Liposarcoma usually occurs in the retroperitoneum and limbs. Liposarcoma of the greater omentum is rare, and most information of such liposarcomas has come from case reports.A 60-year-old woman was found to have an 8-cm intra-abdominal mass (suspected lipoma) by computed tomography. At the age of 63 years, she underwent a medical examination and a mass was palpated in the abdomen. Contrast-enhanced computed tomography and magnetic resonance imaging confirmed the presence of a huge intra-abdominal tumor with the omental artery passing through the mass. The tumor was simply resected. Histopathologically, the tumor was diagnosed as a well-differentiated liposarcoma, and the resection margin was microscopically negative. The patient had developed no recurrence or complications 9 months postoperatively.Liposarcoma of the greater omentum is rare, and differentiation of liposarcoma from other tumors is challenging. Adjuvant therapy has not been established as an effective treatment, and radical (R0) resection of the tumor is recommended. Our case of liposarcoma of the greater omentum was surgically managed with good outcomes.The diagnosis of liposarcoma with a lipomatous tumor is challenging, and resection should be considered for huge intra-abdominal lipomatous tumors. It accounts for approximately 10% of all soft tissue sarcomas, and its peak incidence occurs around the fifth to sixth decades of life . We here2A 60-year-old woman underwent screening blood tests, which revealed a high serum amylase level. Computed tomography (CT) showed an 8- × 8- × 4-cm abdominal mass on the cranial side of the bladder, an intra-abdominal lipoma was suspected and observed .Fig. 1AbThree years later, she underwent a medical examination, and an elastic hard mass with slight tenderness was palpated in the abdomen. She had no abdominal pain, nausea, constipation, or other symptoms. Contrast-enhanced CT and magnetic resonance imaging (MRI) showed a large, well-defined abdominal mass with low attenuation and fat density measuring 20 × 17 × 7 cm. The mass was adjacent to another abnormal region measuring 6 × 6 × 5 cm with septae and a capsule. Contrast-enhanced CT also revealed omental artery involvement in the mass, and an omental tumor was suspected. MRI showed no evidence of invasion to other organs, including the digestive tract, bladder, or great vessels. A liposarcoma  with a lipoma (larger mass) was suspected, and no metastatic lesions were observed a, b. AftIntraoperatively, 20 cm midline incision of the abdominal wall was made. A huge, yellowish soft mass with a dark reddish-gray region adjacent to the mass was found under the abdominal wall without invasion, including colon, intestine, mesentery, abdominal wall, bladder, uterus, and retroperitoneum. After ligation of the feeder vessel originating from the omental artery, existing cranial side of the mass, the mass was resected en bloc a, b. No The resected specimen, which comprised a yellowish mass and reddish-gray region, weighed 3750 g and measured 27 × 20 × 10 cm a, b. HisThe diagnosis was a well-differentiated liposarcoma , and the 5-year overall survival rates were 64.5% vs. 84.5% (P < 0.001), respectively . The proPrimary omental liposarcoma is rare, and De et al.  reviewedLiposarcoma often has different histological components including both benign and malignant areas ,22. The The CT and MRI appearances of a well-differentiated liposarcoma are similar to those of normal fat and other abdominal tumors . A well-4Liposarcoma of the greater omentum is rare, and 19 cases were reviewed. Differentiation of liposarcoma from other tumors is challenging. Adjuvant therapy has not been established as an effective therapy, and radical resection of the tumor is recommended.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This is a case report and it did not require ethical approval from ethics committee. We have got permission from the patient to publish.Written consent to publish this case report was obtained from the patient.Shintaro Hashimoto, Junichi Arai, and Hidetoshi Fukuoka were responsible for the study concept and performed the operation. Masato Nishimuta, Hirofumi Matsumoto, Masashi Muraoka, Masahiro Nakashima, and Hiroyuki Yamaguchi collaborated in the patient’s medical care. Hiroyuki Yamaguchi reviewed the manuscript. All authors approved the final article.Not Applicable.Junichi Arai.Not commissioned, externally peer-reviewed.None.


The sinonasal tract is an area that may be affected by various types of neoplastic lesions with more variety than what is encountered in other parts of the upper airway and food passage.An elderly gentleman of 65 years complained of nose block on both sides for 3 months. On examination, he had firm polypoidal masses arising from the middle meatus and septum on both sides. Computed tomography scan of the sinuses revealed polypoidal mucosal thickening in bilateral sinuses with bilateral concha bullosa. The patient underwent functional endoscopic sinus surgery with the complete excision of the masses from the lateral wall and septum under general anesthesia. The results of the histopathological examination showed inflammatory changes in polypoidal tissues from the right maxillary, bilateral ethmoidal sinuses, and bilateral septal masses. The lesion in the left middle meatus showed the features of respiratory epithelial adenomatoid hamartoma (READ). The case had no evidence of residual or recurrent lesion during 6 months after the surgery.The READ is a rare lesion observed in the sinonasal tract. It is a diagnostic dilemma for clinicians as it can be misdiagnosed as neoplastic lesions, such as inverted papilloma or adenocarcinoma, which would warrant radical surgery or sinonasal polyposis and be treated inadequately. The sinonasal tract is an area that may be affected by various types of neoplastic lesions with more variety than what is encountered in other parts of the upper airway and food passage. The common differential diagnosis of sinonasal mass includes benign lesions, such as sinonasal polyps , papillomas, haemangioma, gliomas, dermoids, inverted papillomas, and malignancies –3.An elderly gentleman of 65 years complained of bilateral nasal block and hyposmia for 3 months. He had no previous complaints suggestive of long-standing sinusitis or allergy. There was no history of epistaxis, ocular symptoms or trauma. The patient was a known hypertensive using regular medications with no other comorbid illness. There was no history of nose surgical treatment or paranasal sinus diseases. No abnormality was observed in the results of routine laboratory investigations. Anterior rhinoscopy showed deviated nasal septum to the right side with polypoidal masses observed in the bilateral nasal cavities arising from middle meatus, and right-side mass was noticed extending inferiorly up to the inferior turbinate. Single sessile mass was observed attached to the septum on each side. The visible part of the mass was firm with smooth surface and nontender and did not bleed on touch on probe test. The resuls of computed tomography (CT) scan of the sinuses revealed polypoidal mucosal thickening in the bilateral middle meatus, sphenoid sinus, and left frontal sinus. There were bilateral conch a bull OSA, bilateral accessory maxillary ostia, and a globular polypoidal mass attached to the left middle turbinate lying in the middle meatus region . The patient was operated to achieve the complete excision of the masses from the lateral wall and septum under general anesthesia. 3 with its base 1.5 cm in length   . No part decade) . Patient decade) . Accordi decade) . Endo R Delbrouck C et al. described a case of READ in the left nasal cavity arising from behind the middle turbinate from the lateral wall and with nasal polyps in the ethmoid sinus . In addith decade of life with hypertension presenting with nonspecific nasal symptoms with no history of long-standing sinusitis or allergic symptoms. In the evaluation through diagnostic nasal endoscopy, there were firm polypoidal masses in the lateral wall and septum anteriorly on both sides, while the masses described in previous studies arose from the posterior aspect of the septum. The results of CT scans of paranasal sinuses showed the features of chronic sinusitis and polypoidal changes in the bilateral middle meatus. During the surgery, these nasal masses were firm, pale, and polypoidal adherent to the surrounding structures. The patient in this case report is an elderly male in the 7How hamartoma develops is still unknown. As READ is sometimes noticed with inflammatory polyps it is speculated that long-standing inflammation can be a cause for that . HistoloOn the contrary, molecular profile showing the presence of mean fractional allelic loss of 31% in READ leads to the suspicion that these lesions may represent benign neoplasias rather than hamartomas. On histology, important features are proliferating and accumulating glands and ducts lined by respiratory epithelium without atypical or metaplastic changes (No particular immunohistochemistry staining is available for READ; however, MIB-1 staining may help differentiate hamartoma from neoplasms because neoplasms have more immunoreaction for MIB-1 than hamartomas (The fact that READ originates posteriorly from septum is in contrast with the polyps, which arise from the lateral walls of nose noted in the present case. Another differentiating feature of the polyps is that READ tends to be firmer than inflammatory polyps, which is referred by clinicians as being unusual for an inflammatory polyp. Other important differential diagnoses include inverted papilloma, nasopharyngeal angiofibroma, and adenocarcinoma among which the latter two need special attention as they warrant radical surgical intervention in contrast to the treatment of hamartoma that is completely excised locally -3. ThereHamartomas and more importantly its subtype READ are extremely rare lesions encountered in the sinonasal tract. Otorhinolaryngologists and pathologists should be aware of this entity as a differential diagnosis of inverted papilloma and adenocarcinoma to avoid misdiagnosing these lesions as actual neoplasia. Thereby subjecting patients to radical operations and misdiagnosing it as chronic sinusitis might lead to suboptimal therapy. The complete local excision of the lesions with histopathological confirmation is important to ensure adequate treatment.


