Pituitary adenomas are well described in the literature and are frequently observed and treated in clinical practice by neurosurgeons. On the other hand, ectopic adenomas are a diagnostic enigma; a good understanding of anatomy and radiological characteristics is crucial for the successful management of such pathologies. In this paper, we describe the case of a 77-year-old woman who presented with a clival mass invading the left cavernous sinus; we also discuss the associated diagnostic techniques, approaches, imaging options, and characteristics. Understanding the normal anatomy of the skull base, in particular, the sellar and parasellar regions, is fundamental for diagnosing and treating pathologies associated with such landmarks. The sellar and parasellar regions are in direct relation with the sphenoid bone. The sella turcica, a midline depression in the posterior sphenoid bone, limited anteriorly by the tuberculum sellae and the anterior clinoid processes, posteriorly by dorsum sellae and the posterior clinoid processes, laterally by the cavernous sinus, and the pituitary gland comprised by its anterior lobe or adenohypophysis and posterior lobe or neurohypophysis are the main structures forming the sellar region .1, and V2 are located in the lateral aspect while the carotid and abducens nerve travel more medially. Also contributing to the parasellar region are the suprasellar cistern structures, the hypothalamus  lying anterioinferiorly to the thalamus and comprising the floor and portions of the walls of the third ventricle. It is bounded anteriorly by the optic chiasm, laterally by optic nerves, and posteriorly by the mammillary bodies. The infundibulum extends off of the hypothalamus between the optic chiasm and the tuber cinereum. The hypothalamic-pituitary network is primarily supplied by the superior hypophyseal artery, a branch from the internal carotid. This arterial branch contains fenestrated capillaries and the blood-brain barrier is absent. The porosity of this vessel permits direct secretion of the aforementioned hormones into the bloodstream [The parasellar region is formed by the cavernous sinus, a trabeculated venous channel that extends from the superior orbital fissure to the petrous apex. Cranial nerves III, IV, VA 77-year-old female presented with a left clival mass, which was found incidentally on magnetic resonance imaging (MRI) Figure . NeuroloDue to its embryological and histological diversity, the sellar and parasellar region imaging is still somewhat challenging. The pituitary gland is a small-volume organ with an average height of 5.4 ± 0.9 mm and should never exceed 10 mm, with the exception of physiologic hypertrophy that occurs during pregnancy and lactancy with the hypophysis measuring up to 12 mm . Two maiThe adenohypophysis comprises almost 70% of the total size of the gland in newborns and up to three or four months of age. It may exhibit some hyperintensity which will gradually disappear, and as early as six months, should exhibit isointensity with the adjacent brain . The posClinical presentation can be classified into three categories: endocrinological, neurological, and ophthalmological. Endocrinological presentations are related to the hormones secreted by the gland and mostly present as hypersecretory syndromes. For instance, hyperprolactinemia may produce decreased libido, impotence, and gynecomastia in men; while in women, it presents typically with amenorrhea and galactorrhea . OphthalThe sphenoidal sinus is the most common site for ectopic pituitary adenomas, and must be differentiated from other lesions that can originate from this area such as chordomas, which present as a destructive lesion showing variable signal intensity on both T1WI and T2WI. When contrast enhancement is low, infectious agents such as fungus will be observed in an MRI with intermediate signal on T1WI and low signal intensity on T2WI . On MRI,For treatment options, surgical resection via the endoscopic binostril endonasal remains the main pillar as it offers a greater angle of attack and greater surgical freedom than the endoscopic uninostril endonasal, or the endoscopic contralateral transmaxillary approach for accessing parasellar structures. Nonetheless, the endoscopic contralateral transmaxillary approach provides a more lateral exposure of the ipsilateral parasellar area, and a shorter surgical trajectory to the contralateral parasellar area .Ectopic pituitary adenomas are a rare finding. Imaging plays a big role in diagnosis and treatment. MRI is preferably used to determine tumor localization and extension, whereas CT scan aids in the resection planning and approach selection. Depending on the aforementioned characteristics exhibited by the tumor, a surgical approach is selected. The endoscopic endonasal has gained much popularity mainly for its straight-forward access, and good and rapid recovery with minimal cosmetic defects.


T1 weighted imaging and high intensity on T2 weighted imaging. On dynamic study, the tumor showed mild enhancement in the early phase and increased enhancement in the delayed phase, and the mass appeared continuous with the prostatic urethra. On follow-up MRI at approximately 10 months, the mass had increased in size. Pathologically, the tumor was located in the muscularis of the prostatic urethra and consisted of spindle cells with fascicular and storiform patterns of growth, and exhibited strong diffuse expression of CD34. The tumor was hypercellular, and a significant number of mitoses were observed. Therefore, this tumor was diagnosed as malignant solitary fibrous tumor (SFT) of the prostatic urethra.A 68-year-old male with dementia presented with gross hematuria. On plain CT, a mass was found at the base of the prostate with intravesical protrusion. On MRI, the mass was well-circumscribed and showed slight hyperintensity compared to the skeletal muscle on  In recent years, several reports on extrapleural SFTs have been published, and it has been reported that extrapleural SFTs are more common than pleural SFTs.3 This tumor type is generally benign, and reports on malignant cases are limited. Here, we report a case of malignant SFT that arose from the prostatic urethra and present the MRI and histological findings. Solitary fibrous tumor (SFT) is a rare tumor that was first described in the pleura. The incidence is approximately 2.8 per 1,00,000 in pleural SFTs.T1 weighted imaging (T1WI) and high signal intensity on T2 weighted imaging (T2WI)  value of the tumor was 0.75–1.00 × 10–3 mm2 s−1  . On dynag (T2WI) . On diff mm2 s−1 . Possible radiological differential diagnoses for the mass were stromal tumor of uncertain malignant potential (STUMP) of the prostate, pheochromocytoma of the bladder, leiomyoma/sarcoma, urethral cancer, bladder cancer, prostatic cancer and benign prostatic hyperplasia. Prostatic needle biopsy revealed stromal spindle cells with no mitosis. As there were benign entities among the radiological differential diagnoses and the biopsy revealed no malignancy, conservative management was adopted. Flexible cystoscopy at 9 months revealed a mass at the trigone of the bladder, which appeared continuous with the prostatic urethra. Biopsy revealed fibroblast-like short spindle cells with no evidence of malignancy. On follow-up MRI at approximately 10 months, the mass had increased in size and measured 6 × 5 cm . Prostat Pathologically, the tumor was found in the muscularis of the prostatic urethra or the bladder. The tumor consisted of spindle cells with fascicular and storiform patterns of growth, and mucinous degeneration and some necrosis were observed in the background. The tumor was hypercellular, and a significant number of mitoses (more than 10 in 10 high-power fields) were present. Immunohistochemical analysis revealed diffuse expression of CD34. Therefore, a diagnosis of malignant SFT was made. The above findings are shown in 4 A decade later, Stout and Murray described hemangiopericytoma, the histopathological pattern of which is shared with those of various tumors, including SFTs.5 As SFT was initially described in the pleura, they have been considered mesothelial tumors. Due to recent advances in our understanding of the pathogenesis of SFTs, it is currently believed that they are pathologically diverse and ubiquitous neoplasms derived from CD34-positive mesenchymal fibroblastic or myofibroblastic cells.7 It has been reported that 16% of SFTs are found in the pelvic region, most frequently in the prostate.8 SFTs are generally benign tumors occurring in middle-aged adults, and extrapleural SFTs have a male to female distribution of 1.2:1.9 Malignant SFTs are rare and there are no established criteria for diagnosis of malignant SFTs but they are commonly evaluated based on the criteria advocated by England et al.1 The characteristics of possibly malignant tumors are large tumors (greater than 10 cm in diameter) with hypercellularity, nuclear atypia, mitoses (>4 in 10 high-power fields) and infiltrative margins. Okada et al reported that atypia was frequently observed in tumors with higher cellularity, which was independent of the tumor size and histological appearance.10 In addition, proteins related to malignancy and proliferative activity, such as p53, ki-67 and PCNA, are more frequently observed in tumors with higher cellularity, and of these, p53 is thought to be a prognostic factor.12 The most frequently reported sites of metastases of pleural SFTs are the lungs and the pleura; other sites include the brain and the liver. Metastasis has been observed a long time after initial resection, and histological malignant transformations are observed at recurrence.16 SFT was first described by Klemperer and Rabin in the 1930s as a mesothelial tumor that arises from the pleura.17 Our case was slightly hyperechoic, and we speculated that variation in the constituents can yield different echogenicity. On plain CT, pleural SFTs often show isodensity with some hypodensity, and they demonstrate mild or marked enhancement on contrast-enhanced CT. It has been reported that the isodense areas on plain CT correspond to hypercellular areas and capillary networks. On contrast-enhanced CT, areas with marked enhancement are correlated with hypervascular areas, areas with intermediate enhancement are correlated with hypercellular areas and patchy or linear hypodense areas are correlated with cystic degeneration, necrosis, or myxoid changes.18 On T2WI MRI, some SFTs exhibit mixed hypointensity or hyperintensity. The variation in signal intensity is thought to depend upon tumor components where collagen-rich areas correspond to hypointense areas, while vascular and hypercellular areas correspond to hyperintense areas.19 On dynamic enhancement studies, prolonged and delayed enhancement is reported and prolonged enhancement is thought to correspond to abundant hypercellular areas, while delayed enhancement is correlated with collagen-rich areas.22 On DWI, the ADC value and ADC map were reported to be useful for identifying malignant transformation, with ADC value in the malignant area of 1.12–1.19 × 10–3 mm2 s−1.23 In our case, pathologically the mass was hypercellular and its prolonged enhancement was consistent with previous reports. In addition, its ADC value was low as to the reported area with malignant transformation. Imaging finding of SFT indicate a well-circumscribed round or ovoid enhancing mass. On ultrasound, the lesions are reported to be generally hypoechoic but can be heterogeneous with probable presence of myxoid degeneration.24 We believe that our case was SFT originating in the prostatic urethra as the tumor was continuous with the urethra on imaging studies and the same findings were seen on cystoscopy. Moreover, pathologically the tumor was present in the muscularis of the prostatic urethra/bladder. Nonetheless, the mass was relatively large and the possibility that the tumor originated in the bladder or the prostate with secondary extension to the urethra could not be excluded. In the literature, we found one case report of SFT in the urethra of a female patient. This report describes a mobile perineal mass, which was attached to the posterior lip of the urethra.25 In our case, the mass protruded to the opposite end, but it appeared to be somewhat similar in morphology. In terms of a round and well-circumscribed mass, prostatic STUMP, leiomyoma/sarcoma and bladder pheochromocytoma are feasible differential diagnoses, and it was impossible to distinguish this case from these entities based on imaging findings alone. Lesions in the base of the prostate are known to mimic bladder-occupying lesions, and it was difficult to identify the exact origin of the tumor.Of note, conservative management was opted in this case after targeted biopsy yielded no malignancy, but the MRI findings were not consistent with a definitely benign lesion and therefore a second biopsy should have been planned soon afterwards.1 Gold et al reported that extrapleural SFTs have a slightly higher risk of local recurrence than pleural SFTs.26 They speculated that this is because of the difficulty in securing wide surgical margins during resection of extrapleural SFTs due to their anatomical location. When the tumors are not surgically resectable or there are metastases, chemotherapy and/or radiotherapy should be considered as palliative treatment. However, the data to establish an evidence-based treatment for advanced SFT are still limited. Surgical resection is the treatment of choice for SFT, and the most important prognostic factor is thought to be complete resection with clear margins. In conclusion, we presented a case of malignant urethral SFT with ultrasound, CT and MRI findings.–3 mm2 s−1.A case of urethral malignant SFT: A T2WI high-intensity round mass appearing to protrude from the urethral opening into the bladder. It showed prolonged enhancement on dynamic gadolinium-enhanced T1WI and high intensity on DWI with an ADC value of 0.75–1.00 × 10SFT can arise from virtually any site of the body. If the diagnosis of a well-circumscribed mass with enhancement is in doubt, SFT should be considered as a differential diagnosis.A mass arising in the area around the base of the prostate can protrude into the bladder making local diagnosis difficult.


