysis revealed that he harbored the MLH1 PGV carrier. Although rare, we should recognize that sarcomas can be part of the spectrum of LS and MTS.This is the first case of MSI-H myxofibrosarcoma with MTS in an The online version contains supplementary material available at 10.1186/s13053-021-00192-z. Muir–Torre syndrome (MTS), which accounts for a small subset 1–3 %) of hereditary non-polyposis colorectal cancer (HNPCC), also known as Lynch syndrome (LS), is an autosomal dominant genetic disorder characterized by sebaceous gland or keratoacanthoma associated with internal malignancies and often occurs before 50 years of age –3 % of h.MLH1, MSH2, MSH6, and PMS2—resulting in increase in errors during DNA replication and tumorigenesis. In contrast to LS, in which MLH1 and MSH2 are equally involved as causative genes, MTS is primarily characterized by a PGV in MSH2 [The characteristic sebaceous tumors of MTS include sebaceous adenoma, sebaceoma, and less commonly, sebaceous carcinoma . These L in MSH2 , 4. Inte in MSH2 –9. Furth in MSH2 , 9–11.Myxofibrosarcoma is one of the most common sarcomas arising in the extremities of elderly patients, with a slight predominance in males . This tuMLH1 germline variant.We herein report a myxofibrosarcoma of the abdominal wall in a 73-year-old man with a sebaceoma occurred synchronic, leading to a diagnosis of MTS. This is the first report of myxofibrosarcoma associated with MTS harboring the max) of the tumor was 3.96. No regional or distant metastases were identified.A 73-year-old Japanese man presented with a 2-month history of a mass at the left abdominal wall. Magnetic resonance imaging (MRI) demonstrated a 7.5 × 7.4 × 6.6-cm tumor involving the left 10th and 11th ribs and extending to the surface of the paraspinal muscles and quadratus lumborum. The tumor showed iso-intensity with muscles on T1-weighted imaging and mixed high and low intensity on T2-weighted imaging  had a history of rectal cancer (at 47 years old), transverse colon cancer (at 51 years old), duodenal cancer (at 54 years old), descending colon cancer (at 71 years old), and pancreatic cancer (at 72 years old)  revealed MSI-H, with four out of five microsatellites being unstable   and daughter (IV-8) underwent genetic testing, but the frameshift variant of MLH1 gene observed in the proband was not detected in either of them  [There have been few reports of LS-related sarcoma, with only 47 sporadic cases reported in the past . The mos86del16) . MTS-rel86del16) , 9–11. TMSH2 (58.1 %), followed by MLH1 (27.9 %) [MSH2 and MLH1 [MSH2 gene c.942 + 3 A > T PGV are diagnosed with MTS [MLH1 PGV, whereas all five previously reported sarcomas with MTS harbored the MSH2 variant  . Most faand MLH1 , and aboMSH2 8.1 %, foMSI-H/MMR-deficient solid tumors have recently been suggested to be susceptible to immune checkpoint blockade , 21. IndMLH1 PGV carrier. Although rare, we should recognize that sarcomas can be part of the spectrum of LS and MTS. These lesions may be highly susceptible to immune checkpoint inhibitors, despite usually showing chemoresistance against systemic therapy.In summary, we documented the first case of MSI-H myxofibrosarcoma with MTS in an Additional file 1.


The surgical indications for liver hemangioma remain unclear.Data from 152 patients with hepatic hemangioma who underwent hepatectomy between 2004 and 2019 were retrospectively reviewed. We analyzed characteristics including tumor size, surgical parameters, and variables associated with Kasabach–Merritt syndrome and compared the outcomes of laparoscopic and open hepatectomy. Here, we describe surgical techniques for giant hepatic hemangioma and report on two meaningful cases.Most (63.8%) patients with hepatic hemangioma were asymptomatic. Most (86.4%) tumors from patients with Kasabach–Merritt syndrome were larger than 15 cm. Enucleation (30.9%), sectionectomy (28.9%), hemihepatectomy (25.7%), and the removal of more than half of the liver (14.5%) were performed through open (87.5%) and laparoscopic (12.5%) approaches. Laparoscopic hepatectomy is associated with an operative time, estimated blood loss, and major morbidity and mortality rate similar to those of open hepatectomy, but a shorter length of stay. 3D image reconstruction is an alternative for diagnosis and surgical planning for partial hepatectomy.The main indication for surgery is giant (> 10 cm) liver hemangioma, with or without symptoms. Laparoscopic hepatectomy was an effective option for hepatic hemangioma treatment. For extremely giant hemangiomas, 3D image reconstruction was indispensable. Hepatectomy should be performed by experienced hepatic surgeons. Cavernous hemangioma, which is usually solitary and asymptomatic, is the most common benign tumor of the liver, with a reported prevalence of 3–20% based on autopsy series . HepaticTreatments for hepatic hemangioma include radiofrequency ablation (RFA), monoclonal antibody therapy, radiation therapy (RT), trans-arterial embolization (TAE), interferon therapy, liver transplantation, and surgical procedures (enucleation and resection). The therapeutic mechanism of RFA may be its induction of localized thermal injury on the flat endothelial cells constituting the walls of widely dilated non-anastomotic vascular spaces –6. The aBetween 2004 and 2019, 152 patients with the primary diagnosis of hepatic hemangioma were referred for surgical evaluation at the First Affiliated Hospital of Anhui Medical University. Hepatic hemangioma was diagnosed based on imaging studies, clinical data, and histological analyses. The indication for operation was giant (> 10 cm) liver