We present a case of a 57-year-old female diagnosed with invasive ductal breast cancer, which was treated and in remission for 12 years. In 2018 she presented a progressive dorsal back pain, which prevented her from performing basic tasks. An MR study was performed and revealed the presence of an extramedullary metastatic sleeve located in the thoracic intradural space. Concomitant multiple small nodular foci were adhering diffusely to the spinal cord, compatible with leptomeningeal metastatic disease. The occurrence of both forms of spread in the spine is uncommon, and its distinction on imaging is of particular importance taking into account the differences in treatment approach and prognosis. With the advent of improved systemic therapies, there has been an increase in the number of long-term survivors of cancer disease, which is particularly relevant in the case of breast cancer. Despite this improvement in survival, there was also an increase in the incidence of late onset metastases, which constitutes a concerning clinical issue and a challenge for current oncology .Intradural neoplasms are located outside the spinal cord but within the dural sheath. The growth of these masses can cause spinal cord compression related symptoms, thus representing a significant cause of morbidity.The leptomeninges, on the other hand, are a rare location for metastases , occurriWe present a case of a 44-year-old female patient diagnosed in 2006 with a bifocal invasive ductal breast cancer, HER-2 positive, who underwent mastectomy, chemotherapy, and radiotherapy. The patient was in remission and was under tamoxifen for five years. Twelve years after the initial diagnosis, she developed debilitating dorsal pain, and an MR of the spine was performed.The study revealed signs of diffuse medullary metastatic disease, assuming a sleeve-like appearance in the dorsal segment , fillingGiven the described findings and symptoms, radiotherapy (RT) treatment (30Gy) was delivered, being successful in the reduction of the volume of the metastatic sleeve at the thoracic level. As a consequence there was a partial improvement in the symptoms and reduction of the analgesic drug dose for eight months now. The patient is currently under surveillance and is also being consulted in a pain management unit. Hormonotherapy, consisting of anastrozole, an aromatase inhibitor, was also prescribed.Central nervous system (CNS) metastasis occurs quite frequently in cases of primary breast cancer. In the CNS, the cerebral parenchyma stands out as being the most frequent localization of metastatic disease. The average life expectancy in these patients is reduced to 9 months on average, with an estimated one-year survival of 20%. [The long period between the initial diagnosis and the appearance of the dural and leptomeningeal disease makes this case an uncommon occurrence. According to literature, the median time for the onset of leptomeningeal spread is 18 months . In the Literature tends to separate leptomeningeal from the dural metastases incidence. The true incidence of occurrence of both at the same time is challenging to define and the published articles that address the issue are scarce. A study, by Rumana et al.,  focused Studies have shown that spinal dural and leptomeningeal spread should be regarded as different forms of disease, each carrying a different prognosis . The mecIn breast cancer, leptomeningeal spread occurs most often with triple negative and lobular tumor subtypes . In thisTreatment may differ for each of the entities: in the case of dural metastasis, surgery may be indicated in selected cases. Radiation therapy, in the case of spinal cord compression and/or nonresectable disease, should be regarded as a valid option , 10. In Although CSF culture makes the definite diagnosis of leptomeningeal spread, this was not performed in this particular case given the very suggestive findings on MR. According to literature, an abnormal MR study is sufficient to reach the diagnosis of leptomeningeal metastases when the clinical context suggests that possibility even if CSF cytological results are negative. . Also noNeuroimaging played a crucial role in the case of this patient by depicting both the dural and leptomeningeal components of the disease. MR, including gadolinium-enhanced T1-weighted sequences, using at least 1.5T field strength, is considered the gold standard for the comprehensive neuroradiological assessment of patients with suspected leptomeningeal disease spread , 12.Both types of lesions depicted avid contrast enhancement, reflecting their vascular nature and lack of a blood-brain barrier . The extThe case we present had the complexity of both a compressive symptomatic dural mass and leptomeningeal disease being present at the same time which brought difficulties in the treatment. The approach, in this case, was to tackle the acute dorsal symptoms the patient was dealing with and radiation therapy was delivered to debulk the dural thoracic metastatic mass, with a moderate improvement in the symptoms after treatment. The role of RT in the palliation of bone metastases is well established. When compared to other primary solid tumors, patients with breast cancer tend to have a better response to radiotherapy when it comes to compressive symptoms and duration of remission .The tumor board has regarded the possibility of intrathecal chemotherapy but the fact that the patient had a dural mass causing spinal cord compression made the debulking a priority. Intrathecal chemotherapy would mostly tackle the leptomeningeal component and not the dural mass . Most seProlonged back pain with no apparent relief factor in a patient with a history of oncologic disease should alert the clinician to the possibility of metastatic spinal spread no matter how much time has passed since the initial diagnosis, and imaging should not be stalled in these cases.MR with visualization of the entire spine is the examination of choice, and it will likely reveal or exclude the possibility of metastatic disease. The simultaneous presence of pachy and leptomeningeal metastases is uncommon and indicative of poor prognosis. The clear distinction between both is essential concerning patient orientation and treatment.


Primary melanomas of the female genital tract are rare and usually occur in the vulva and vagina. Involvement of the cervix, uterus, and ovary are extremely rare. Surgery and adjuvant therapy remain the mainstay of treatment. The majority of patients experience poor long-term survival. This report aimed at highlighting an extremely rare case of primary melanoma of the female genitalia, synchronously involving the vulva and uterine cervix.A 58-year-old multiparous female presented with postmenopausal bleeding for 10 days.Speculum examination and histologic analysis of the surgical specimens revealed synchronous involvement of the vulva and uterine cervix by malignant melanoma. According to the American Joint Committee on Cancer stage grouping for melanoma, this tumor was at stage V.The patient subsequently underwent radical surgery and postoperative chemotherapy.She has been on regular follow-up, and is now free of disease for 50 months after the operation.Primary melanomas of the female genital tract have biologically aggressive characteristics. Optimal management consists of individualized surgery and adjuvant therapy. However, early recognition and prompt intervention offer maximal benefit from treatment. Involvement of the cervix, uterus, and ovary is extremely rare. MM commonly presents at advanced stages. The diagnosis is confirmed by histologic examination using specific staining techniques and immunohistochemical analyses. Since more radical approaches do not improve survival, limited surgery has become the trend for optimal management.,2 Ancillary therapeutic strategies include immunotherapy, chemotherapy, and biochemotherapy. In general, the majority of patients exhibit poor long-term survival. This report describes a rare case of primary MM of the female genital tract synchronously involving the vulva and uterine cervix.Primary malignant melanomas (MMs) of the female genital tract are rare, comprising 3% to 7% of all mucosal melanomas.2A 58-year-old multiparous female visited her local hospital with a complaint of postmenopausal bleeding for 10 days. Her past and family medical histories were uneventful. She had no personal history of vaginal discharge or postcoital bleeding. In her local hospital, gynecologic examination revealed a gray-white irregular mass on the right labia minora. At the local hospital, a biopsy was taken from the mass, which measured 2.5 × 1.5 cm. Histologic examination indicated the possibility of a primary melanoma of the vulva. For further treatment, the patient was admitted to our hospital. Immunohistochemical analysis revealed that the tumor cells were strongly positive for HMB-45 and SM-100 protein, and negative for cytokeratin  staging system still appears to be applicable to primary melanomas of the uterine cervix.Since this gynecologic neoplasm is relatively rare, tumor staging may be challenging. At present, the 2002 revision of the AJCC staging system for cutaneous melanomas is commonly employed for evaluating recurrence and survival in vulvar and vaginal melanomas.,2 However, this decision showed be made with caution. For cervical melanomas, radical hysterectomy with or without pelvic lymphadenectomy is the optimal technique.,10 In our case, we performed radical hysterectomy with bilateral salpingo-oophorectomy, total vaginectomy, partial urethrectomy, and pelvic lymphadenectomy as the melanoma involved the vulva and uterine cervix and had biologically aggressive characteristics, which was conducive to high rates of local and distant recurrence. However, it appears that the best approaches to this disease are early recognition and prompt surgical excision.Surgery is the optimal treatment of choice. For vulvar melanoma, the trend is toward more conservative surgery as there is no difference in overall survival between wide local excision and radical vulvectomy. The benefit of lymphadenectomy is also questionable. Complete regional lymphadenectomy does not seem to have any beneficial role in patients with vulvar melanoma, and should be avoided if the sentinel lymph node biopsy is negative.,8 These drugs may be useful in the treatment of melanomas of the female reproductive tract. However, the role of chemotherapy among women with gynecologic melanomas remains unclear; in addition, the biotherapy methods described till date have been anecdotal. Reports have recommended combination chemotherapy with cisplatin, vinblastine, and bleomycin, which is possibly associated with a better response than single-agent dacarbazine.,12 The efficacy of radiotherapy in genital melanomas remains uncertain. A few studies have shown that radiotherapy may provide benefit in patients with metastatic melanoma in the palliative setting. Despite the advanced stage, our patient responded well following surgery and combined adjuvant chemotherapy with interferon α. At present, she remains disease free for at least 50 months after surgery. On the basis of our experience, we recommend a combination of dacarbazine and platinum-based regimens in advanced gynecologic melanomas. Interferon α may be incorporated into the adjuvant regimen following standard therapy or may be administered intermittently.Various chemotherapy and biotherapy  regimens have been used in locally advanced or metastatic melanomas. At present, the American Food and Drug Administration (FDA) has approved several drugs for the treatment of melanoma, which include dacarbazine and interleukin 2 for advanced melanomas, interferon α for adjuvant treatment of surgically resected high-risk disease, and ipilimumab, a monoclonal antibody against the T-lymphocyte antigen, for advanced melanomas.In conclusion, for optimal outcomes, primary melanomas of the female genital tract should be diagnosed early with confirmation using immunohistochemistry. Although surgery remains the primary modality of treatment, adjuvant therapy should be chosen carefully. Combination regimens including chemotherapy and biotherapy may offer better survival.Data curation: Yingxin Pang, Hang Yuan, Anji Ren.Software: Yingxin Pang.Investigation: Yingxin Pang.Writing – original draft: Yingxin Pang, Hang Yuan.Writing – review & editing: Yingxin Pang, Hang Yuan, Shiqian Zhang, Peishu Liu.