An inguinal hernia is a common disease; however, a malignant tumor within the inguinal hernia sac is rare, and perforated colon cancer in the hernia sac is extremely rare.A 73-year-old man presented to our hospital with high fever and painful bulging of the lower abdomen. Computed tomography showed air-containing fluid in the abdominal wall, as well as localized wall thickness of the sigmoid colon in the left groin. An emergency operation revealed a huge subcutaneous abscess and a hard mass of the sigmoid colon within an indirect inguinal hernia sac. Sigmoidectomy and hernia repair using the Marcy method were performed. Lymph node dissection was performed through a transrectal abdominal incision. Histopathological examination of the resected specimen revealed moderately differentiated adenocarcinoma invading the serosal layer with lymph node metastasis.Incarcerated inguinal hernia with perforated colon cancer is rare; an emergent operation should accordingly be performed based on infection control, oncological principles, and secure hernia repair. An inguinal hernia is a common disease; however, a malignant tumor within the inguinal hernia sac is rare. An inguinal hernia associated with perforated sigmoid colon cancer is extremely rare, and the treatment of this condition is challenging. The incidence of malignant tumors within the inguinal hernia sac is reportedly 0.4–0.5% among the cases with excision , 2. We p3/μL) and C-reactive protein (20.4 mg/dL) and a low hemoglobin level (5.9 mg/dL). Computed tomography (CT) showed air-containing fluid in the abdominal wall (Fig. A 73-year-old man presented to our hospital on May 2017 with painful bulging of the lower abdomen. He was febrile with a temperature of 38.4°C and had a swollen reddish lower abdomen and a large left scrotum (Fig. When the left inguinal skin was incised, purulent fluid flowed from a subcutaneous abscess cavity, and a huge hernia sac was identified Fig. a. Upon oEscherichia coli and Bacteroides fragilis were identified by bacterial culture of the abdominal wall abscess. Additional abdominal wall debridement was performed to promote infection control. He was discharged on the 29th postoperative day. At 9 months post-surgery, he had multiple liver metastases and has undergone systemic chemotherapy.Postoperatively, meropenem 1.5 g/day was administered intravenously, however, the patient developed a large infectious abdominal wound. Although inguinal hernia is commonly observed, approximately 10% of this disease is irreducible and can cause bowel obstruction or strangulation . CoexistOur case was specific for developing a huge abscess cavity outside the hernia sac. Benfatto et al.  reportedWe repaired the inguinal hernia with the Marcy method and combined with suturing the external oblique aponeurosis to the iliopubic tract that was because there was no stiff fascia tissue excluding the external oblique aponeurosis because of severe inflammation. If the patient will develop hernia recurrence without infection, hernia repair using a mesh is one of options.Although primary colonic malignancy within an inguinal hernia sac has rarely been reported, our extensive literature search yielded 12 cases of perforated colonic cancer within an inguinal hernia sac (Table Clinical presentation of perforated malignant tumors within an inguinal hernia sac mimics strangulation of the incarcerated bowel. This critical condition, with the associated infection and circulatory disturbance, can have a significant effect on the clinical outcome. Surgery should immediately be performed because any delay can lead to fatal complications, such as necrotizing fasciitis and sepsis . SurgeonIt is not clear whether it is necessary to screen bowel malignancy in patients with an inguinal hernia. Avidan et al. reported no significant association between inguinal hernia and colon cancer , 18. HowIn this report, we discussed a rare case of perforated colon cancer in the hernia sac in a 73-year-old man. Although incarcerated inguinal hernia with perforated colon cancer is rare, it should be considered in patients with an inflammatory irreducible groin mass. Precise diagnosis is important, and an emergent operation should accordingly be performed.


Cytologic features of such a finding.•Treated with surgical excision on leg (x2) with resolution of local site. Secondary site of EHE discovered at 7 month mark right groin mass which was also excised.•Identified how to approach and treat a rare vascular tumor (EHE) type based upon limited literature review. A rare vascular tumor, epithelioid hemangioendothelioma (EHE), can be difficult to diagnose for physicians. Although uncommon, EHE has the potential to become malignant and cause patient death. The five year mortality rate with the diagnosis of the high risk type has been reported to be as high as 41. Thus this finding requires aggressive treatment to prevent amputation or death .In this case, a 60-year-old male patient was evaluated for a suspicious subepidermal nodule on the upper lateral aspect of the lower right leg just distal to the knee. It was excised to the level of muscle with appropriate margins of 1 cm circumferentially. The specimen underwent appropriate pathological testing and did reveal a high-risk-type epithelioid hemangioendothelioma with remaining tumor present at the deep margin. The patient had additional surgery by an orthopedic surgeon in order to obtain clear margins of the lesion and retain maximum function of leg. Despite surgical excision with ultimately clean margins, the lesion did metastasize to the right groin area seven months after surgery and the secondary metastatic site also required surgical excision.There is very little information available to the identification and treatment of a finding of EHE. The only definitive treatments to prevent malignancy is excision or amputation, possibly in conjunction with radiation therapy. The role of oncology intervention should be considered because the finding may be either a cause or an effect of malignancy.The goal of this paper is to raise awareness of the importance of pathology for soft issue lesions even if there is initially a low clinical index of suspicion. Unique characteristics in the pathology is the cornerstone to the identification and treatment. Although surgical excision can appear to be a curative treatment, EHE may inevitably metastasize, so aggressive and definitive treatment is best. There aAccording to the World Health Organization, EHE is considered intermediate malignancy. In an article by Deyrup, 49 cases of EHE were examined to determine the risk stratification between low and high risk type of EHE. The study showed that when the tumor had increased size >3.0 cm or mitosis >3 mitosis/50 high power fields (hpf), it was associated with a worse prognosis and should be considered high risk type. The high risk type was associated with 59% 5 year survival while low risk did not have any deaths in their study. Metastasis occur in 25% of cases and the 5 year mortality rate is 19% [The uniqueness of EHE as a distinct vascular tumor is due to WWTR1 (protein known as TAZ)-CAMTA1 (WC) fusion oncoprotein. This immunohistochemical marker, TAZ-CAMTA 1 (TC), which is the result of a t1;3)p36.3;q25) translocation appears to be found in EHE in greater than 90% of cases [(p36.3;q2.3;q25 trClinically, the lesion may be difficult to distinguish as it can appear in several locations and can resemble many other soft tissue tumors. EHE is mostly identified by unique pathological characteristics and immunohistochemistry findings ,9. The dTreatment options for EHE vary depending on low or high risk type. As these cases are rare in nature, each treatment should be individualized. The basis of treatment, if possible, is wide excision of the tumor, followed by chemotherapy or radiation therapy in some cases. There have been several case studies showing some promising anti-angiogenesis agents, particularly for unresectable tumors. One such agent, pazopanib, may be a therapeutic option to help control unresectable tumors . Combina2A 60 year old Caucasian male patient was referred to general surgery for multiple unrelated complaints including umbilical hernia and left arm lipoma. The patient also had an additional complaint of a fast-growing right leg mass located on upper lateral right calf distal to the knee. The patient had no other suspicious skin lesions and admitted to having the lesion shave biopsied two years prior by dermatologist with benign findings. No picture was taken of the lesion prior to surgical intervention as it was expected to be benign based upon prior dermatological findings. The patient stated that the leg lesion was non-painful in nature but was concerned that it may have increased in size over the previous 2 months and had a brown-gray discoloration. No prior imaging was obtained for the leg lesion. A wide margin elliptical excision was performed with a minimum goal of 1 cm margins on all sides of the lesion and the depth was resected to the muscle layer. The full specimen was marked for orientation and submitted to pathology. The excised elliptical portion measured 4.3 cm in length and 2.5 cm in width at widest points. The nodular lesion measured 2.4 × 1.8 × 0.9 cm. Ancillary studies showed that the lesion was CD31 positive, CD34 positive, and negative for cytokeratin markers. The pathology report confirmed EHE with tumor close to circumferential margins and present at the deep margin. The lesion was staged as pT1a pNX in accordance with AJCC staging. Given the deep margin extending to the thin layer of muscle just distal to the knee, the patient was referred to orthopedic surgery for further evaluation and operative intervention. The mainstay of treatment for invasive sarcoma is surgery often coupled with radiation and/or chemotherapy. A second surgical excision 19 days later following the original surgery was performed into deeper tissue. The second lenticular ellipse measured 8.1 cm in length and 2.1 cm in width at widest points at a depth of 1.4 cm. Multiple frozen sections were examined and clean margins of a minimum of 1 cm was determined in all directions.Due to the diagnosis of EHE, it was prudent to obtain additional imaging to determine if the malignancy had metastasized. Although incredibly rare, there have been documented cases of pulmonary epithelioid hemangioendotheliomas, as well as cases of tumors found on the liver. A CT scan was performed with IV and oral contrast of the chest and abdomen. The findings were unremarkable for the chest but multiple hepatic cysts and an enhancing lesion in the right lobe of the liver were identified. A follow up MRI with and without gadolinium confirmed a 2 cm well-defined focal area of delayed enhancement within the posterior segment of the right lobe of the liver corresponding to the CT findings, likely representing a cyst and not a metastatic lesion. These findings suggest that no metastasis had occurred and that the leg skin lesion appeared to be the primary