hemangioma, with or without symptoms and Kasabach–Merritt syndrome . Patients’ medical records were reviewed retrospectively and we report two notable cases.t test, and the χ2 test were used to determine the significance of differences between experimental groups. All statistical analyses were performed using SPSS software . P values < 0.05 were taken to indicate statistical significance.Results are presented as means ± standard errors of the mean. Analysis of variance, Student’s 9/l–89 × 109/l) increased after surgery   years, and most (61.8%) patients were female. Most (63.8%) patients with hepatic hemangioma were asymptomatic, and 29.6% of patients had hepatic hemangiomas larger than 15 cm (Table 6–71 yearP < 0.01) (Table Most 64.5%) hemangiomas were solitary. Hepatic hemangiomas were treated by enucleation 30.9%), sectionectomy (28.9%), hemihepatectomy (25.7%), and the removal of more than half of the liver (14.5%) through open (87.5%) and laparoscopic (12.5%) approaches  image reconstruction was performed to understand future remnant liver volumes and the relationships between intrahepatic blood vessels and tumors Fig. .Fig. 1A One notable case was that a 62-year-old female patient with a giant hemangioma in the right lobe of the liver was misdiagnosed with hepatocellular carcinoma. In 2006, the patient’s physical examination revealed a liver mass. The patient was diagnosed with hepatocellular carcinoma and underwent five rounds of transhepatic arterial chemotherapy and embolization and multiple cytokine-induced killer cell treatments at another hospital. In December 2015, the patient was admitted to our hospital and we determined that she was not infected with hepatitis B virus and was alpha-fetoprotein negative. Computed tomography (CT) revealed a large mass in the right lobe of the liver, and the patient’s liver reserve function was normal. Thus, she underwent extensive right hepatectomy, and the final pathologically confirmed diagnosis was hepatic hemangioma  with symptoms of obstructive jaundice who had a ~ 5-cm hepatic hemangioma near the first porta hepatis. CT and magnetic resonance imaging (MRI) revealed that the hepatic hemangioma was located at the first porta hepatis and compressed the intrahepatic bile duct, resulting in obstructive jaundice. We enucleated the tumor and the patient’s bilirubin level returned to normal Table ; Fig. 3.For extremely giant hemangiomas, the surgical procedure was as follows. First, 3D image reconstruction was performed and radiographic results were studied scrupulously to design an optimal operative protocol. Next, a transverse incision was made in the epigastrium corresponding to the longest diameter of the tumor to fully expose the tumor and first porta hepatis. For obese patients or especially giant tumors, incisions extended to the xiphoid process. The first porta hepatis was exposed and the hepatic portal blocking band was prearranged; then, the hepatic artery and portal vein on the tumor side were ligatured and severed to shrink the tumor. The second porta hepatis was exposed and dissected. The tumor was bandaged to reduce bleeding, and liver resection was performed using hectogram pliers along the border between the liver and tumor. The intrahepatic small vessels and bile ducts were disposed of using titanium clips. Autologous blood transfusion was performed, and the middle hepatic vein was carefully protected as much as possible. Finally, the hepatic cutting surface was sutured with 4-0 prolene for hemostasis, and drainage tubes were placed under the liver and on the liver section  hemangiomas may lead to misdiagnosis –39. ThusHepatic hemangiomas tend to grow slowly and rupture infrequently , 44. As Hepatic resection has historically been the most common therapy for hepatic hemangioma . HoweverLaparoscopic liver resection is used widely for hepatic hemangioma because it decreases postoperative complications, enables more rapid patient discharge, and supports better postoperative cosmetic satisfaction –52. LapaKasabach–Merritt syndrome is characterized by the occurrence of disseminated intravascular coagulation due to hepatic hemangioma, and has a fatality rate of 7–10% that rises to 80% in the first year . HepatecWe summarize our center’s surgical recommendations for giant hepatic hemangioma as follows. A large curved incision should be created in the upper abdomen to expose the tumor body and the first porta. The first hilum of the liver should be exposed as much as possible, the hepatic artery/portal vein of the affected side should be ligated and devascularized to shrink the tumor, and the liver parenchyma should be transected as far as possible within 30 min after blocking while avoiding repeated opening to minimize blood loss. Hemihepatic blood flow occlusion, hepatic inflow occlusion, and complete hepatic vascular occlusion should be applied, and highly efficient electrosurgical instruments should be used to resect the liver. Intratumoral blood transfusion should be performed and a low central venous pressure should be maintained during the operation. Multiple small tumors should not be treated simultaneously, and TAE should not be used unless the tumor ruptures; radiofrequency or microwave treatment should not be used at all.The present study showed that the indication for operation was giant (> 10 cm) liver hemangioma, with or without symptoms, and that laparoscopic hepatectomy was an effective treatment option for hepatic hemangioma. For extremely giant hemangiomas, 3D image reconstruction was indispensable. Hepatectomy should be performed by experienced hepatic surgeons.