Fibromatosis or desmoid tumour is a benign fibroblastic proliferation with aggressive infiltrative growth. High incidence of recurrence is noted after incomplete resection of the involved margins of the lesion. Pelvic fibromatosis is a rare condition and usually affects females. Patients frequently complain of pelvic pain, which can mimic gynaecological abnormalities. A case of pelvic fibromatosis involving pelvic floor muscles with unchanged appearance during 5 years of follow-up is presented. In 1991, a 29-year-old female was referred by a general practitioner to the gynaecology clinic with a several-month history of diminishing periods, deep dyspareunia and increasing difficulty and pain with defaecation. The patient felt like had a hard lump in the vagina. Vaginal examination revealed a firm, fixed tumour arising from the ischiorectal fossa suggesting a bony tumour, but no X-ray abnormality was seen.Review of the CT scan report showed the presence of a 12-cm oval mass in the posterior and right lateral aspect of the pelvis that extended into the sacrosciatic notch with some obliteration of the intergluteal fat but with no localized invasion of the glutea. The right obturator internus muscle was not seen separately from the mass. The heterogeneously enhancing mass extended into the ischiorectal fossa towards the pelvic floor and was displacing the perineal body to the left. The bladder, uterus and rectosigmoid were also displaced and compressed by the mass.Unfortunately, images of the CT scans were not available, as the analogue films from that era had been destroyed and subsequent images were digital. No record of digitization of the old CT images could be traced.A needle biopsy was performed and showed that the tumour consisted of spindle cells rich in collagen fibres without cytological atypia and it was confirmed as fibromatosis (desmoid tumour).The patient was prescribed chemotherapy—methotrexate 50 mg and vinblastine 10 mg i.v. weekly. Repeat CT scan in July 1992 showed no objective change in the longstanding enhancing pelvic mass. The patient continued with the treatment. On vaginal examination in 1996, the mass appeared significantly smaller in size, measuring 8 × 4 × 4 cm. It was present in the paravaginal area and no involvement of the rectal or vaginal wall was noted. It was found during surgery that the right obturator internus muscle had been infiltrated by the desmoid tumour. Therefore, only incomplete resection of the mass was performed.After the surgery, there was a significant worsening of the patient's longstanding problem with defacation, leading to continuous use of laxatives. This was thought to be related to the surgery.A report of CT scan from August 2000 showed that the mass was continuing to expand the obturator internus muscle and extending to the right piriformis muscle, down to the level of the perineum. Infiltration of the pouch of Douglas was also seen. The mass was felt to be too close to the anal sphincters, and therefore only conservative management was offered with annual follow-up appointments. The appearances were stable, and on physical examination, only a small nodule on the posterior fornix was noted.T1 and T2 weighted, and short tau inversion-recovery sequences involving the right obturator internus muscle and which extended posteriorly inferior to the right piriformis muscle along the right sacral ligament to the S5–S6 level on the right side of the sacrum. The low signal abnormality was also seen along the obturator internus muscle posterolaterally and the right levator ani muscle  or pelvis.6Aggressive fibromatosis or desmoid tumour is an infiltrating proliferation of fibroblasts without any evidence of inflammation. As it originates from the musculoaponeurotic structures,Intrapelvic fibromatosis is rare and involvement of the pelvic floor is uncommon, which is also reflected in the literature, as not many cases have been described.1 The aetiology of fibromatosis is not clear; however, trauma, abdominal surgery, drugs, irradiation, genitourinary inflammation or Gardner’s syndrome are thought to be causative factors.11 In this case, the patient did not have any of these conditions; therefore, this would represent a case of primary or sporadic fibromatosis. The primary form is extremely rare and is defined as fibroblastic proliferation with no relation to the patient’s medical or surgical history.7 The diagnosis of primary fibromatosis is difficult to establish preoperatively, especially in patients with no medical history.Desmoid tumours occur more frequently in females of child-bearing age , occurring most commonly in the third or fourth decade of life.12 However, wide surgical resection with tumour-free margins could be achieved in only 50% of cases.11 It is noted that even in cases with negative margins of resection, the incidence of local recurrence varies between 13% and 68%.13 In our case, the pelvic floor muscles were initially infiltrated by the tumour, which prevented complete resection. No further surgical resection was considered appropriate, as imaging appearances had remained stable during the follow-up years. Moreover, the parasphincteric focus of fibromatosis was found to be too close to the anal sphincters and any intervention could have led to sphincter injury, and consequently faecal incontinence.Initially, the patient underwent chemotherapy and surgical resection of the tumour, which is considered the ideal treatment for this type of fibromatosis.T1, low signal on T2 and avid enhancement on T1 weighted images with fat suppression techniques. The signal appearances are not diagnostic of fibromatosis but are characteristic. In cases of suspicion of recurrence, MRI is the imaging modality of choice.1 However, recent advances in ultrasound imaging, the emergence of high frequency transducers and automatic three dimensional (3D)/four dimensional acquisition, allow precise assessment of the pelvic floor.16 These ultrasound techniques are commonly used in gynaecological, urogynaecological or proctological practices, but are not yet so widely applied by radiologists. Various studies have shown the usefulness of 3D high frequency endoanal ultrasound imaging in the evaluation of the normal anatomy and injuries of the anal sphincters.15 3D endovaginal and transperineal ultrasound imaging are well-recognized techniques in the assessment of pelvic floor structures, levator ani muscle and levator hiatus,17 with good interobserver reliability.19 It would be worthwhile to assess their usefulness in the diagnosis of such a rare condition as pelvic fibromatosis.MRI typically shows isointense features on In our case, MRI showed a tumour in relation to the right levator ani muscle and right obturator internus muscle and focus of fibromatosis in the perianal region, determining its further conservative management. These appearances have remained stable during 5 years of follow-up.Primary pelvic floor fibromatosis is extremely rare; however, it should be considered in females of child-bearing age with pelvic symptoms.Owing to lack of definitive therapy, desmoid tumours are exceedingly difficult to treat and require an interdisciplinary approach for best management.MRI is the method of choice when fibromatosis and recurrence are suspected.Novel ultrasound techniques with the use of high frequency transducers, 3D data acquisition and endoanal/endovaginal/transperineal approach enable precise assessment of the pelvic floor structures.Informed consent has been obtained.


Altitudinal visual field defect is a rare presentation of retrochiasmal lesion especially when bilateral visual fields were affected. In fact, bilateral inferior altitudinal visual field defect (BIAVFD) usually occurred in patients who survived a gunshot injury to the occipital lobe or as a direct trauma to the brain. We report a rare case of BIAVFD secondary to occipital meningioma. A high index of suspicion enables timely investigation and diagnosis when dealing with atypical presentation of intracranial meningioma. Meningioma is a primary intracranial neoplasm that arises from the meningothelial cells of the arachnoid layer which surrounds the spinal cord and the brain . The mosBilateral inferior altitudinal visual field defect (BIAVFD) or inferior hemianopsia is a rare presentation of a retrochiasmal pathology. BIAVFD is mainly associated with nonarteritic anterior ischemic optic neuropathy (NAAION), retinal lesion (choroiditis and coloboma) or optic nerve lesion  in which all of these mainly affect structures anterior to the optic chiasm ,5. NonetA 52-year-old gentleman presented with generalized headache, blurring of vision and unsteady gait for one-year duration. He described his headache was throbbing in nature and progressed to be persistent throughout the day. There was no aura and no preceding history of seizure. He also started to have unsteady gait, followed by blurring of vision especially at downgaze.Otherwise, he had no known underlying medical illness. He denied of any history of head trauma or fall. There was no memory loss or personality changes. He was recently diagnosed to have ischemic heart disease via stress test.At presentation, he was alert and conscious with stable vital signs. Visual acuity was 6/6 on both eyes. Optic nerve function tests were normal with no relative apparent pupillary defect. The anterior and posterior segment examination was unremarkable. Surprisingly, both optic disc appeared normal with cup-disc ratio of 0.3, and no signs of papilloedema or optic nerve atrophy seen. Extraocular muscles movement were full in all directions. The only positive finding was the confrontational test revealed a left lower homonymous quadrantanopia. Systemic review and neurological examination were normal.He underwent computed tomography (CT) scan and whereby he was noted to have a large solitary tumour located at the parasagittal area of occipital region suggestive of parasagittal meningioma Figure . MagnetiSurveillance MRI after one year of post-surgery revealed a residual tumour at the right occipital area with another new tumour growth at the left occipital area. He was then subjected to radiotherapy treatment. However, a second craniotomy with excision of tumour surgery was performed at the second year of follow-up after radiotherapy failed to shrink the tumour. Prior to his second surgery, his visual field started to deteriorate whereby he was unable to gauge the downgoing staircases Figure .During his ophthalmological follow-up, his visual acuity was still good with 6/7.5 over both eyes. Humphrey visual field demonstrated a bilateral altitudinal visual field defect which was denser at the left inferior quadrant. Fundus examination had no sign of optic atrophy. Currently, the patient is under ophthalmology regular follow-up and on-going visual rehabilitation therapy.Meningioma presents with an incidence rate of 8.33 per 100,000 populations in the United States, which is four times higher than the incidence rate of all the brain and other nervous systems tumors in Malaysia  ,6. MeninEven though meningioma has a high survival rate , patients may develop sequalae either due to its mass effect or as a manifestation of post-operative surgical complications . In a stMany reported incidents of visual field problem in meningioma usually found in cases of tuberculum sellae meningioma. In these cases, patients usually presented with bitemporal hemianopia, bilateral superior quadrantanopia or unilateral visual loss , 8. SuchBIAVFD is one of the presentations of occipital lobe lesion, which can be due to penetrating injury such as a bullet or as direct trauma to this area. Such presentation occurs when there is a direct insult towards bilateral occipital lobe which lies above the calcarine fissure. Should the insults affect the area inferior to the calcarine fissure, superior field defect resulted, and almost inevitably a fatal condition due to its close proximity to the cerebral sinuses ,9. This In our patient, the progression of the diseases was slow but severe, and due to this, his quality of life was affected even though he has 6/6 vision at both eyes. In patients with BIAVFD, this is an expected situation faced by those bearing this disease as they will have difficulty in reading, climbing stairs or even estimating distance while walking. Frequent stumbling and falling in elderly patients will be dangerous and this can lead to fractures and morbidity.Previously, the management of BIAVFD was mainly conservative and the patient has to bear the visual field defect and limit his daily life activities. With the advent of visual rehabilitation, Romano has suggested two approaches for management of visual field defect in patients. First is by implementing compensatory strategies such as prisms or saccadic training which can improve the ability to scan object within a visual field defect . Even thWhile the second strategy is by restitution therapy in which such techniques can enlarge the visual field by using a home-based vision restoration therapy (VRT). This VRT stimulates the border zone between the seeing and the blind field repetitively on a daily basis over many months . By stimIn retrochiasmal lesion, BIAVFD can be atypical manifestation of occipital meningioma when both of the occipital lobes were affected. High index of suspicion with timely diagnosis and prompt treatment is the best management for better survival outcome. It is incumbent for all team that facilitates the management of this patient to offer rehabilitative measures to patients that have any form of visual field defect.