site of EHE.3The identification of the skin lesion as EHE was determined by a combination of microscopic, immunohistochemical, and gross pathologic findings. The gross pathology showed a raised brown-gray firm nodule measuring 2.4 × 1.8 × 0.9 cm in size within an ellipse of hair-bearing skin measuring 4.3 × 2.5 × 1.2 cm. Microscopic analysis showed a dermally centered proliferation of epithelioid to spindle shaped cells arranged in broad intersecting fascicles and lobules. Spindle shaped cells can be observed within the vascular tumor as observed in In the largest cytologic study of EHE to date by Murali et al., 11 histologically confirmed EHEs all showed occasional intranuclear pseudoinclusions and intracytoplasmic lumina found in epithelioid cells, whereas only 45% cases showed rare erythrocytes . Rare mi4At 6 months follow up the patient had not had any recurrence in the area and was fully healed. The patient, however, had a right inguinal mass excised at 7 months that also was confirmed to be a metastatic site of epithelioid hemangioendothelioma. This metastatic lesion was surprising as the right growing mass had previously been tested as acellular. Even more surprising, flow cytometry was positive for CLL, which was not previously identified in this patient. The patient did have a follow up PET/CT scan which showed a 1.3 cm soft tissue nodule superior to the resection cavity. Patient was also referred to radiation oncology and will likely start radiation treatments six days a week. He will also require further lymph node resection due to new mass findings. This patients follow up is ongoing and will need continued multi-specialty care.5Due to the rarity of this dermatological finding, the literature is very limited. The importance of physicians being aware of the features of EHE allows more accurate identification of this vascular tumor. Treatment options continue to expand as individual case reports with various agents have been shown to be promising. Anecdotal evidence of pharmacologic agents will require larger population and long term studies to determine the effectiveness of anti-angiogenesis agents. EHE in soft tissue has the potential to be either a primary lesion or site of metastases. Patients should also have additional imaging if EHE is found on the skin to ensure that it is not a site of metastasis. Five year mortality rate is significantly increased in high risk findings based on microscopic appearance and should be treated in a more aggressive, multimodal manner. As shown in this case study, a second site of metastasis was identified because of a high index of suspicion and appropriate oncological surveillance. It is the hope of this article to raise interest in EHE and to spread awareness that although surgical resection can be an effective means of treatment. It may, however, not be curative and close patient monitoring is of the utmost important.None.None.Exempted by our institution since it is a single case report.Verbal and Written consent obtained.Joshua Kazdan-Writing of paper.Victoria Sharpe-Primary surgeon.John Pui-Images, pathology analysis.Joshua Kazdan.Not commissioned, externally peer-reviewed.


Primary thoracic dumb-bell yolk sac tumor (YST) with both epidural and extraspinal extension is a rare disease with no standard curative managements yet. The objective of this study is to report a primary thoracic dumb-bell YST presenting with severe spinal cord compression successfully treated with posterior-only approach operation, followed by chemotherapy. The management of these unique cases has not been fully documented.A 26-mounth-old, previously healthy girl presented with progressive numbness and weakness of the lower extremities. Neurological examination revealed paralysis of both lower extremities, sensory disturbance below T-8 and bladder-bowel dysfunction.CT and MRI of spine showed a dumb-bell mass lesion with both epidural and extraspinal extension through enlarged intervertebral foramina and marked spinal cord compression at T7–T9. The AFP level was 13738 ng/ml. Preoperative puncture and Postoperative pathology confirmed the diagnosis of YST.By needle biopsy, we identified the pathological diagnosis is YST. Subsequently, the patient was treated with one-stage posterior-only approach operation, followed by 9 courses of chemotherapy based on cisplatin, bleomycin, etoposide.The patient has a complete neurologic recovery and remains recurrence free as of more than 2 years after the completion of operation. There were no other complications associated with the operation during the follow-up period.YST should be considered in the range of children with thoracic dumb-bell tumor presenting with spinal cord compression. Needle biopsy is valuable for preoperative diagnosis and design of the treatment strategy. If there is no evidence of CSF spread, metastasis or multiple diseases, it is effective to remove tumors as thoroughly as possible immediately, avoid further nerve injury and conduct enough chemotherapy. This case suggests that this treatment strategy is an effective option for primary YST with both epidural and extraspinal extension and severe spinal cord compression. To date, just a few cases of primary YST with both epidural and extraspinal extension have been reported in the literature. We report a case of a primary thoracic dumbbell YST presenting with both epidural and extraspinal extension and severe spinal cord compression from T7-T9. We believe this to be the first reported case of a dumbbell epidural and extraspinal YST presenting with severe spinal cord compression, successfully treated with one-stage posterior-only approach operation and chemotherapy based on cisplatin, bleomycin and etoposide without radiation, with a complete neurologic recovery.Yolk sac tumor (YST), also called endodermal sinus tumor, is a rare malignant germ cell neoplasm that usually occurs in the testis or ovaries of children or young adults. Occasionally, it can affect extragonadal sites involving posterior midline structures in the mediastinum, retroperitoneum, sacrococcygeal region, and intracranially in the suprasellar and pineal regions.22.1The patient provided written informed consent authorizing use of his protected health information for publication of this report and any accompanying images. A 26-mounth-old, previously healthy girl who had been noticed to fall suddenly when she walked 10 days earlier presented with progressive numbness and weakness of the lower extremities. She could not stand and moved her lower limbs. Neurological examination revealed paralysis of both lower extremities, sensory disturbance below T-8 and bladder-bowel dysfunction. The muscles of lower extremities were graded as 0/5 and the Frankel grade was B. Both knee-jerk and Achilles tendon reflexes were absent. Babinski sign was positive bilaterally. Cranial nerve and upper extremity neurologic functions were normal. Blood tests showed her AFP level were 13,738 ng/ml. β-human chorionic gonadotropin level was normal. CT and MRI were performed immediately and demonstrated a dumb-bell mass lesion with both epidural and extraspinal extension through enlarged intervertebral foramina and marked spinal cord compression at T7–T9. The epidural component occupied three-quarters of the spinal subarachnoid space and part of 8th left rib was invaded by the larger extraspinal component (Fig. 2.2A needle biopsy of the superficial part of the extraspinal mass was performed at prone position by a posterior approach under general anesthesia. Histopathological examination indicated a YST. It was highly reactive for AFP and CK. As the lesion was suspected of being responsible for the progressive paraparesis, emergent posterior decompressive laminectomy from T7-T9 were performed and revealed the epidural tumor. It compressed the spinal cord obviously. The epidural component was removed first. Through the removal of the left T8 vertebral pedicle, zygapophyseal joint and part of 8th left rib, the extraspinal component was exposed and resected thoroughly. Vertebral pedicle screws and bar systems were performed for reconstruction of spinal cord stability Fig. . The fin2.3Nine cycles of chemotherapy based on bleomycin, etoposide and cisplatin were administered two weeks after the operation. The doses were 3.5 mg/day of bleomycin on days 1 to 2, 50 mg/day of etoposide on days 1 to 5 and 8 mg/day of cisplatin on days 1 to 5. After the completion of second cycle of chemotherapy, AFP dropped to 386ng/ml. AFP levels rapidly decreased to the normal range after completion of 3 cycles. Two months after operation, she could stand up. Neurologically, the child continued to improve and could walk independently and run six months after operation. Internal fixation was removed 1 year after the operation. After more than 2 years of operation, the patient remained without evidence of recurrent and metastasis. The serum AFP and neural function of lower limbs remained normal.3Here, we have reported a case we encountered of primary thoracic dumb-bell YST, which is extremely rare. The patient was successfully treated with needle biopsy, surgery and chemotherapy. Our experience and review of the literature suggest that this treatment strategy might be effective for primary thoracic dumb-bell YST, although further evaluation of the treatment protocol is warranted.The diagnosis of YST may be inferred from elevated serum AFP that is a very good tumor marker in patients with YST, irrespective of their location. Serial serum AFP determinations can be used for diagnostic purposes, for monitoring the results of treatment, and for early detection of metastases and recurrences.,4Preoperative needle biopsy is helpful to identify the nature of the tumor and make a treatment plan early. Final diagnosis is dependent on the demonstration of characteristic features by histopathological examination. The histopathological features include Schiller–Duvall bodies, hyalin globules, and immunohistochemical staining for AFP.