Epithelioid sarcoma is a rare soft tissue sarcoma. It is a slow-growing neoplasm, which usually presents as a painless mass in the extremities and typically grows along deep dermal and subcutaneous planes. In contrast to other types of sarcoma, it has a strong tendency for nodal metastasis and local metastasis adjacent to the primary lesion within the affected limb. In this article, we present a case of chronic traumatic ulcer in the upper extremity in an adolescent male that was subsequently diagnosed as epithelioid sarcoma, which is a very unusual mode of presentation of this particular tumour. The patient was treated with wide local excision and reconstruction with a free flap. Histopathological examination and immunochemistry studies confirmed the diagnosis and the patient underwent radiotherapy post-operatively as a part of the treatment regime. His post-treatment period was unremarkable, and he was put on regular surveillance to monitor the development of any signs of disease recurrence. Patients with epithelioid sarcomas often present late due to the slow-growing nature of the tumour. Unusual presentations like this will further delay the diagnosis and treatment, which will eventually worsen the prognosis. Awareness of such presentations can encourage primary care physicians to make early referrals to experts, which, in turn, may help the patients get early treatment and have a better prognosis. Epithelioid sarcoma, a rare neoplasm that makes up less than 1% of all soft tissue sarcomas, is a slow-growing neoplasm seen mainly in the adolescent and young population. First described by Enzinger in 1970, it typically presents as a deep dermal or subcutaneous mass in the distal aspect of the upper extremity. Though a slow-growing neoplasm, it has a strong predisposition for spreading to regional lymph nodes and local recurrence in the vicinity of the primary tumour, in contrast to other types of sarcoma [Due to its slow-growing nature, epithelioid sarcoma often tends to be misdiagnosed as a benign lesion, thus delaying the diagnosis and treatment. The time between detecting the first symptom and commencement of treatment ranges between one and 36 months, with the median being 3.5 months . This saA 21-year-old male, not known to have any chronic illness, was seen in the outpatient department. He had sustained a superficial laceration to the left wrist in a road traffic accident 18 months previously and had been undergoing regular wound care at a peripheral health centre since. There was no documented history of any surgical procedure or episode of wound infection. Despite the management, the wound had not healed completely; rather it healed partially with eschar and unhealthy granulation tissues. Surrounding skin became thin and hyperpigmented. Examination revealed a well-defined elliptical ulcer with irregular edges, 6x4 cm in size, over the radial border of the wrist. There were areas of scarring within the ulcer and on the surrounding skin. The floor had scattered pale granulations, and the edges were keratotic  scan, revealed no local or distant metastasis. He was followed up for four years in outpatient clinic regularly and MRI scan was performed every six months. Clinical examination during the latest visit revealed a well-settled flap with inconspicuous scars  ovoid through polygonal to spindle. The most important tool in making the diagnosis of epithelioid sarcoma is immuno-histochemical examination . The staThe treatment of choice of epithelioid sarcoma is wide surgical resection. According to some studies, resection of the tumour should be radical, despite the morbidity it may lead to, as the recurrence rates after marginal resection are up to 77% . HoweverLiterature reviewIn 2016, Nishibaba et al. reported a case of epithelioid sarcoma in a 74-year-old woman that was misdiagnosed as a fungal infection. Failure of initial treatment prompted a re-biopsy of the lesion, which surprisingly revealed lymphocyte infiltration and proliferating atypical oval or polygonal epithelioid cells along the dermis. Immunohistochemistry tests were positive for cell adhesion molecule 5.2, E26-related gene, vimentin and epithelial membrane antigen. They concluded with a recommendation for repeat biopsy and immuno-histochemical studies in cases that are resistant to conventional treatment methods, with epithelioid sarcoma included as one of the differential diagnoses . GuillouIn 2013, Mendes dos Santos et al. reported a case of proximal-type epithelioid sarcoma in a 25-year-old man. This presented as a rapidly progressing and painful lesion over his right buttock of three months duration and eventually ulcerated. Diagnosis of proximal type-epithelioid sarcoma was made from immuno-histochemical and histopathological studies. A staging CT scan revealed multiple metastases in the lungs and brain. The tumour exhibited an aggressive clinical course, with rapid distant metastasis and death nine months after diagnosis . Stang eEpithelioid sarcoma is a rare and aggressive neoplasm with high local recurrence rates and early nodal and distant metastases. For early detection and treatment, it should be considered one of the differential diagnoses when encountering a young adult with an unusual presentation of traumatic wounds and non-healing ulcers. An MRI scan is the initial diagnostic investigation of choice, and biopsy is necessary for confirmation. Deeper biopsies are recommended to demonstrate the overtly malignant morphological characteristics of epithelioid sarcoma. Once the diagnosis is confirmed, prompt treatment should be launched as any delay will worsen the prognosis. Common treatment modalities include wide surgical excision and radiotherapy. Postoperative periodic surveillance with MRI scan is the key to early detection of disease recurrence.