Mirror aneurysms are a rare subtype of multiple aneurysms, located in identical or adjacent arterial segment bilaterally. We report a case series of 3 such patients amongst whom one of them had 3 sets of mirror aneurysms and the other patient had 2 sets of mirror aneurysm on the same arterial segment which has not been reported till date.A retrospective analysis of 3 patients with incidentally detected multiple mirror aneurysms, who were treated with microsurgical clipping and coiling, was conducted. A systematic search was performed using the PUBMED database and relevant articles were reviewed with particular attention to incidence, associated conditions, risk factors and management strategies. Written informed consent was obtained from all of the patients 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. This research work has been reported in line with the PROCESS criteria .All the 3 patients were females with incidentally detected multiple mirror aneurysms. All the 3 patients were known Hypertensives. All the aneurysms were successfully clipped by a multistage, bilateral craniotomy except the one in the cavernous ICA, for which an endovascular procedure is planned. All of them had an uneventful postoperative course with the CT angiogram showing obliteration of all the clipped aneurysms except the one in the cavernous ICA.Multiple mirror aneurysms represent a rare occurrence of a diverse pathology. Both these described types of cases have not been reported so far in the literature. The treatment strategy for mirror aneurysms should be determined individually based on the location, size, and morphology of the aneurysms, as well as, on the clinical manifestations of each patient. Their incidence varies from 5% to 40% of all patients with multiple aneurysms. The commonest anatomical location is the middle cerebral artery (MCA), followed by the Internal cerebral artery (ICA) and the Posterior communicating artery (Pcom). They are present in the other vessels as well but are more uncommon . Multipl2A retrospective analysis of 3 patients with incidentally detected multiple mirror aneurysms, who were treated with microsurgical clipping and coiling, was conducted. A systematic search was performed using the PUBMED database. Relevant articles were reviewed with particular attention to incidence, associated conditions, risk factors and management strategies. Written informed consent was obtained from all of the patients 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. This research work has been reported in line with the PROCESS criteria .3A 57 years old lady, who was a known case of hypertension on medications, was incidentally detected to have multiple aneurysms when she was screened for the same as she had a family history of subarachnoid haemorrhage but not of any detected aneurysms. She had no history of smoking, alcohol abuse or history of any syndromes. On examination, she did not have any neurological deficits. She underwent CT angiogram of the brain with three-dimensional reconstructions and a 4-vessel DSA which demonstrated the following aneurysms: - basilar top, bilateral M1, bilateral MCA bifurcation and bilateral anterior choroidal artery aneurysms , Fig. 2.4A 63 years old lady, who was a known case of hypertension on medications, was incidentally detected to have multiple aneurysms when she was evaluated for a nonspecific type of headache. She had no family history of SAH or aneurysms. She had no past history of smoking, alcohol abuse or any syndromes. On examination, she did not have any neurological deficits. She underwent CT angiogram of the brain with three- dimensional reconstructions and a 4-vessel DSA which demonstrated the following aneurysms:- Acom, 2 sets of bilateral M1 and a right cavernous ICA aneurysms , Fig. 4.5A 74 years old lady, who was a known case of hypertension on medications, was incidentally detected to have multiple aneurysms when she was screened for the same as she had a family history of subarachnoid haemorrhage but not of any detected aneurysms. She had no history of smoking, alcohol abuse or history of any syndromes. On examination she did not have any neurological deficits. She underwent CT angiogram of the brain with three-dimensional reconstructions and a 4-vessel DSA which demonstrated the following aneurysms: - bilateral M1, bilateral anterior choroidal artery and left ICA bifurcation aneurysms. There were a total of 5 aneurysms in this patient. After careful evaluation of the radiologic images, we decided to attempt a 2 stage surgical procedure and clipping of all the aneurysms. She initially underwent a left pterional craniotomy and clipping of the left M1, ICA bifurcation and choroidal artery aneurysms followed by a similar procedure on the right after 1 month. The post-operative course after both the procedures was uneventful. The post-operative CT angiogram showed complete exclusion of all the aneurysms while preserving the normal flow.All the surgeries were performed by the senior most professor in the hospital. Intraoperatively, we used electrophysiological monitoring like MEP, indocyanine green videoangiography with DIVA  for an i6Multiple aneurysms are a heterogenous group of patients within the broader group of intracranial aneurysms accounting for 12.9%–26.4% of all aneurysms . They arVarious authors have postulated an embryological basis for mirror aneurysms. Baccin et al.  has discThe mere presence of mirror aneurysms is not a predictor of poor outcome or SAH ,12. The Despite recent advances in knowledge and techniques, treatment strategies for mirror aneurysms remain controversial. Both single and multi staged treatments are associated with good results. Hence, treatment has to be customised to every case accordingly ,26,27.7Multiple mirror aneurysms represent a rare occurrence of a diverse pathology. We have described 3 such cases of which one had 3 sets of mirror aneurysms and another case had 2 sets in the same arterial segment. Both these types have not been reported so far in the literature. Further studies are required to elucidate the possible theories of development, inheritance pattern, and association of these lesions and the need for screening of 1st- degree relatives with twin aneurysms. The treatment strategy for mirror aneurysms should be determined individually based on the location, size, and morphology of the aneurysms, as well as, on the clinical manifestations of each patient.Nil.The paper was on a retrospective case series. The procedure followed was the standard treatment of care as highlighted in the manuscript. There was no testing of any form done. Hence there was no nee of an ethics approval.Written informed consent was obtained from all of the patients 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.Dr. Niranjana - data collection, data analysis, writing of the paper.Dr. Arun Balaji - data collection and inputs.Dr. Yamada - guidance for writing.Dr. Kawase- Guidance and editing.DR kato - study concept.IJS Publishing Group Ltd.Invoice #09C57F19-0001Receipt #2944-4204.Research RegistryUIN : researchregistry4800.I take complete responsibility for the work and conduct of the study - Dr Niranjana Rajagopal.Not commissioned.There are no conflicts of interest.


Pulmonary malignancies carry a significant morbidity and mortality and are one of the leading causes of cancer-related deaths worldwide. Primary pulmonary lymphoma is a rare malignancy which should be considered in the differential of solitary pulmonary nodule or lung mass especially in a low-risk patient presenting with constitutional symptoms. Here, we describe a case of an elderly male who presented to our clinic with incidental pulmonary nodules and subsequent workup revealed low grade B cell non-Hodgkin's lymphoma consistent with diagnosis of primary pulmonary marginal zone lymphoma. Primary pulmonary lymphoma (PPL) is a rare neoplasm accounting for 0.5-1% of pulmonary malignancies [18F]Fluorodeoxyglucose-positron emission tomography with CT (18F –FDG PET/CT) was performed showing multiple 18F –FDG avid nodules in the right upper lobe, right lower lobe, and left upper lobe [An 83-year-old male with past medical history of mild Alzheimer's dementia, nonischemic cardiomyopathy, aortic regurgitation, and an ascending aortic aneurysm measured at 4.1 cm presented to the pulmonology clinic with an abnormal CT of the chest. He was seen by his PCP recently for follow-up of ascending aortic aneurysm and had a CT chest without contrast performed which showed 14.8 mm pleural-based nodular density in the posterior medial right upper lobe, irregular 20.5 mm right lower lobe nodule, and a 2 mm left upper lobe partially calcified nodule . He had per lobe . Initialper lobe . The patPrimary pulmonary lymphoma (PPL) is a rare clinicopathologic entity, which comprises less than 0.3% of all primary lung malignancies, less than 1% of all cases of NHL, and 3% to 4% of all extranodal NHL –4. It is API2 (apoptosis inhibitor 2) and the MALT1 genes which induces activation of the NF-κB pathway resulting in cell proliferation [ Helicobacter pylori, MALT lymphoma of the lung has not been linked to any infectious or specific autoimmune conditions, although there have been case reports associated with tuberculosis [The most common type of PPL is the marginal zone lymphoma (MZL) of mucosa-associated lymphoid tissue (MALT), otherwise known as MALT lymphoma or “MALToma,” which comprises 70-80% of all cases of PPL . These Mferation . Unlike rculosis . Like gaThe clinical presentation is highly variable. Most patients are clinically asymptomatic or present with constitutional symptoms, cough, hemoptysis, or dyspnea; B-symptoms are uncommon. Median age at time of diagnosis is 60 years, however, it has also been diagnosed in younger individuals who are usually immunocompromised . One-thiRadiographic appearance is variable, ranging from consolidations to inconspicuous nodules or masses. The presence of ground glass opacities, air bronchograms, and bronchiectasis may confound the diagnosis suggesting an infectious or inflammatory process. Presence of air bronchograms is due to relative airway-sparing nature of the disease . Hilar lHistologic confirmation is required for definitive diagnosis and is characterized by reactive lymphoid follicles with diffuse infiltration by small lymphocytes and lymphoid proliferation which leads to expansion of the marginal zone; lymphoepithelial lesions  support the diagnosis but are not required for diagnosis . LymphoePrimary pulmonary MALT lymphoma is associated with a good prognosis; 5-year and 10-year survival rates are 90% and 70%, respectively , 14. CurNonspecific presentation and indolent course make the diagnosis of primary pulmonary lymphoma very challenging and often lead to misdiagnosis or delayed diagnosis. This diagnosis should especially be suspected in individuals who present with lung nodules but lack usual risk factors for primary non-small-cell and small-cell lung cancer, similar to our patient.