–8 There are no recognized guidelines for the management of dumb-bell YST due to rarity of the disease. Based on published literature, early diagnosis and multimodal treatment with surgical excision, chemotherapy, and radiotherapy may improve the prognosis and limit the morbidity and mortality.To date, including our case, 5 cases of primary dumb-bell YST causing spinal cord compression have been reported. reported a 13-month-old male with an approximately 4-week history of complete paraplegia. CT showed a paravertebral solid mass on the right side of the 11th and 12th thoracic vertebrae extending to the 11th rib, aorta, muscle complex of the back, and the intraspinal canal. He was treated with radiation, followed-up by chemotherapy and surgical excision completed by thoracotomy with decompressive laminectomy from the 10th to 12th vertebrae. A pathological diagnosis could not be obtained because the specimen was highly degenerated due to preoperative radiotherapy and chemotherapy. At the age of 34 months, a back tumor recurred at the site of the laminectomy. An immediate biopsy confirmed the lesion to be an YST. He did not recover neurologically.Todani et al reported a 21-month-old boy with an approximately 2-week history of flaccid paraplegia. MRI showed a large left suprarenal mass with epidural extension and marked spinal cord compression at T9–L1 from a primary YST. The child underwent an urgent osteoplastic laminotomy and resection. After surgery, he did not recover lower extremity function. He completed first cycle of chemotherapy with bleomycin, VP-16, and cisplatin on postoperative Day 12 and died suddenly 4 days later. The cause of death is unknown.Resnick et al reported a 17-month-old boy with a 3-day history of near-complete paraplegia secondary to spinal cord compression from a primary YST. CT showed a large left suprarenal mass with epidural extension and marked spinal cord compression at T10-L1. He was treated with cisplatin-based chemotherapy without laminectomy or radiation therapy. The child had an excellent tumor response and complete neurologic recovery.Pashankar et al reported a 2.5year-old girl with spastic paraparesis and bladder dysfunction. Thoracic X-rays showed a left posterosuperior mediastinal mass with rib erosion. MRI showed that this mass had developed intraspinally between the intervertebral foramina and caused spinal cord compression at T4-T6. Surgical resection via laminectomy was performed in emergency, but the T5 root had to be excised. Pathologic examination showed histologic features of a primary YST. The patient was given chemotherapy for 6 months and is well 2 years later.Thomas et alIn this report, we describe the fifth case of a primary dumb-bell YST presenting with compression. One-stage posterior-only approach was used in this operation of epidural and extraspinal tumors. The advantages of this way are less damage without thoracotomy and avoid related complications. It required high technical requirements relatively. The excision of partial appendix of vertebra influenced the stability of the spine. Therefore, internal fixation using vertebral pedicle screw and bar system was performed. Pashankar et al thinks that chemotherapy alone is an alternative to laminectomy or radiation therapy in the management of epidural cord compression from YST and this approach decreases the incidence of severe spinal deformities or instability after laminectomy. It is worth noting that patients who have recent neurologic dysfunction or show rapidly progressive neurologic deficits should be indications for neurosurgical decompression. Neurosurgical decompression was performed if paraplegia had evolved within 72 hours of presentation or if neurologic deterioration occurred while undergoing observation during a 12-hour period.In patients with YST, the cumulative high-dose chemotherapy with bleomycin, etoposide and cisplatin regimen resulted in excellent overall survival and did not seem to impair ovarian function. think whether irradiation should be performed before or after several courses of chemotherapy is a matter for discussion. Initial irradiation often causes severe myelosuppression and would thus reduce the strength of subsequent intensive chemotherapy. As a result of the complete removal of tumors, we did not carry out radiotherapy.Mukasa et al4In conclusion, YST should be considered in the range of children with thoracic dumb-bell tumor presenting with spinal cord compression. CT and MRI are the first selected imaging examinations for the diagnosis of these tumors. Needle biopsy is valuable for preoperative diagnosis and design of the treatment strategy. Radical resection of the tumor is the key to success. Timely nerve decompression and spinal internal fixation can improve nerve function significantly and reduce the incidence of spinal instability. If there is no evidence of CSF spread, metastasis or multiple diseases, it is effective to remove tumors as thoroughly as possible immediately, avoid further nerve injury and conduct enough chemotherapy.Conceptualization: Jianmin Li.Investigation: Zhaorui Lv, Qiang Yang.Methodology: Jianmin Li.Resources: Zhenfeng Li, Qiang Yang.Supervision: Jianmin Li.Writing – original draft: Zhenfeng Li, Zhaorui Lv.Writing – review & editing: Zhaorui Lv, Jianmin Li.


Tumors of the diaphragm are uncommon. The overwhelming number of cases is metastatic combined with metastases to the liver, lungs and other organs. Only a minority of cases are described as solitary lesions.Fifty-five years old female with a history of radical curative surgery for pT3N0M0 endometrial cancer eight years ago was admitted to the Department of Thoracic Surgery with a feeling of discomfort in the right hypochondrium. The contrast-enhanced MDCT revealed a large, well-circumscribed lesion of the right hemidiaphragm deforming upper contour of the liver. A clear boundary between the lesion and the liver suggested former’s diaphragmatic origin. PET-CT did not show any distant metastasis. Intraoperative revision revealed a tumor growing from the dome of the diaphragm with well-defined contours and without any signs of lung involvement. The diaphragmotomy was performed. The morphological study with immunohistochemistry showed an endometrial carcinoma metastasis to the diaphragm.The diaphragm lesions can have various etiology, but a probability of tumor metastasis after a previous radical surgery should not be excluded. Preoperative differential diagnostics can be difficult, leaving surgical treatment followed by a pathology study as the most informative diagnostic method of tumor morphology. Secondary malignant tumors of the diaphragm are most often combined with metastases to liver, lungs and other organs . Only a 2Fifty-five years old female was admitted to the Department of Thoracic Surgery in July 2018 with heaviness in the right hypochondrium. In 2010, she underwent radical curative surgery for pT3N0M0 endometrial cancer . Histological examination depicted an endometrial glandular squamous carcinoma with invasion of the uterine myometrium. The adjuvant combined radiation and chemotherapy was as follows: 40 Gy for pelvis, 20 Gy for vaginal stump and three courses of cyclophosphamide, adriamycin, 5-fluorouracil (CAF scheme). Annual check-ups have not shown any signs of relapse for seven years. In May 2018, the patient noted a new dull, nagging pain in the right hypochondrium. Abdominal ultrasound revealed a 22 × 56 mm focal liver lesion in the SVIII. Contrast-enhanced MDCT of the chest and abdomen was performed to clarify lesion’s nature, location, and size. The study revealed a large, well-circumscribed tumor in the SVIII of the liver. Positron emission tomography combined with computed tomography was used to determine the lesion’s metabolic activity and exclude distant metastases. The scan visualized a large, hypermetabolic 11.4 × 13.5 × 10.7 cm lesion of the right hemidiaphragm. We hypothesized that the tumor originates from the diaphragm and invades the right liver lobe, deforming its upper contour in a wavy manner. Computed tomography suggested a clear the boundary between the diaphragmatic tumor and liver in the form of the fatty tissue layer. Post-processing with volume rendering depicted this relationship more vividly .Fig. 1ChGiven the lesion’s size, solitary nature, close contact with the right liver lobe, clear tumor margins without lung involvement, the multidisciplinary team decided to treat the case surgically. The team initiated the video-assisted thoracoscopic surgery procedure with subsequent conversion to the open right lateral thoracotomy through the fifth intercostal space due to lesion’s size. Intraoperative revision revealed a tumor growing from the dome of the diaphragm with clear even contours and without any signs of lung involvement. The diaphragmotomy was performed: the tumor is closely adjacent and connected with the right liver lobe  by loose adhesions without signs of invasion . The tumThe postoperative period was unremarkable. Physiotherapeutic inhalations with antiseptic solutions were performed to prevent postoperative complications. The pleural drainage was removed, and the patient mobilized on the second day. The follow-up chest radiograph was within the normal limits, right hemidiaphragm located at the seventh intercostal space. Therefore, the patient was discharged on the seventh-day post-operation. On the follow-up chest and abdominal contrast-enhanced CT at six months after the operation, there were no signs of recurrence.The morphological study showed that the tumor had been an endometrial carcinoma metastasis to the diaphragm.Immunohistochemistry was as follows:Estrogen receptor  - IS +++, 3 points; PS 40%, 4 points; TS = 7 points; Progesterone receptor  - IS +++, 3 points; PS 40%, 4 points; TS = 7 points .Fig. 5Im3M. Grancher first described a benign diaphragmatic tumor in 1868 at an autopsy . PrimaryIn 2012, 527 600 new cases of endometrial cancer were diagnosed worldwide . MortaliFrom a clinical point of view, the diagnostics and treatment of diaphragmatic tumors are of great interest. Due to the casuistic nature of such lesions, there were no recommendations on preoperative verification and staging of diaphragmatic tumors at the time of writing. In the presented clinical observation, the metastasis manifested eight years after supposedly curative surgery. Despite the medical history and presence of the feeding vessel on computed tomography, it was impossible to exclude a primary malignancy before the operation. We decided to operate the lesion after considering its size, location, growth pattern and the high risk of complications associated with a transthoracic biopsy.4The type of surgical treatment depends on the size and nature of the neoplasm. Plastics with the autogenous tissue or mesh implants after benign tumor resection provides the best results. In the case of an indeterminate diaphragmatic lesion, follow-up may be advisable. Malignant lesions of the diaphragm comprise a separate group. Preoperative differential diagnostics in an isolated tumor can be challenging, leaving surgical treatment followed by a pathology study as the most informative diagnostic method.None.The case report was written without any funding.This is a case report without personal data or personal figures of the patient. Therefore no ethical approval is required.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.I.S. Gruzdev - data curation, writing - original draft, visualization, project administration.I.A. Blokhin - data curation, writing - original draft, visualization.A.N. Lednev - data curation, writing - original draft.A.A. Pechetov - conceptualization, writing - review & editing.Yu.S.  Esakov - writing - review & editing, data curation.M.A. Makov - data curation.A.G.  Arevin - data curation.A.V. Glotov - data curation .G.G. Karmazanovsky - conceptualization, writing - review & editing, project administration, supervision.The case report does not contain data of human studies.Grigory G. Kаrmаzаnovsky.Not commissioned externally peer reviewed.


Tumoral calcinosis is an idiopathic condition resulting in the periarticular deposition of calcium crystals and salts in soft tissues. It is rare in children, and even rarer in idiopathic form. We present a case of a 2-year-old female with tumoral calcinosis in the supraclavicular region, and, in particular, focus on the pertinent radiological findings with radiography, MRI and bone scintigraphy. Remaining full blood count and renal function tests were normal.A Kuwaiti female child, residing and receiving treatment in Kuwait, initially presented aged 20 months with a 6-month history of an enlarging left supraclavicular mass. There was no associated trauma or preceding illness. She was a term baby with an uncomplicated birth. All vaccinations were up to date. There was no family history of malignancy. On examination, she was systemically well. A 5-cm painless, firm mass was palpable in the left supraclavicular fossa. It was fixed to the underlying tissue, but not the overlying skin. There was no overlying erythema. Biochemical testing of the blood showed mildly raised Ca at 2.52 mol lThe differential diagnosis suspected in this case was a neoplastic process originating from bone or soft tissue.Initial neck ultrasound demonstrated a large, complex, densely calcified left supraclavicular mass. Subsequent plain radiography showed a 4-cm lobulated, heterogeneously calcified mass .T1, T2 and short tau inversion-recovery signal mass in the left retroclavicular region (99mTc) revealed avid uptake in the mass, with normal uptake in the remaining skeleton , and are seen more in JAfro-Caribbeans and males. Biochemistry Jreveals an elevated serum phosphorus, normal Jserum calcium and normal parathyroid Jhormone assay. Up to one-third of cases are thoughtJ to be familial.4 have also been described.Secondary tumoral calcinosis. These cases are secondary to conditions such as chronic renal failure with secondary hyperparathyroidism, hypervitaminosis D, milk-alkali syndrome and bone destruction. Engelmann disease , Down’s syndrome and even Turner’s syndrome5
The differential diagnosis includes neoplasia originating from bone or soft tissue. It is therefore imperative to correlate the laboratory and radiological findings with the clinical assessment. Other conditions that can cause localized soft tissue calcification include heterotopic ossification (myositis ossificans), calcified haemangioma or lymphatic malformation, teratoma, parosteal osteosarcoma and soft-tissue sarcomas, chronic renal failure, calcinosis universalis, hypervitaminosis D, milk-alkali syndrome and calcinosis circumscripta.6 Surgical excision is typically curative in children, but not usually in adults.The classical pathological findings at surgery include a "chalky" fluid extruded from pseudocapsules.7 published an early paper outlining the radiological features of tumoral calcinosis, with more recent case reports having similar findings. On plain radiography, an amorphous, cystic, multilobulated para-articular mass, commonly on the extensor surfaces, is often demonstrated.9 A fluid–fluid level correlating with cystic components of the mass can also be seen. CT findings are similar to that of plain radiography, but with more clarity to the lesion. Cystic components may show a layer of calcium within them, which is known as the "sedimentation sign".6 discussed their radiological findings in a 16-month-old female with a mass along the scapular border. The MRI findings showed that the soft-tissue component was isointense to skeletal muscle on T1 weighted imaging, but heterogeneously hyperintense on T2 weighted imaging with multiple hypointense areas correlating with areas of calcium and fluid–fluid levels. Post contrast, the mass heterogeneously enhanced.6 In general, the lesions tend to be either (a) diffuse low T1 and T2 signal or (b) mixed high signal T2 with signal voids and low T1.8
Martinez et al7 Guveli et al2 describe in their case report heterogeneous uptake of 99mTc tracer into tumoral calcinosis in the lower limbs of a 28-year-old female. It is well recognized that tumoral calcinosis behaves differently in adults and is more likely to recur following excision, as in the case described.2 There are, however, only a few cases in the literature that describe such findings in the paediatric population.10
Bone scintigraphy has shown avid uptake of tracer in some of these lesions in adults.Our case describes the radiographic, MRI and bone scintigraphy findings of an unusual case of tumoral calcinosis in a child. Despite the rarity of this condition, it should be considered when encountering a calcified soft-tissue mass in all paediatric age groups. Its radiographic features have been described here and can aid in making a confident diagnosis.Idiopathic tumoral calcinosis is a rare condition in children, which most commonly affects large joints, typically the hips, pelvis, elbows and shoulders.On plain radiography, the typical findings are those of a cystic, multilobulated, para-articular calcified mass.T1 and T2 signal or mixed high signal T2 with signal voids and low T1.On MRI, lesions tend to be either diffuse low On bone scintigraphy, we have demonstrated avid tracer uptake.


After removal of a dental implant or extraction of a tooth in the upper jaw, the closure of an oroantral fistula (OAF) or oroantral communication (OAC) can be a difficult problem confronting the dentist and surgeon working in the oral and maxillofacial region. Oroantral communication (OAC) acts as a pathological pathway for bacteria and can cause infection of the antrum, which further obstructs the healing process as it is an unnatural communication between the oral cavity and the maxillary sinus. There are different ways to perform the surgical closure of the OAC. The decision-making in closure of oroantral communication and fistula is influenced by many factors. Consequently, it requires a combination of knowledge, experience, and information gathering. Previous narrative research has focused on assessments and comparisons of various surgical techniques for the closure of OAC/OAF. Thus, the decision-making process has not yet been described comprehensively.The present study aims to illustrate all the factors that have to be considered in the management of OACs and OAFs that determine optimal treatment. Oroantral communication (OAC) acts as a pathological pathway for bacteria and can cause infection of the antrum, which further obstructs the healing process as it is an unnatural communication between the oral cavity and the maxillary sinus. The oroantral fistula (OAF) develops if the OAC remains open and becomes epithelialized. The oroantral fistula has its origin either from iatrogenic complications or from dental infections, trauma, radiation therapy, or osteomyelitis .Clinical decision-making determines the optimal strategy in a particular clinical situation. Consequently, it requires a combination of knowledge, experience, and information gathering. Previous narrative research has focused on assessments and comparisons of various surgical techniques for closure of OAC/OAF . Thus, tClinical decision-making in closure of an OAC/OAF depends on multiple factors that include the size of the communication, time of diagnosis, presence of infection, and clinician’s experience. Moreover, the selection of management strategy is influenced by the quantity and quality of tissue available for closure of OAF/OAC and the potential placement of dental implants in the future . The metIdentifying the etiology of the OAC is essential to create an effective procedure. Harrison demonstrated that the bone lamella between the maxillary posterior teeth and the maxillary sinus is occasionally 0.5 mm . Thus, tMedical history serves to identify patients who have a higher risk to develop complications during or after closure of OAC. Cardiovascular disease, diabetes, renal dysfunction, and hematological disorders may increase the risk of complications such as bleeding, infections, and delayed tissue healing .The symptoms of an OAC can vary from purulent discharge through the fistula to the patient’s subjective feeling entry of oral liquids into the nostril on the same side of the maxillary . The preFigure Diagnosis represents the first decision-making about the patient. It determines all subsequent treatments and the course of each patient. It mainly based on a comprehensive evaluation of dental and medical examination and patient history, specifically looking for diagnostic criteria for maxillary sinusitis. Figure The large OAC is easily seen on the investigation Fig. . At a laThe patient is instructed to try to exhale through a blocked nasal airway. However, a negative test does not exclude the possibility of antral perforation. It is worth noting that the detection of small perforations is not always possible .The patient is asked to blow air into the cheeks against a closed mouth. This test is considered a risk of antral complications due to the spread of microorganisms from the oral cavity into the maxillary sinus.Attempt of probing the fistula is likely to result in sinusitis or widening of the fistula due to pushing of foreign bodies or bacteria into the maxillary sinus. . FurtherRadiological investigation of the site of OAC and OAF is required to validate the clinical findings and to investigate the presence of foreign body within the antrum. From an anatomical point of view, several different radiographic investigations are required to show all areas of the antral anatomy well because of the complexity of its anatomy .Radiologically, bone discontinuity of the floor of the maxillary sinus is evident. Patients with OAF are most susceptible to sinus infections. Therefore, radiological investigation of the maxillary sinus is recommended. Periapical film or panoramic radiography can provide an idea about the bony defect size of the OAC and OAF. Radiologically, they reveal the disruption of the border of sinus. Periapical radiograph provides detailed information about the bony radiographic changes owing to its inherent technique quality. Moreover, it confirms the presence and location of the foreign body that may have been dislodged into the antrum , 15. TheComputed tomography (CT) and cone beam computed tomography (CBCT) scans are the gold standard modality of radiological assessment to rule out the presence of maxillary sinusitis . Figure The objective of the management of OAC/OAF is the closure of the defect and prevention of oral bacteria and food debris penetrating the sinus. Oroantral communication can cause sinus contamination leading to infection, impeded healing, and chronic sinusitis . It is pPreoperatively, drainage and irrigation with saline through the OAC of the affected maxillary sinus should be achieved in cases with sinus infection and degenerated mucosa . This prAdditionally, the use of appropriate antibiotics is necessary prior to surgery.The size of the OAC and opening duration are crucial prognosis factors in treatment. However, primary suturing the gingiva with a figure-of-eight suture closes the communication effectively. When this does not provide adequate closure, a soft tissue closure using a buccal or palatal flap is indicated . It is aPrior to surgical treatment of oroantral communication, a previous diagnostic is achieved to exclude the presence of a foreign body and/or inflammatory changes of the mucous membrane . It is oIn case of fully developed fistulae, excision of the fistulous epithelial tract must be achieved, mucosa should be debrided up to the well-perfused tissue, and the infected bony structures should be curetted .Many techniques have been described for the closure of oroantral fistula, including local and soft tissue flaps. Other techniques include grafts, allogenous, xenografts, alloplastic materials, and other methods like guided tissue regeneration (GTR) or immediate implantation of a dental implant Fig.  