Schwannoma is a benign encapsulated tumor of the peripheral nervous system which is mainly located in the head and neck. However, axillary Schwannoma is rare. In this article, the author presents an interesting case of a right axillary Schwannoma, where the diagnosis was preoperatively made on a Tru-cut biopsy.We report a case of an enlarged right axillary swelling in a sixty-year-old male. Proper radiologic workup was performed. Furthermore, a Tru-cut biopsy was taken which revealed evidence of schwannoma. Having such symptomatic lesion, operative excision was done with the use of a nerve stimulator, which aided in preserving nerve function.With such non-specific presentation, axillary Schwannoma may be easily missed and mismanaged. A Tru-cut biopsy may provide great help in expert hands, aiding operative planning; likewise in the case we are presenting. Furthermore, utilizing an intraoperative nerve stimulator will facilitate nerve preservation. This paper has been dictated fulfilling by the SCARE criteria .2examination, no skin changes were observed. He had a right axillary mass that is measuring about 4 × 3 cm, which was firm, mobile and tender on palpation. It was nonadherent to the underlying tissue. No palpable left axillary or cervical lymph nodes. Muscle power in all muscles was 5/5; the sensation was intact. Tinel sign was positive with tingling sensation along the shoulder tip. The left axilla was normal. Chest examination was unremarkable as well. Based on the history provided by the patient and the examination findings, our differential diagnosis included axillary lymphadenopathy, lipoma, fibroma, vascular tumors, and paraganglioma. Laboratory investigations were normal. Furthermore, Ultrasound-Soft tissue of the right axilla, revealed a subcutaneous, well defined, hypodense lesion, measuring 3.7 × 2.4 cm with evidence of cystic degeneration  is one of the methods of diagnosing schwannoma, although it is difficult to recognize tissue architectural pattern on cytology, it was reported that FNA was used for the diagnosis of schwannoma . They fuComparing FNA and CNB in the diagnosis of extremity soft tissue tumors, showed that FNA had 79.17% sensitivity, and 72.7% specificity, while CNB had 81.8% sensitivity, and specificity of about 79.2%. Regarding the accuracy in identifying the correct diagnosis, FNA had a 33.3% accuracy and CNB had a 45.6% accuracy .A retrospective study conducted in 2013, evaluated the sensitivity and specificity of CNB in determining musculoskeletal tumors. Among these tumors, Eleven had schwannomas , yet there was no specification of the location. The sensitivity and specificity of CNB were reported to be 95%, and 97%, respectively . CNB wasUpon searching the literature, to our knowledge, there are no reported cases of axillary schwannoma which is diagnosed, preoperatively by a CNB. In the case described, an Ultrasound guided true-cut needle biopsy was performed with no complications. The histopathology features and Immuno-histo-chemistry of the tumor cells confirmed the diagnosis of an Axillary Schwannoma.The differential diagnosis included axillary lymphadenopathy, lipoma, fibroma, vascular tumors, and paraganglioma. Schwannoma should also be kept in the differential diagnosis when dealing with an axillary mass.Treatment of schwannoma depends on the location, size of the lesion, nature: benign or malignant, age and condition of the patient. The gold standard is surgical excision. On the other hand, malignant schwannomas may require radiation therapy and chemotherapy. Fortunately, surgical excision usually results in complete and immediate resolution of symptoms ,31,32.Because they are rare and have complex locations, they have diagnostic and therapeutic challenges. On the other hand, axillary Schwannoma was not well described in the literature where only a few similar cases have been reported. Schwannoma is rarely identified pre-operatively based on a radiologic biopsy. In the presented case, the diagnosis of axillary schwannoma was made before the operation, based on Ultrasound guided tru-cut biopsy and the tumor was surgically excised with no residual neurological deficit.4Axillary Schwannoma is a rare and challenging condition. Its complex anatomical locations could present diagnostic misinterpretation. Because of the non-specific symptoms, many cases can simply be missed and mismanaged. Schwannoma must be kept in mind, and the operation must be planned according to this possibility. A tru-cut biopsy may provide great help in expert hands, aiding operative planning; Likewise, in the case, we are presenting. Furthermore, utilizing an intraoperative nerve stimulator will facilitate nerve preservation.There is no conflict of interest. The authors did not receive any financial support.No funds were provided prior to submission.We have received an approval from the ethical committee in our institute’s research centre .Written informed consent was obtained from the patient at the clinic. The patient was informed that his case will be written for publication as a case report with the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.-Hager Aref: Literature reviewer; she wrote the article’s manuscript and submitted the paper for publication.-Georges A. Abizeid: Operating surgeon; he wrote the operative details and part of the discussion, reviewed and edited the manuscript.researchregistry4412.Dr. Georges Abizeid.Data were obtained from our institute’s Health Information System, a computer-based in-house system.Not commissioned, externally peer-reviewed.


The development of Castleman’s disease in the pulmonary hilum is extremely rare. Although resection of only the lesion is sufficient because of its benign nature, lobectomy or more extensive procedures performed for the pulmonary hilar tumor have been reported.The patient was a 15-year-old male with a tumor in the right pulmonary hilum. Endobronchial ultrasound-guided transbronchial needle aspiration was performed but no specific findings were obtained from the cytological and histological evaluation. 18F-fluorodeoxyglucose positron emission tomography showed moderate accumulation in the tumor, which suggested potential malignancy. Intraoperative frozen section diagnosis did not show any malignant findings. Thus, we performed only tumor enucleation without any lung resection. The pathological diagnosis was hyaline vascular type Castleman’s disease. No recurrence has been observed for seven years.Because hyaline vascular type Castleman’s disease in solitary pulmonary hilar tumor is one of the benign diseases common in young people, intraoperative frozen section diagnosis is recommended to avoid unnecessary lung resection. Castleman’s disease (CD) is a rare disorder of lymph propagation first reported by Castleman and colleagues in 1954 from a case with chronic fever and mediastinal tumor . ClinicaA 15-year-old male without any symptoms was referred to our hospital because he was noted as having an abnormal shadow on chest X-ray at a health checkup. No abnormal findings were observed on his hematological and biochemical examinations. On chest computed tomography (CT), a 40 × 33-mm wide tumor shadow with clear boundaries in the right pulmonary hilar area was found. The tumor was strongly enhanced in the early phase. Abnormal findings were not found in the lung field and mediastinum (Fig. On operative findings, the tumor existed between the middle and lower lobes of the right lung with no pleural involvement. The interlobar pulmonary artery was revealed on the back side of the tumor. We performed 18Ga needle biopsy for intraoperative frozen section diagnosis, which showed only chronic inflammation findings. Moreover, macroscopically, no tumor invasion into the pulmonary vessels, bronchi, and lung parenchyma was found. Therefore, only the tumor enucleation was performed Fig. a. An intThe extirpated specimen was a 30 × 23-mm smooth and well-encapsulated tumor. Histologically, the lesion had a fibrous capsule with clear boundaries consisting of lymph follicle hyperplasia. There were clearly hyalinizing concentric fibrotic nests around the lymph follicle and vessel hyperplasia on the hyalinizing wall. There were almost no plasma cells outside the follicle. Histological diagnosis was that of HV type CD (Fig. HV type CD is common in young people. The most common sites of this disease are in the cervix, mediastinum, abdomen, and retroperitoneum , but it Keller et al. retrospectively examined six localized HV type CD patients who received partial resection, biopsy, or observation alone. They reported that disease progression was noted at four years after surgery in one patient and, in another patient, complete resection was performed eight years after an initial biopsy and observation following the onset of symptoms . MoreoveIn young patients with isolated solitary pulmonary hilar tumor that does not lead to a diagnosis before surgery, intraoperative frozen section diagnosis should be performed to consider the possibility of CD. If malignant findings are not recognized in intraoperative frozen section diagnosis, the choice of procedures that preserve pulmonary function as much as possible is desirable because CD is a benign disease commonly seen in young people. However, an accumulation of cases with such localized HV type CD in the pulmonary hilum will be required to determine whether surgical mode of only tumor enucleation with long follow-up term is medically satisfactory.