Table 11.Fig. 8DA rational decision-making process has to be followed for the closure of OAC/OAF rather than randomly practicing the available technique. Clinically, the well-perfused flap demonstrates a wider base and is well vascularized. The site of anastomosis should be free of tension and situated over the intact alveolar bone leaving at least 5 mm from the margin of fistula .Local buccal soft tissue flaps are often indicated in the closure of small to moderate size defects . It wortBorgonovo et al. proposed the use of the buccal flap for the closure of oroantral fistulae of moderate size, provided that not too posteriorly located; the palatal flap is best used in the case of fistulae located in the premolar teeth area; and the buccal flap combined with displacement of the buccal fat pad (BFP) is appropriate for fistulae located in the third molar area . IdeallyGiven the limitations of local flaps option for closure OAF, distant flaps and bone grafts can be used with success in the closure of large defects or in cases where local flaps have failed .Application of alloplastic, biological material, or immediate implantation for the closure of OAC is usually indicated in the closer of OAC with a diameter of 3–4 mm provided that the maxillary sinus is uninfected or no foreign body is within the antrum , 23.Among the various synthetic materials, Bio-Oss-Bio-Gide Sandwich technique has yielded excellent results for OAF closure. The technique achieves both bony and soft tissue closure, by contrast with only soft tissue closure obtained by local flaps . CollageThe failure rate of closure of large oroantral fistulas increases owing to the large defect in the underlying bone that supports the overlying flap . Many teConsidering autogenous bone grafts as the technique of choice for closure large OAF, donor site morbidity, anatomic and structural problems, and increased level of bone resorption during healing should be borne in mind . HoweverIt is recommended to use resorbable guided tissue regeneration membrane when endosseous implant with bone graft is considered . More reFurthermore, single-stage alveolar augmentation with autogenous bone graft and platelet-rich fibrin (PRF) has found its application as a non-invasive contemporary technique for the closure of OAF , 36.Non-surgical closure of OAC with absorbable polyglactin/polydioxanon implant can be applied in higher risk patients with blood disorders . MoreoveOral care, a diet of soft foods, analgesics ) and nasal decongestants are recommended postoperatively. Further, nose blowing, sneezing with a closed mouth, and vigorous sports should be avoided .To the authors’ knowledge, decision-making in the closure of OAC and OAF has not been previously reported. With the above mentioned steps, it is possible to close an oroantral communication or fistula by different techniques with particular emphasis on choosing the most relevant technique. A comprehensive clinical and radiographic examination and consideration of the patient history serve to assess the severity of the OAC and the patient’s treatment needs. The criteria of severity of closure of OAF include the size, time of diagnosis of OAF, improper treatment of sinus infection preoperatively, epithelialization of the fistulous tract, and excessive tension on the flap impeding blood supply for healing . Technic


Peritoneal mesothelioma is a rare abdominal disease; that occasionally occurs congenitally in younger calves. Cytologic examination of peritoneal effusion (PE) was utilized to diagnose this disease, and was not diagnostic. Diagnostic accuracy has been elevated by recent use of ultrasonography (US), despite most diagnoses have been obtained post-mortem in slaughter houses or during clinical necropsy. In humans, ante-mortem diagnosis is highly associated with clinical use of computed tomography (CT) and laparoscopy together with imaging-assisted biopsy. The present report evaluates the diagnostic applicability of CT and laparoscopy as well as US via the practical application of these imaging modalities in an affected calf, and compares the cytologic and histologic findings among in PE, and specimens obtained from fine-needle aspiration and core-needle biopsy. In addition, the present results were reviewed in comparison with those of previous bovine and human reports.A 58-day-old male Japanese black calf presented first with scrotal swelling, followed by progressive abdominal distention. Abnormalities of the case included: 1) accumulation of anechoic PE inside the swollen scrotum and abdomen; 2) formation of multiple echogenic nodules within the peritoneal membrane based on US images; 3) presence of hyper-dense spots  along the margins of the nodules; 4) anatomic connections between intra-abdominal nodular lesions and the swollen tunica vaginalis via the inguinal region based on CT images; 5) serosanguineous-colored and less-turbid characteristics of PE; and 6) formation of multiple nodules over all of the serosa of the rumen as well as the peritoneal wall based on laparoscopic views. Fine-needle aspiration and core-needle biopsy were successfully performed under US and laparoscopic observations, respectively. Histology findings of the core-needle biopsy specimen appeared more indicative  diagnostically of peritoneal mesothelioma than did findings of the fine-needle aspiration specimen.To the best of our knowledge, this report is the first description of clinical applications of CT and laparoscopy to diagnose peritoneal mesothelioma in a calf. Laparoscopy enhanced the diagnostic accuracy due to clear gross visualization of the intra-abdominal abnormalities and applicability to imaging-guided core-needle biopsy. Stenström first described peritoneal mesothelioma in a 3-day-old calf in 1921 , and theAccumulation of peritoneal effusion (PE) is a common clinical sign of peritoneal mesothelioma in bovines , 9, 11. A 58-day-old male Japanese black calf showed sudden loss of appetite. Body temperature was recorded as 40.8 °C, and both scrotal sacs were enlarged and felt soft upon palpation, initially causing suspicion of orchitis. The elevated body temperature and decreased appetite normalized following daily injections of a non-steroidal anti-inflammatory drug and antibiotic for 3 days. However, the calf showed progressive scrotal enlargement and abdominal distension; the anorexia resumed after the daily injections were discontinued. On day 18, the calf was admitted for imaging examinations.On day 18, a complete blood count revealed a slight elevation of the red blood cell (RBC) count and thrombocytosis, but normal white blood cell (WBC) count  was applied to the swollen scrotum using a 6.6 MHz convex probe, and the abdomen a using a 6.0 MHz linear probe in a standing position. Transverse trans-scrotal US imaging revealed accumulation of anechoic effusion in the space between the scrotal wall and the testicles, which appeared round in imaging Fig. a. The tuThe PE was clear and serosanguineous. The PE WBC level was low, and the LDH level was high Table  21]. Th. Th21]. The animal was placed in a right recumbent position under general anesthesia with 2–3% isoflurane via an endotracheal tube, inserted after sedation with an intravenous injection of xylazine hydrochloride (0.2 mg/kg). CT examination using a helical scanner  revealed accumulation of PE throughout the abdominal cavity. Dense assemblages of enlarged nodules were predominantly seen in the caudal abdominal cavity and connected to the swollen tunica vaginalis via the inguinal region on sagittal images  was performed with the animal in a supine position soon after CT examination (under the same anesthesia). After removal of approximately 20 l of PE via catheter in order to ensure a wider laparoscopic field of view, a 10 mm trocar was introduced approximately 10 cm from the lower right part of the umbilicus. Laparoscopic views of the cranial abdominal cavity revealed multiple nodules throughout the serosa of the rumen Fig. a. The noThe animal was died suddenly 1 day after these examinations. Necropsy revealed that numerous (more than 100) nodular lesions were found on the peritoneum with bloody PE in the abdominal cavity Fig. a. The noThe pieces of tissues obtained from the laparoscopy-guided core-needle biopsy and the masses collected at necropsy were fixed in formalin and routinely processed for paraffin embedding, then stained by hematoxylin and eosin (HE) stain. Microscopic examination revealed the proliferation of cubical or columnar neoplastic cells in the nodule. These cells were aligned and formed papillary structures Fig. c,d. FurtMalignant mesotheliomas generally have a poor prognosis in bovine cases affecting at any anatomical place, because of the extensive invasion, and poor response to various treatments, with the exception of previous therapeutic success using unilateral orchiectomy for two bulls with localized involvements . Thus, tUS was used as an imaging modality for the ante-mortem diagnosis of mesothelioma in cattle –9. PreviCT is commonly used in humans for the diagnosis of peritoneal mesothelioma because of the characteristic CT findings and usefulness of contrast media –15, 17, CT is utilized to evaluate prognosis in humans based on the invasion of lesions into the intra-parenchymal layers of organs and extension of lesions throughout multiple body cavities via the involved lymph nodes and ducts , 18. TheLaparoscopy is applied in approximately half of human patients with peritoneal mesothelioma, providing high diagnostic accuracy , 17–19. Laparoscopy was applied to abomasopexy around 2000 and to biopsy involving the abdomen around 2010 in bovine medicine , 29. TheIn the cytological examinations, ultrasound-guided fine-needle aspiration might allow collection of a larger amount of abnormal tissue compared to a fragment exfoliated into PE. However, the cytology of these two specimens was of minimal value for the definitive diagnosis of peritoneal mesothelioma, as expected. PE cytology can provide evidence of atypia and hyperchromasia of mesothelial cells, consistent with reactive mesothelial cell proliferation, but this is non-diagnostic , 19; it In cattle, desquamated mesothelial cells are normally seen in PE, and frequently cannot be differentiated from abnormal mesothelial cells . The celHistology of the necropsy specimen in the present case could contribute to a definitive diagnosis of peritoneal mesothelioma together with immunohistochemistory, in which the neoplastic cells were positive for both epithelial and mesenchymal marker intermediate filaments (cytokeratin and vimentin) , 30 In b