Mediastinal pseudopancreatic cyst (MPP) is the extension of a pancreatic pseudocyst through esophageal or aortic hiatus into the posterior mediastinum. It can produce a range of manifestations caused by compression by the cyst, for instance, odynophagia, dysphagia, pericardial, or pleural effusion. Here we report a case of MPP in a 7-year-old child who was presented with repeated chest infections and left pleural effusion. It was successfully drained by cystogastrostomy. Pancreatic pseudocyst (PP) is a localized collection of pancreatic secretions, rich in amylase and other enzymes that is lined by fibrous tissue and do not have an epithelial lining. Only few cases had been reported in childhood in literature. Mediastinal extension of a PP is even rarer. Depending on the mass effect it exerts, and it can cause pericardial or pleural effusion, dysphagia, or odynophagia.A 7-year-old male child was presented to the Pediatric Department in Shatbi University Hospital with recurrent chest infections since 1 year. Repeated chest X-ray showed left pleural effusion. The child was managed conservatively and discharged from the pediatric department. During the course of follow-up for the respiratory condition an abdominal ultrasound was ordered to investigate a new onset minor abdominal discomfort. An abdominal cyst was found which, otherwise, was not clinically palpable during abdominal examination. Subsequent computed tomography (CT) scanning of the abdomen and pelvis with intravenous contrast revealed a retroperitoneal thick-walled fluid filled mass, measuring approximately 11.5 × 13 cm in close relation to the main pancreatic duct with inflammation of the adjacent pancreatic tissue. Provisional reports indicated a pseudo-pancreatic cyst with further extension into the posterior mediastinum through one of the diaphragmatic hiatus . Serum The decision after surgical consultation was to perform laparotomy. The child was prepared for the operation. Through an upper midline incision, the abdomen was explored. This revealed a large, smooth, and fluctuant mass behind the stomach extending up to the posterior mediastinum through the esophageal hiatus, mostly arising from the pancreas. Aspiration of the coffee ground contents was done followed by a drainage procedure by anastomosing the posterior wall of the stomach to the anterior wall of the cyst wall (cystogastrostomy) using running 4/0 vicryl sutures. A Penrose drain was inserted in the left upper quadrant followed by a layered closure. The postoperative course was uneventful. Nasogastric suction and intravenous fluids were continued for 5 days, after which oral feedings were gradually given. The drain was removed after 5 days and the child was discharged from the hospital on the 9th postoperative day. Follow-up abdominal ultrasound was done after 2 weeks and revealed dramatic improvement regarding the size of the cyst. Serum amylase gradually fell to the normal limits. A repeat ultrasound confirmed complete resolution of the cyst after 6 months. The patient is doing well after 1 year of regular follow-up visits.PP is a major and common complication of pancreatitis, though few cases are reported in children. Approximately 80% of PPs are located within the head and the body of the pancreas, while the rest lie extrapancreatic in areas, such as mediastinum, liver, spleen, pelvis, and neck.As MPP decompresses through the diaphragm, it is usually not felt while performing abdominal examination. It can present with nonspecific manifestations caused by compression by the cyst. This includes abdominal pain, gastrointestinal upsets, chest pain, dyspnea, dysphagia, odynophagia, and symptoms of pericardial or pleural effusion like our case.Owing to the vague nature of symptoms, imaging remains the cornerstone of diagnosis of such a rare disease. While chest radiography is not diagnostic but can illustrate lower mediastinal widening, retro or paracardiac well-defined opacity in addition to associated features, such as pleural or pericardial effusion.The approach to treatment of MPP is individualized depending on the underlying etiology, ductal anomaly, and whether the patient is symptomatic or not. Indications for intervention include increasing pseudocyst size or persistence over 4 to 6 weeks.Although extremely rare, the diagnosis of MPP should be considered in the differential diagnosis of any cystic mediastinal mass. The finding of a thin-walled cystic mass in the posterior or middle mediastinum in continuity with pancreas in addition to an elevated serum amylase level can establish the definitive diagnosis.


In this case report, giant calculus in the urethral diverticulum was found through ureteroscopy investigation, the pneumatic lithotripsy combined with ultrasound lithotripsy (PLCUL) was successfully performed to break down this rare and giant urethral calculus in the diverticulum without open surgery.A 82-year-old male presented to the urology department, complaining of frequent urination and dysuria. One giant, dark brown stone (6.5 × 6 × 5.5 cm) was revealed in the diverticulum of the anterior urethra using combination of local ultrasound, pelvic Computer Tomography (CT) and Magnetic Resonance Imaging (MRI). The stone was then successfully broken down via the PLCUL, and the emptied anterior urethral diverticulum was left untreated. In the 18 months’ follow-up, no new calculus was found in urethral tract, anterior diverticula became gradually smaller, eventually disappeared.In the treatment of giant calculus in the urethral diverticulum, this case report provides an effective method of lithotripsy in the clinical trials. Urethral calculus in male often cause dysuria with urinary tract irritation and acute urinary retention, which is considered as a urological emergency. Usually, small stones can be discharged naturally. Those small ones located at the anterior or more deep positions in urinary tract can be squeezed out followed by application of lubricants with low pressure injection. If the procedure fails, open surgical interventions may be adopted. For the huge anterior urethral diverticulum with urethral calculus, open surgery (i.e. diverticulum resection and urethrostomy) is conventional approach. Krystian  performeA 82-year-old male presented to the urological department, complaining of swelling and pain in perineal region, along with a frequent, painful, and difficult urination, when initially started 6 years ago. The patient was diagnosed with prostatitis and treated with quinolone antibiotics in several local hospitals. However, the symptoms did not ease and the patient showed up in our hospital where he was referred to our urology department. After multiple urinalysis, it was confirmed the patient had urinary tract infection. Blood parameters, biochemical, coagulation mechanisms, virus screening and other indicators were in normal level. In the physical examination, swelling and tenderness were observed in bilateral scrotum and perineum. A hard mass with a size of 7 × 7 × 6 cm was detected below the scrotal skin near the root of penis. The surrounding tissue boundaries of the mass was not clear. The patient experienced pain during the physical examination of the mass Fig. . In the The patient was treated with pneumatic lithotripsy combined with ultrasound lithotripsy (PLCUL) via LithoClast® Master , the procedure lasted a total of 60 min and the amount of bleeding was about 15 ml. The stone was successfully broken down and removed  and endoscopic ultrasonography in the treatment of urethral calculus. However, because the low energy ESWL equipped with the shock waves and X-ray radiation can cause damage to the surrounding tissue, it is not preferred in clinical trials. The heat generated by high-frequency vibration in endoscopic ultrasonography can also damage the surrounding tissue, the procedure also needs a lot of circulating water to cool sonophoretic probe, which is susceptible to damage during clinical use . VariousPneumatic lithotripsy overcome the above shortcomings and suitable for almost all urinary tract stones. Pneumatic lithotripsy is the new lithotripsy technology invented in the 1990s . It has Urethral lithotripsy has been successfully performed with any type of efficient energy source: ballistic , ultrasoFor the treatment of emptied urethral diverticulum after lithotripsy, if the open surgery is performed to remove the stone, the diverticulum resection and urethral modeling are usually performed. For endovascular calculus removal without open surgery, several conservative treatments on the emptied urethral diverticulum has been reported, such as urethral massage and prophylactic use of antibiotics, tamponade of cellulose or injection of teflon, but the effect was not as expected . In our


Tuberculous abdominal cocoon is an uncommon manifestation of abdominal tuberculosis. As a rare clinical entity, it is often encountered unexpectedly in patients with small intestinal obstruction. Here we presented a rare case of tuberculous abdominal cocoon which was suspected to be peritoneal carcinomatosis and was finally diagnosed by laparoscopy.A 47-year-old man developed small intestinal obstruction and massive ascites that did not resolve with conservative management. Surgical exploration revealed a fibrous sheath covering the small-bowel, and pathologic assessment of biopsies confirmed intra-abdominal tuberculous infection. After antituberculosis therapy, the ascites has greatly diminished and the patient was functioning normally.Preoperative diagnosis of tuberculous abdominal cocoon is a true challenge. Early diagnostic peritoneal biopsy should be recommended and surgery is usually unnecessary if definitive diagnosis can be made. Abdominal cocoon, also known as sclerosing peritonitis or sclerosing encapsulating peritonitis, is a rare cause of small intestinal obstruction and is characterized by total or partial encasement of the small bowel by a thick, fibrous, cocoon-like membrane . AbdominA 47-year-old man was referred to our hospital with a 3-month history of abdominal distension, intermittent abdominal pain and nausea. Despite weight loss of 4 kg, the patient had no symptom of fever, chronic cough or night sweats. He had no history of abdominal surgery, liver cirrhosis or chronic hepatitis virus infection, but suffered from tuberculous pleurisy about 20 years ago. Physical examination revealed gross abdominal distension without tender and ascites of unknown aetiology. Laboratory blood analyses including serum tumor markers, erythrocyte sedimentationrate (ESR), adenosine deaminase activity (ADA) and anti-tuberculosis antibody (TB-Ab) were all within normal limits, and tuberculin skin test was negative. The results of antibody testing for HIV were negative. Chest radiograph did not demonstrate features suggestive of pulmonary tuberculosis. Plain upright abdominal X-ray showed some air in the colon without presence of air fluid levels in the loops or free gas under the diaphragm Fig. a. ContraTwo months later, the patient was presented to our hospital again with persistent symptoms. Despite abdominal distension, nausea and vomiting, he also complained of increasing fatigue, emaciation, and 10-kg weight loss for the recent two months. Laboratory blood analyses revealed that serum ADA was 21 U/L , ESR was 28 mm/h , but TB-Ab was negative. Ascitic fluid obtained by paracentesis was still negative for bacteria, acid-fast bacilli and malignant cells, but ascities ADA was significantly elevated (41 U/L). Serum CA-125 was also significantly elevated . In addition, despite the presence of well-encapsulated fluid collection and central accumulation of the small intestine (Fig. Mycobacterium tuberculosis 3 weeks later. A diagnosis of tuberculous abdominal cocoon was made. Complete excision of the thick membrane and lysis of adhesions were tried but failed due to the extreme difficulty in separating the fibrotic tissue from the abdominal wall and small bowel. Since there were no perforated, ischemic or dilated bowel loops, the operation was completed after obtaining samples for diagnostic biopsy.Diagnostic laparoscopy was performed in our patient, and the entire small bowel was found to be encapsulated in a dense, white, fibrous, cocoon-like membrane filled with a large amount of brownish ascites Fig. d. MultitAfter operation, the patient had recurrent episodes of partial bowel obstruction that was resolved with conservative management. The patient was given rifampicin, isoniazid, ethambutol, and pyrazinamide for 2 months, followed by rifampicin and isoniazid for 4 months. By the end of the 2 month of anti-tuberculous therapy, serum ADA, ESR and CA 125 levels have returned to normal. Though a repeat CT scan of the abdomen and pelvis continued to show the small bowel wall thickening and membrane covering the small bowels Fig. b, howeveWith the introduction of effective antituberculosis chemotherapy and improvements in the socioeconomic environment, the incidence of tuberculosis has been decreasing . HoweverMycobacterium tuberculosis do not exclude the diagnosis. Direct microscopic smear detection of acid-fast bacilli in the ascitic fluid is insensitive, with sensitivity ranging from 0 to 6% [Because peritoneal tuberculosis may have an insidious onset and nonspecific clinical presentation, early diagnosis is often difficult to make. A negative smear for acid-fast bacillus, a lack of granulomas on histopathology, and failure to culture  0 to 6% . Ascites 0 to 6% , but CA- 0 to 6% . Periton 0 to 6% . As dela 0 to 6% , 7.The most common symptoms of peritoneal tuberculosis were abdominal distension, weight loss, fever, abdominal pain and abdominal mass, obstruction caused by tuberculous abdominal cocoon is extremely rare. Encasement of varying lengths of small bowel in a fibrocollagenic cocoon-like sac is a pathognomonic feature of abdominal cocoon . Though Undiagnosed and untreated tuberculous peritonitis can result in a mortality rate of 50–60% , but theDespite ATT, conservative treatment such as bowel rest, nasogastric decompression, and nutritional support also contribute to ameliorating abdominal symptoms . TamoxifIn summary, though various biochemical parameters and characteristic radiological findings of CT scan play a major role in establishing the diagnosis of tuberculous abdominal cocoon, preoperative diagnosis is a true challenge. The first and most important step towards diagnosis of tuberculous abdominal cocoon is awareness and clinical suspicion proportional to experience and knowledge of the disease. Early diagnostic peritoneal biopsy for patients with unexplained ascites should be recommended, especially in localities where tuberculosis is prevalent.


The thalami are bilateral ovoid grey matter cerebral structures bordering the third ventricle on both sides, which participate in functions such as relaying of sensory and motor signals, regulation of consciousness, and alertness. Pathologies affecting the thalami can be of neoplastic, infectious, vascular, toxic, metabolic, or congenital origin.The purpose of this review is to provide a comprehensive approach to the thalamus focusing on its anatomy, the main pathologies affecting this structure and their radiological semiology on CT and MRI. We will also illustrate the importance of multimodal MR imaging  for the diagnosis and treatment of these conditions. Multimodal MRI plays a crucial role in the detection and characterisation of thalamic lesionsBilateral thalamic lesions should point to venous thrombosis, which is reversible if treated earlyMR imaging is crucial for guiding stereotactic surgical positioning of DBS electrodesThe main differential diagnosis of bilateral thalamic lesions are tumour, ischaemia, and venous thrombosisThe thalamus is a complex structure involved in several cognitive, motor, and sensory processes. Interactions between the thalamus and cortical areas are well known. Thalamic pathologies can be classified into neoplastic, metabolic, congenital, vascular, and infectious. Multimodal MR imaging, which includes morphologic sequences, diffusion-weighted imaging, and vascular and perfusion imaging as well as spectroscopy, is useful for the diagnosis and management of these conditions. CT also plays an important role and often complements MRI.The two thalami are paired ovoid deep brain structures composed mainly of grey matter, located in the dorsal diencephalon together with the epithalami and the metathalami. In some classifications, the metathalami, also known as the geniculate bodies, are considered part of the thalami.The thalami process and relay information through afferent and efferent fibers. They play a key role in the integration of sensory information (except for the sense of smell), as well as in motor and cognitive functions .Each thalamus is approximately 3.5 cm long, and both thalami are linked across the midline by a thin interthalamic adhesion, also composed of grey matter . The thaThe thalami include several nuclei. The anterior nucleus is the most anteriorly located. Conditions associated with this nucleus result in diencephalic amnesia, from which the degree of recovery is variable . The medFrom a functional point of view, only the ventral tier nuclei of the lateral part of the thalamus and the geniculate bodies are considered to be specific. A lesion affecting the geniculate bodies will cause homonymous hemianopsia or quandrantanopsia . The VPMNon-specific nuclei include the anterior nucleus, implicated in cognitive functions, such as attention and short-term memory, and the medial dorsal nucleus, which is associated with mood. Here, connections exist with the limbic system. The relative position of the thalamic nuclei is illustrated in Fig. Vascularisation is assured by branches of the posterior cerebral artery , the posterior communicating artery (anteroinferior territory), and the posterior choroidal arteries stemming from the P2 segment of the posterior cerebral artery. The artery of Percheron, originating from one of the two P1 segments, is a normal variant and supplies the posteromedial aspect of both thalami . Diffusion restriction is seen in hypercellular tumours. Spectroscopy often shows increased choline, choline/creatine ratio and myoinositol, and decreased NAA. In high-grade glioma, there may be a lactate and lipids peak reflecting necrosis .Primary CNS lymphoma is a rare form of non-Hodgkin lymphoma , and it Metastatic disease should be suspected in patients with a known primary tumour and when multiple lesions are seen. Lesions can be haemorrhagic and/or necrotic and show variable patterns of enhancement Fig. .Fig. 4MR1. The classic triad of symptoms includes altered consciousness/confusion, ocular dysfunction, and gait disturbances/ataxia. Approximately 50% of Wernicke’s encephalopathy cases are not alcohol related and are caused by malnutrition and intractable vomiting [Wernicke’s encephalopathy, or alcoholic encephalopathy, results from dietary deficiency of vitamin Bvomiting , among ovomiting . These rFahr’s disease is a degenerative condition involving the basal ganglia bilaterally and symmetrically, including the thalamus, dentate nuclei, and deep or subcortical white matter Fig. . It showCT shows calcification of the basal ganglia, thalami, and subcortical white matter. MRI shows variable signal intensity on T1WI and T2WI in the same locations.This autosomal recessive condition leads to deposits of copper in the liver and brain. Clinical symptoms include dysarthria, dystonia, and tremor. On MRI, copper deposits in the lentiform nucleus and thalamus are hypointense on T2WI and gradient echo (GRE). High signal intensity in the outer rim of the putamen is often seen on T2WI and FLAIR Fig. .Fig. 7HiNeurofibromatosis type 1 (NF1) is an autosomal dominant disease characterised by multiple neurofibromas. Focal areas of signal intensity (FASIs) of the white matter, basal ganglia, and thalamus are found in this pathology. Possible causes include transitional myelinopathy with vacuolation of the myelin sheath, dysplasia, and hamartomatous lesions.N-acetylcholine) whereas tumours have markedly decreased NAA. Concerning perfusion, tumours are hyperperfused whereas FASIs will show similar or decreased perfusion relative to normal brain.As in other locations, lesions in the thalamus appear as bright foci on T2WI and FLAIR, isointense to hyperintense on T1WI, and typically show no contrast enhancement. They are not associated with mass effect or peripheral oedema. Spectroscopy and MR perfusion may be useful for distinguishing NF1 lesions from glial tumour, which is the main differential diagnosis Fig. . AlthougCauses of brain haemorrhage include hypertension, cerebral amyloid angiopathy, tumour (primary and secondary), and vascular malformations. Intraparenchymal haemorrhage shows high attenuation on CT in the acute and subacute stages. The attenuation progressively decreases until it becomes lower than normal brain in the chronic stages. On MRI, haemorrhage shows variable signal intensity depending on the age of the blood products. Susceptibility-weighted imaging (SWI) is a magnetic susceptibility sequence which includes both magnitude and phase imaging and is therefore able to distinguish haemorrhage from calcifications. Hypertension is the most common cause of intracerebral haemorrhage, and typical locations are the basal ganglia, thalamus Fig. , pons, aArteriovenous malformations (AVMs) are considered congenital lesions, and intracerebral haemorrhage is the most common and serious presentation . SymptomAVMs appear as heterogeneous lesions on T2WI and T1WI with flow voids best appreciated on T2WI and usually likened to a “bag of worms”. Dynamic MRA plays an essential role in demonstrating the arterial supply, the nidus, and the venous drainage of these lesions Fig. .Fig. 10HThrombosis of arteries supplying the thalamus is responsible for unilateral or bilateral ischaemic events. In the acute phase, ischaemia appears as low attenuation on CT due to cytotoxic oedema and reduced cerebral blood flow. A high-attenuation thrombus in the obstructed artery may be seen on non-contrast CT (dense artery sign) and as low signal intensity on T2* or SWI sequences. CTA will show an arterial filling defect at the site of thrombosis. MRI shows unilateral or bilateral lesions (in the case of thrombus in the artery of Percheron) Fig.  seen as In low-output states, ischaemic lesions initially occur at specific locations usually referred to as the watershed areas, which are located between two adjacent arterial territories. Structures in these locations, which include the thalami, basal ganglia, and deep white matter, receive part of their blood supply through end arteries Fig. . The relCT and MRI findings are the same as for ischaemia caused by arterial occlusion, but the distribution of the lesions does not follow an arterial territory. In severe asphyxia, the “reversal sign” may be seen on CT, in which white matter shows higher attenuation than grey matter.Thrombosis of veins draining the thalamus  leads to venous congestion with the development of infarction, oedema, and/or haemorrhage, usually in both thalami. The differential diagnosis includes ischaemia, due to occlusion of the artery of Percheron, and tumour. Venous thrombosis causes sudden onset of symptoms and is rapidly progressive. It should be suspected in patients with risk factors, which include head trauma, pregnancy, oral contraception, and hypercoagulable states.Non-contrast CT shows low attenuation in the thalamus and/or linear high attenuation of the internal cerebral veins. In the early stages of venous thrombosis, MRI shows T2WI, FLAIR, and DWI hyperintensity with high ADC values reflecting vasogenic oedema from venous congestion. This often progresses to acute ischaemia which will cause diffusion restriction. Contrast-enhanced CTV and MRV are helpful to depict the thrombus and confirm the diagnosis of venous thrombosis Fig. .Fig. 13NMycoplasma pneumoniae, Mycobacterium tuberculosis) frequently with the involvement of the brainstem, basal ganglia, cerebellum, and periventricular white matter. As in other locations, a thalamic abscess can complicate bacterial infection and present the same semiology as in other brain regions with diffusion restriction and ring enhancement  and bacterial  or spongiform encephalopathy, a disease caused by a prion and resulting in rapidly progressive dementia. In CJD, MRI depicts T2WI/FLAIR hyperintensity as well as diffusion restriction of grey matter including the basal ganglia, thalami, and cortex . Brain atrophy rapidly ensues. The “pulvinar sign” or “hockey stick sign”  may be seen. There is typically no enhancement, and white matter is usually not involved. The differential diagnosis includes hypoxic-ischaemic encephalopathy, arterial ischaemia, Wilson’s disease, and HIV1 encephalopathy .Following status epilepticus, but also in the case of an isolated episode or cluster of epilepsy, MRI may show abnormalities in the thalamus as T2WI hyperintensity and diffusion restriction in the early postictal phase . These anucleus ventralis intermedius  electrodes in parkinsonism , 19 for ius Fig.  and also