Solitary fibrous tumor are rare and benign, soft tissue growth of any part of the human body including orbit and eyes. This case report describes a middle age female presented with a slow-growing painless mass in the superior orbital sulcus in the left eye. The lesion was surgically excised revealing the microscopic features characteristic of solitary fibrous tumor, with immunohistochemically reactivity for CD34 and STAT6 stains. Solitary fibrous tumor (SFT) is typically cured with complete surgical excision and CD34 immunohistochemistry proved to be a useful adjunct to the microscopic diagnosis of this type of tumor. Solitary fibrous tumor (SFT), a benign mesenchymal fibroblast-like tumor, was first described as a primary mesothelial spindle-cell tumor of the pleura in 1931 by Klemperer and Rabin.A 32 years old married female, stay at home mother, reported in orbit oculoplastic clinic of eye ward of our tertiary care center with a chief complain of painless mass with swelling in left lateral portion of upper eyelid for one year . The masWe decided to go for an excision biopsy under local anesthesia with all the pre-operative assessments completed. Upon surgical excision, measuring approximately 1.5 x 1.3 x 0.5 cm in maximum diameter a deep reddish brown, nodular tissue with no well-defined margins, adherent to palpebral conjunctiva was identified. However, blood vessels near the mass found moderate to severe engorged and tortuous. Complete excision of the growth carried out and no local invasion or extension was assured . SubsequMicroscopic examination revealed spindle cell lesion composed of cells arranged in a storiform pattern with variable areas of congested blood vessels. Individual cells showed scanty cytoplasm with spindle shaped nuclei, whereas scattered multinucleated lesional cells were also present. Moreover, cells showed positivity for CD34 and STAT6 immunohistichemical stains.SFT is a rare, mostly benign, nevertheless can transform into malignant, and slowly progressive spindle cell tumor originating from mesenchymal fibroblast-like cells.4With the ongoing research and advanced staining techniques more cases of orbital solitary fibrous tumor are being diagnosed and reported. SFTs can affect any orbital space including lids, lacrimal gland fossa, lacrimal sacs, conjunctivae, and sclera.5On radiological imaging, solitary fibrous tumor usually presents as an isolated soft tissue mass with a smooth, well-circumscribed surface. CT scan will usually show a well-defined soft tissue mass with heterogeneously or homogenously strong enhancement. The MRI findings of SFT describe the mass lesion as isointense or hypointense to gray matter in a T1-weighted image. In a T2-weighted image, the lesion shows hypointensity, hyperintensity, or variegated intensity. When gadolinium is used as contrast, the lesion shows homogeneous enhancement.6The classic histopathological feature of SFT is the presence of spindle cells growing in a haphazard manner in a variable cellular stroma described as “pattern less pattern” or keloid-like hyalinization. Other features are thick bands of collagen interspersed between the tumor cells, alternating hypo-.and hyper-cellular areas, branching thin walled vessels of varying caliber and “staghorn” vascular pattern, similar to Hemangiomapericytoma.3Before the widespread use of immunohistochemical studies and CD34 labelling, the diagnosis of orbital and periorbital SFT based solely on the histopathological findings was confused with other benign lesions, such as fibrous histiocytoma and hemangiopericytoma [HPC]. SFT as an entity is rarely diagnosed clinically.1Immunohistochemical studies show SFTs have strong and diffuse positivity to CD34, vimentin, bcl-2 and STAT6. Among them, SFTs possess strong sensitivity and specificity towards STAT6.9STAT6 immunohistochemistry was recently established as a reliable method to detect solitary fibrous tumor. Multiple researchers have reported the sensitivity and specificity of STAT6 expression in SFTs and its histopathologic mimickers. In one study the immunoreactivity of 10 SFTs was checked for various markers including CD34 and STAT6. All ten SFTs were CD34 positive, while all other previously performed immunohistochemical stains were unreactive. STAT6 antibody nuclear reactivity was diffusely strong for 9/10 cases, while one case exhibited weak and focal nuclear reactivity.Eyelid SFT appears to be very rare and so far very few other cases in the HPC-SFT spectrum have been described in the literatures. Previous reports of eyelid lesions from SFT appears to be eyelid extensions or coexisting eyelid symptoms affected by a primary orbital lesion. Most of SFTs behave in a benign fashion, but a local invasion, and recurrences usually follows an incomplete initial excision.The mainstay of treatment of SFTs is surgical resection with long-term follow-up. In general, SFTs represent a benign disease, and most cases have been treated by local excision. Complete surgical resection is critical to diagnose, treat and prevent recurrence and progressionThere have been a very few reported cases of primary SFT of the eyelid, so the information concerning etiologic factors, treatment and prognosis is limited and new additions to the literature may prove useful.Solitary fibrous tumors are rare tumors of mesenchymal origin for which positive staining for CD34 is the most specific diagnostic test. They generally follow a benign course and their definite treatment is complete surgical excision. In our case the lesion was causing mechanical ptosis and complete surgical excision resulted in good functional and cosmetic outcome.NH: Received the patient, did all examination and performed surgery. Conceived, designed, critical review and final approval.MMA: Assisted in surgery, editing of manuscript, data collection and manuscript writing.VD: Helped in treatment prescription and surgery.


BRAF) gene, resulting in activation of a downstream signaling pathway and cancer development. Vemurafenib is a BRAF inhibitor used to treat patients with BRAF V600E-mutated cancer. Although a few studies have reported the clinical responses in gangliogliomas, the sequence and duration of treatment have not been established. We describe a case of an adult with a progressive BRAF V600E mutant spinal cord ganglioglioma 9 years after surgery who was treated with vemurafenib. This treatment resulted in a partial response within 2 months, which was sustained for more than a year. The patient then decided to stop treatment because of side effects. Despite this decision, the tumor showed no sign of progression 21 months after treatment discontinuation. This is the first reported case of a response to vemurafenib in an adult with progressive spinal cord BRAF V600E-mutated ganglioglioma which was sustained after treatment discontinuation.Spinal ganglioglioma is a rare low-grade, slow-growing tumor of the central nervous system affecting mostly children and young adults. After surgery, some patients show tumor recurrence and/or malignant transformation. Gangliogliomas harbor molecular deficiencies such as mutations in the B-rapidly accelerated fibrosarcoma ( Ganglioglioma is a neuronal tumor representing 1% of all primary brain tumors and nearly 5% of pediatric and young adult central nervous system tumors. Histologically, ganglioglioma is composed of both neoplastic neuronal cells and neoplastic glial cells. The glial cells contingent includes astrocyte cells with atypia . GanglioTreatment strategies are limited for recurrent disease. Radiotherapy has been indicated for high-grade or incompletely resected low-grade ganglioglioma, but these recommendations are not based on high scientific levels of evidence , 11–15. BRAF is located on chromosome 7 (7q34) and encodes B-raf, a serine/threonine protein kinase that mediates the cellular response to growth signals  of the spine revealed a suspicious lesion within the left spinal cord at the levels of C3–C5. The patient underwent subtotal resection in August 2006. An MRI of the spine 1 month following surgery showed a residual tumor of 27 × 8 mm with strong patchy enhancement following gadolinium administration within the left spinal cord at the level of the bottom of C3 to the top of C5, isointense T1 signal, and heterogeneously hyperintense T2 signal. There was an associated syringomyelia at the rostral and caudal aspects of the enhancing tumor, mostly from C2 to C7. Moreover, T2 hyperintensity was observed in the spinal cord above and below the syringomyelia without associated enhancement .IDH1 R132H) and a loss of chromosome 9p. Despite the presence of an IDH mutation, central pathological review led to the diagnosis of WHO grade I ganglioglioma . The results revealed a V600E BRAF mutation and no mutation in RAS.Molecular testing for evaluation of target therapy was implemented using tissue collected during surgery after obtaining written informed and signed consent. In July 2015, genomic DNA was extracted from the tumor tissue with a QIAamp® DNA mini Kit  for standard direct sequencing of exon 15 of Based on these results, in November 2015, the patient was started on vemurafenib 960 mg orally twice daily [100% of the recommended dose in adults for melanoma ]. This tTwenty-one months after vemurafenib discontinuation in October 2018, MRI and neurological examination showed stable disease  and the BRAF V600E-mutated spinal ganglioglioma successfully treated with vemurafenib as a single agent and with ongoing and prolonged stable residual disease 21 months after vemurafenib discontinuation.To our knowledge, this is the first case of an adult with progressive The first description of ganglioglioma was detected in 1870 by Loretz and further studied in 1926 by Perkins. Ganglioglioma is a rare tumor of the central nervous system accounting for 1–1.5% of all spinal tumors , 40, 41.BRAF mutation-positive ganglioglioma were contrast-positive  who underwent surgical resection, the 5- and 10-year overall survival rates were 89 and 83%, respectively. The spinal cord location was associated with a 3.5-fold increased risk of recurrence compared to cerebral gangliogliomas .The efficacy of chemotherapy for adjuvant or recurrent ganglioglioma is uncertain and remains controversial , with a BRAF V600E mutation suggests that use of BRAF inhibitors are efficient for treating recurrent gangliogliomas. BRAF mutation appears in 8% of human cancers   have been shown to be associated with the d status . However% have bed status –59. IDH  neurons . Howevertations) –65. Occatations) . In contBRAF inhibitor) in low- and high-grade gliomas other than ganglioglioma  and partial response in 50% (10/20) of cases at a median of 3.2 months after starting treatment and the estimated progression-free survival was 14 months. In 12 patients in whom a BRAF inhibitor was administered as a single agent, the response rate was 50% (6/12) . Additionally, 33% (4/12) showed stable disease and 17% (2/12) showed progressive disease. The estimated progression-free survival was 11 months. The median follow-up time after starting treatment was 14.5 months, while this time period was 36 months in our case, including 21 months of stable disease after discontinuation. The present case is remarkable because our patient had spinal ganglioglioma treated with vemurafenib alone and a long follow-up. Interestingly, 2 months after vemurafenib disruption for patient convenience, a moderate (<25%) increase in the size of the contrast enhancement was observed, after which the tumor remained stable in subsequent MRIs. This rapid but not significant regrowth was consistent with the previous report of a “rebound effect” following vemurafenib disruption after protracted exposure to this treatment . Moreover, the association between the BRAF and MEK inhibitor should be studied in a large cohort, as this treatment may have survival benefits in melanoma . Second-generation BRAF and MEK inhibitors are also being evaluated .Treatments after surgery for recurrent or progressive spinal cord melanoma , and enrWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.LG participated in the treatment of the patient, did the literature search, and drafted the manuscript. EC and CV instructed and participated in the treatment of the patient. EC and FD provided critical revisions of the manuscript for important intellectual content. M-IM carefully reviewed the pathological findings. FC carefully reviewed the radiology findings. AP carefully reviewed the surgical findings. All authors read and approved the final manuscript.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.