Calcific myonecrosis is a rare disease that has been shown to be a late sequela of trauma. This article presents a 68-year-old man with calcific myonecrosis of the leg 40 years after a tibial fracture complicated with peroneal nerve palsy. The soft tissue mass increased in size after another injury to the leg that occurred two years before his presentation. Physical examination at presentation showed a palpable extra-osseous mass at the anterior aspect of the left leg; the mass was not adherent to adjacent soft-tissues and bone, and it was painless but tender to palpation. Radiographs of the left leg showed extensive calcification at the soft-tissue of the anterior and posterior leg. An ultrasonography-guided trocar biopsy was done; histological findings were indicative of calcific myonecrosis. Given the benign entity of the lesion and known high rate of complications, he was recommended for no further treatment except for clinical and imaging observation. Located at the site of the biopsy, he experienced infection with drainage that eventually healed after six months with antibiotics and wound dressing changes. During the last follow-up examination, two years after diagnosis, the patient was asymptomatic without progression of the mass. Calcific myonecrosis is a rare disease that has been shown to be a late sequela of trauma ,2. The tTo enhance the literature, this article presents a 68-year-old man with calcific myonecrosis of the leg 40 years after a tibial fracture. The soft tissue mass increased in size after another injury to the leg that occurred two years before his presentation. The diagnostic approach, differential diagnosis and treatment are discussed. Written informed consent for publishing this study was obtained from the patient.A 68-year-old man presented with a progressive painless swelling of his left leg. Past medical history revealed an ipsilateral proximal tibia and fibula fracture 40 years before; the tibial fracture was treated then with an open reduction and internal fixation with a plate and screws. Since then, he experienced a postoperative deficit of the left common peroneal nerve. Two years before, after a minor injury (a muscle strain) to the same leg, he noticed a palpable, painless mass that had increased in size substantially over the last five months.Physical examination at presentation showed a palpable extra-osseous mass at the anterior aspect of the left leg; the mass was not adherent to adjacent soft-tissues and bone, and it was tender but painless to palpation. The skin was dry and not erythematous. Dorsiflexion of the left foot was weak secondary to the known left common peroneal nerve deficit. Radiographs of the left leg showed extensive calcification at the soft-tissue of the anterior and posterior leg .Computed tomography (CT) scan of the left leg showed a calcified fusiform soft-tissue mass with peripheral plaque-like calcification linearly oriented through the muscles of the anterior and posterior leg and extending through the interosseous membrane .Laboratory studies were within normal values. To exclude malignancy, an ultrasonography-guided trocar biopsy was done. Histological sections of the biopsy specimens showed multiple fragments of pultaceous s and partially calcified tissue, presence of sclero-hyaline and necrotic tissue with calcifications without any vital cells; histological findings were indicative of the diagnosis of calcific myonecrosis .The patient was informed of the benign entity of the lesion. Given the known high rate of complications, he was recommended for no further treatment except for clinical and imaging observation. Located at the site of the biopsy, he experienced infection with drainage that eventually healed after six months with antibiotics and wound dressing changes. During the last follow-up examination, two years after diagnosis, the patient experiences no noticeable increase in the size of the mass, and diminished pain. Repeat radiographs of the leg were similar to those at presentation. He was advised to continue full activity and to monitor his leg for new symptoms or mass enlargement.Calcific myonecrosis is rarely reported in literature ,25,26,27A closed fracture or trauma often associated to compartment syndrome are the most common causes of calcific myonecrosis ,25,26,27Radiographs and CT scans usually show fusiform soft-tissue masses with longitudinal peripheral plaque-like calcifications resembling an eggshell, and multiple fragmented calcifications involving the entire compartment ,19. CT sThe differential diagnosis should include soft-tissue sarcomas with a propensity for calcifications  or ossifications (dense bone formation) such as synovial sarcoma, epithelioid sarcoma and extraskeletal osteosarcoma, as well as benign lesions such as myositis ossificans and inflammatory diseases ,17,19. SWhen calcific myonecrosis is confirmed, treatment is controversial. Various treatments have been reported; some authors have recommended surgical excision for symptomatic patients ,10, whilTo conclude, calcific myonecrosis is a benign entity that usually affects the leg secondary to trauma. Biopsy is not necessary in asymptomatic patients with a stable lesion, typical medical history  and imaging. Conservative treatment with clinical and radiographic follow-up is the best treatment approach due to the high risk for infection.


Paratesticular tumors are rarely observed among scrotal neoplasm. Various types of benign lesions are described. Cavernous hemangioma belongs to uncommon epididymal benign tumors. Clinical and sonographic features are not conclusive and diagnosis requires histological confirmation. Authors report a case of an epididymal hemangioma in a 56-year-old patient, consulting for a painful scrotal swelling. As malignancy was suspected, he underwent inguinal orchiectomy. Histological examination confirmed the diagnosis of cavernous epididymal hemangioma. Clinical and therapeutic aspects of this rare entity are discussed. Epididymis is an infrequent location of cavernous hemangioma. Diagnosis is rarely made preoperatively as symptoms and radiological aspects are not specific. Conservative surgery must be attempted once feasible for aesthetic and functional purposes. Vascular intrascrotal tumors, arising primarily from the epididymis, are not commonly documented in daily practice. The distinction between benign and malignant epididymal tumors is not obvious, as clinical, radiological, and even operative features are not formally evocative.Herein, authors report a case of a rarely observed epididymal tumor, the cavernous hemangioma. Clinical, sonographic, operative, and histological features will be described and discussed.A fifty-six-year-old patient, father of two, trader, with no past medical history, consulted for a scrotal swelling. History-taking revealed neglected left scrotal pain for three years, increasing progressively. He denied any episodes of orchitis, scrotal traumatism, or micturition disorders. On physical examination, a three-centimeter tender and indurated mass was palpable on the epididymal caput. The right scrotum and the inguinal region's examination was without abnormalities. Routine blood testing and semen analysis were normal. Urinalysis was aseptic. Testicular tumor markers bioassay, including Alpha-fetoprotein, lactate dehydrogenase, and human chorionic gonadotropin, was performed. They were all in the normal rates.Scrotal ultrasound showed a heterogeneous tumefaction of the left epididymal caput, measuring 70 millimeters. The epididymal cauda and the left testis had a normal aspect. As malignancy was strongly suspected, surgery was performed after sperm cryopreservation. A left scrotal approach was done in order to attempt an epididymectomy. A 70-millimeter regular and solid mass was observed in the epididymal caput. As inflammatory phenomena were intense, epididymal dissection was laborious. It was decided to perform an orchiectomy, sectioning the spermatic cord as near as possible to the external inguinal ring . Postope∗7∗6-centimeter orchiectomy specimen. Testicular parenchyma had a normal microscopic aspect. The epididymis caput contained a regular hemorrhagic nodule measuring 55 millimeters. Microscopic examination of the nodule revealed a vascular proliferation made of enlarged vessels, sometimes cystic, separated by an abundant connective tissue (Figures Histological examination concerned a 12 Figures . Vascula Figures . The vesThe patient was examined three months and afterwards annually for three years. Scrotal examination and ultrasound did not reveal any signs of local recurrence. The patient did not complain of any erectile or sexual dysfunction.Paratesticular tumors are heterogeneous and infrequent among scrotal neoplasms. They concern the spermatic cord in 90% of the cases, and less frequently the epididymis and the testicular tunics. Malignancy is observed in almost 30% of the cases . EpididyHemangioma is defined as a benign mesenchymal tumor. Different types are described. They may be capillary, cavernous, veinous, and arteriovenous. These subtypes may be observed in the same tumor .Epididymis represents only 1% of all hemangiomas, which concern mainly the liver, the spleen, and the musculoskeletal system . The firClinical presentation is not specific. The tumor may occur at any age. The main complaint is usually a scrotal swelling. Tenderness is often reported. It is difficult to distinguish benign and malignant tumors based only on the physical examination. Spermatogenesis disorders are reported and can be explained by the increase of scrotal temperature by the hemangioma .Scrotal ultrasonography is rarely conclusive. Benign tumors usually present as homogeneous and hyperechoic masses. Hemangioma may be hypo- or hyperechoic. A heterogeneous aspect has also been described . Blood fMagnetic resonance imaging can be rewarding in describing the tumor, its location, and its extension to the other paratesticular elements .Definitive diagnosis is histological. Macroscopically, the epididymis is enlarged and contains blood clots on section. Microscopic examination shows epididymal tubules separated by blood-filled ectatic vascular spaces, without atypia or malignancy lesions .As malignancy cannot be ruled out on clinical or radiological features, surgery is mandatory.In most of the cases, like in the one we report, orchiectomy was performed. That being said, a conservative surgery is recommended once feasible. It depends on the preoperative surgeon evaluation of the lesions and the frozen section examination. A complete epididymectomy allows conserving the testis and avoids recurrence . In our Prognosis is favorable and recurrence is essentially related to incomplete epididymal excision . MalignaA better knowledge of benign paratesticular tumor allows realizing conservative surgery, with a favorable outcome and an acceptable aesthetic, psychological, and sexual impact. A thorough preoperative evaluation and eventually frozen section examination allow avoiding an unnecessary orchiectomy.