In less than three months, two middle-aged women – 51 Figure  years olThe typical radiological features of infarction and/or torsion of the greater omentum and epiploic appendages have been extensively reported during the last two decades. Similar imaging findings have also been more recently sporadically reported, including infarction and/or torsion of other peritoneum-covered lipomatous components of the gastrohepatic (lesser omentum), gastro-splenic, and falciform ligaments.All these clinical entities have the same clinical acute presentation, etiology, radiological features, prognosis, and treatment. They only differ in their anatomical location or dimensions. The common denominator is fatty tissue necrosis, and for this reason the general term of intra-abdominal focal fatty infarction (IFFI) has been introduced.IFFI of lipomatous appendage of the falciform ligament is by far the rarest type, first radiologically described in 2001 [The double-layered peritoneal falciform ligament starts at the umbilicus and traces back to the liver at the level of the hepatic fissure separating the right and left anatomic hepatic lobes. It contains the ligamentum teres, the obliterated umbilical vein, and a variable quantity of extraperitoneal fat and/or fatty appendages.IFFIs of the falciform ligament typically present with acute epigastric and/or right upper quadrant pain with or without constitutional symptoms and closely mimic other common gastroduodenal or bilio-pancreatic diseases comprising cholecystitis.The sonographic diagnosis may reveal difficult in obese patients. It is merely useful to exclude cholecystitis.CT classically demonstrates an area of fat density with a thin peripheral rim of hyper attenuation and with or without the classical “central dot” corresponding to the thrombosed vein. CT also clearly identify the vicinity of the ligamentum teres making unambiguous the diagnosis of IFFI of appendage of falciform ligament that allows a conservative treatment in the vast majority of cases.


A spontaneous rupture of the spleen is a rare but critical diagnosis of an acute abdomen, which may accompany unspecific symptoms mimicking acute pancreatitis, rupture of aortic aneurism, or acute coronary syndrome, delaying diagnosis and treatment. In patients that have experienced a severe spleen rupture, hypovolemic shock may cause catastrophic clinical outcomes. Therefore, early diagnosis is very important in order for physicians to declare the etiology for prevention and timely correction of the shock status. Several causes of spontaneous splenic rupture have been reported, including infection, vasculitis, pancreatitis, or hematological malignancies. Acute lymphoblastic leukemia (ALL) remains a rare but important cause of non-traumatic splenic rupture that physicians are required to assess for. Here, we describe a case presenting an acute abdomen due to spontaneous spleen rupture as the first manifestation. The purpose of this case report was to highlight the importance of considering spontaneous ruptures of the spleen as a rare but critical differential diagnosis of an acute abdomen, especially in patients with acute lymphoblastic leukemia. Spontaneous splenic ruptures are a rare clinical phenomenon that may lead to hemodynamic instability due to hypovolemic shock, and may also be difficult to diagnose as a first manifestation in an emergency department . The incA 23-year-old male was transferred to our emergency department from a different hospital presenting sudden onset progressive abdominal pain. He was suffering from intermittent fever and progressive abdominal pain for 1 day. He confirmed that he had not undergone any traumatic injury recently. There were no other accompanying symptoms, such as nausea, vomiting, diarrhea, tarry stool, or bloody stool. His pain was localized in the epigastric area without radiation to the back or left shoulder. On admission, his temperature was 36.7 °C, blood pressure was 102/86 mmHg, and heart rate was 98 beats/min. A physical examination revealed a soft abdomen without any ecchymosis, Cullen’s, or Grey Turner’s signs. There was no local tenderness, muscle guarding, Murphy’s sign, or McBurney’s point tenderness. The laboratory test revealed severe leukocytosis, thrombocytopenia, and elevated lactic dehydrogenase (LDH). The detailed laboratory results are listed in The bedside ultrasound revealed much ascites, which confirmed the emergency abdominal contrast enhanced computed tomography (CT) in the previous transfer hospital and showed splenomegaly and splenic rupture with hemoperitoneum . AdequatThe patient was hospitalized in the intensive care unit (ICU) for post-embolization care. There was no progressive abdominal pain. The follow-up abdominal circumference was decreased, which reflected that intra-abdominal bleeding was under control due to a decreased amount of ascites . The folSpontaneous splenic rupture is a rare but devastating etiology of an acute abdomen in ALL patients. In a review by P. Renzulli et al. , the autThe detailed mechanism of pathologic splenic rupture in hematological disorders remains unclear. Two major theories have been reported to explain the pathophysiology of spontaneous splenic ruptures in acute lymphoblastic leukemia. One theory demonstrates that the splenic structure is destroyed by the severe infiltration of malignant cells. The direct infiltration leads to overloading the organ beyond its capability of compensation and expansion, which may potentially promote a rupture of the splenic capsule. Infiltration of malignant cells also causes progressive splenomegaly with a potential risk of splenic rupture due to accidental trauma. Another theory promotes that the rapid expansion of the organ causes insufficient blood supply, which may lead to local infarction, and the infarction site may become a weak point ,12,13. IThe diagnosis of splenic rupture must be considered in all ALL patients who presented with sudden onset left upper abdominal pain, a persistent hemodynamic unstable condition, or acute anemia . However


Appendiceal intussusception is very rare condition with an estimated incidence of 0.01%. Therefore, it is likely to be overlooked. In addition, making the diagnosis before or during surgery is very difficult.A 60-year-old male who was referred to our gastroenterology center with cecal inflammation found during a colonoscopy. An abdominal computed tomography (CT) following endoscopy revealed a 5 × 2.5 × 4 cm mass-like lesion in the cecum around the ileocolic (IC) valve and appendiceal orifice. The main lesion seemed to be an inflammatory mass rather than a malignancy because it appeared to be an extraluminal or extramucosal lesion. Ultrasonography revealed diffuse wall thickening of the cecum around the appendiceal orifice that was suspicious for an inflammatory mass or a benign mass. A diagnosis was uncertain. The differential diagnosis included chronic appendicitis, appendiceal neoplasm such as appendiceal mucocele, low grade appendiceal mucinous neoplasm. The patient underwent a laparoscopic partial cecectomy. In the surgical field, there was a large mass in the appendiceal orifice. The cecum was partially resected, with care taken to preserve the IC valve. Final histopathological analysis of the surgical specimen revealed an appendiceal intussusception without any mucosal lesion of the appendix. Narrowing of the terminal ileum with a small bowel obstruction and stenosis of the IC valve occurred postoperatively. Therefore, ileocecectomy was performed via a laparoscopic approach. The patient was discharged 11 days after the second surgery without another significant postoperative complication.We report a rare case of appendiceal intussusception that required reoperation due to ileocolic valve stenosis. If the correct diagnosis of appendiceal intussusception is made, we can select an appropriate surgical treatment based on the classification of appendiceal intussusceptions. The appendiceal diseases that require surgery are mostly appendicitis or appendiceal neoplasms, such as appendiceal mucoceles. Appendiceal intussusception is quite rare and is likely to be overlooked . The incA 60-year-old male was referred to our center with cecal inflammation found during a screening colonoscopy. He did not complain of any abdominal discomfort, such as pain, nausea, vomiting, and diarrhea. He had no past medical history except surgery for an inguinal hernia. He was afebrile with stable vital signs. On a physical examination, there was no tenderness in the abdomen.Colonoscopy performed at the local clinic revealed a hyperemic inflammatory lesion in the cecum around the appendiceal orifice. Because the lesion felt very hard during the colonoscopic biopsy, it was likely associated with a long period of inflammation. An abdominal CT performed after the colonoscopy in the clinic revealed a 5 × 2.5 × 4 cm mass-like lesion in the cecum around the ileocolic (IC) valve and appendiceal orifice; it had heterogenous enhancement and an ovoid calcification (8 mm) at its center, which was suspected to be an appendicolith Fig. . The lesThe patient underwent laparoscopic partial cecectomy. In the surgical field, there was a large mass in the appendiceal orifice Fig. . There dAppendiceal intussusception is very rare. Since the first report on the intussusception by McKidd in 1858, the literature on it has been confined to a few case reports and small cases series . In partUltrasonography plays an important role as a diagnostic method for appendiceal intussusceptions in children , 7. AbdoIf the intussusception is misdiagnosed as an appendiceal neoplasm before or during surgery, such as this case, treatment is performed as if the lesion is an appendiceal neoplasm. This is because we need to check first if it is malignant. Therefore, it is important to remove the suspicious part of the tumor and perform an accurate pathologic examination. An appendectomy can be performed if the lesion can be resected completely. A partial cecectomy should be performed if clear resection margins cannot be achieved because the mass lesion involves the cecum . If the However, the possibility of stenosis is sometimes ambiguous as in the present case. If open surgery is performed, the diameter and preservation of the IC valve can be confirmed with fingers. However, this is technically limited in laparoscopic surgery. Here, we can consider two methods. First, the angle between the resection line and the IC valve can be checked, regardless of whether the distance between them is sufficient. On the contrary, if the cecum should be resected close to the ileocecal valve because of close proximity of the mass, the angle between the resection line and the ileocecal valve could be meaningful. This does not pose any problems if the predicted angle is > 90°. However, partial cecectomy at an angle of < 45° might confer a risk of stenosis or congestion. The angle was approximately 40° in this case Fig. . FurtherIleocecectomy should be considered if stenosis is suspected. However, if the neoplasm is revealed to have malignant potential in the pathological report, a right hemicolectomy may be considered in the future , 9. TherIf we suspect an appendiceal intussusception before or during surgery, what is the optimal surgery? We can select a surgical procedure based on the classification of appendiceal intussusceptions. Moschcowitz et al. first classified appendiceal intussusceptions, and McSwain expanded the existing classification . ForshalIn conclusion, surgeons and gastroenterologists can perform safe and reliable treatment by considering appendiceal intussusceptions in cases of appendiceal and cecal diseases. An appropriate surgical treatment can be selected on the basis of the classification of appendiceal intussusceptions. If the cecum should be resected close to the ileocecal valve, it is helpful that we check the angle between the resection line and the ileocecal valve, or exam the IC valve on colonoscopy.