Anorectal malformation (ARM) and Hirschsprungs disease (HSCR) are frequently associated with other congenital malformations, but rarely with one another. We describe the case of a child with intermediate anorectal malformation who underwent ARM correction. This child experienced recurrent postoperative symptoms, including intestinal obstruction, nutrition intolerance, and weight loss. The child was diagnosed with Hirschsprung's disease by colon barium contrast and pathological findings from a rectal biopsy, and subsequently underwent pull -through procedure after conservative treatment failed. After six months of postoperative follow-up, the patient still experiences occasional episodes of enteritis, but the symptoms are substantially less severe than they were before surgery, and the patient's weight is slowly increasing. We described a case of a child who had ARM combined with HSCR. Although the association between ARM and HSCR is uncommon, severe constipation or enteritis following complete correction of ARM in the absence of anal stricture should prompt consideration for HSCR. Before the second stage of ARM surgery, pay close attention to the barium enema examination, as an abnormal shape may indicate the presence of HSCR. Anorectal malformation (ARM) is a complex congenital rectal disease of anus, rectum and urogenital system.With an incidence of 1/5,000 to 1/1,500, it is the most prevalent malformation of the neonatal digestive system. Hirschsprung's disease (HSCR) is incredibly rare, and some researchers have estimated that its prevalence ranges from 1/250,000 to 1/75,000 . ConstipA male  was admitted to our facility due to the absence of an anus in the anal fossa. Neither parent had a family history of digestive or liver disease. There was no substance misuse by the mother during pregnancy. Prenatal examination did not reveal any abnormalities.Twenty-four hours after birth, an inverted abdominal radiograph revealed that the rectum was approximately 1.8 cm away from the marker of the anal opening in dimple, Blind rectal end between lines PC and I . He was At the age of eight months, or two months after surgery, the infant developed abdominal distension, regurgitation, and additional symptoms. Radiographs of the abdomen in standing position revealed a low intestinal obstruction . During At the age of 11 months, the child was referred to our hospital again for intestinal obstruction. Barium enema examination showed that the diameter of the rectum, sigmoid and descending colon tubes was small, with the narrowest diameter about 1.4 cm, and the transverse colon near the spleen showed the transitional segment, slightly flared shape, and the transition zone is in the splenic flexure of the colon, which the widest part was about 3.2 cm , and 24 The child's rectum was biopsied, and the pathological results revealed that neither the submucosal nor intermuscular nerve plexuses contained any ganglion cells . We diagThe 18-month-old was brought back to the hospital to undergo a pull-through procedure. During the operation, a biopsied sample of the proximal intestinal tract of the transverse colostomy revealed nerve plexus and well-developed ganglion cells. Therefore, we lower the proximal intestinal conduit of the transverse colostomy to the anus. The patient began to eat one week after surgery and was discharged from the hospital after two weeks of excellent recovery.Currently, after six months of follow-up, the patient still has enteritis, which can be treated with intestinal washing and oral antibiotics, as well as intermittent fecal contamination, and his weight has increased by 3 kg compared to before surgery.While both ARM and HSCR are prevalent congenital malformations in newborns, the presence of ARM in conjunction with HSCR is extremely uncommon, with an incidence of only 2.4%–3.4% . HirschsHSCR usually shows up as delayed meconium discharge and abdominal distension in newborns. Children with medium-high ARM often need a diverting stoma. The position of the stoma above the absence of the ganglia does not produce the typical distended symptoms , 10. DueTherefore we mistook the child's constipation, abdominal distension, and other symptoms for complications following ARM correction surgery. All of these factors ultimately cause us to delay the patient's diagnosis and treatment. After the patient repeatedly exhibited symptoms of enteritis and constipation, we realized that the patient was suffering from additional diseases. Barium enema examination and biopsies of the rectum or colon ultimately confirmed the diagnosis of HSCR.In reviewing this case, we discovered that the barium enema examination performed prior to the second phase ARM correction operation on this child revealed that the blind end of the colon was small and the haustrum was not obvious. All of those are different from those of typical ARM children, the majority of whom exhibit dilatation of the colon's blind end and significant colonic pocket .Due to a incomplete barium enema examination reading, we lost the ideal opportunity to diagnose Hirschsprung's disease. In addition, when the child had enteritis and constipation, we did not conduct a barium enema examination in a timely manner. In the study by Watanatittan et al. , barium The gold standard for diagnosing HSCR is the absence of ganglion cells in the distal intestinal intermuscular and submucosal nerve plexus , 14. TheThere is still the chance of HSCR-complicated ARM cases. Before an anoplasty, care must be given to the cologram. Attention should be paid to colography before anoplasty. Its abnormal morphology can indicate the possibility of HSCR in children with ARM. For patients with intractable constipation and recurrent enteritis, the possibility of HSCR should be suspected, and rectal biopsy should be performed to confirm the diagnosis if necessary.


Cat scratch disease (CSD) is a benign condition caused by the inoculation of Bartonella henselae. The imaging findings are non-specific, and it is difficult to diagnose the disease via imaging. However, imaging studies help exclude other differential diagnoses in diagnostic dilemmas. We encountered a case of a 17-year-old adolescent who presented with painful neck swelling. CT showed multiple bilateral cervical lymphadenopathies with triangular soft tissue mass at the anterior mediastinum likely to be thymic hyperplasia, which is unusual in CSD and was mistaken for a lymphoproliferative disorder. Tissue diagnosis with a thorough clinical history yielded the diagnosis of cat scratch disease, and follow-up imaging showed resolution of the cervical lymphadenopathy and thymic hyperplasia. A 17-year-old adolescent presented with painful right-sided neck swelling for two weeks; this gradually increased in size and was associated with right otalgia. The patient had no history of ear discharge or skin redness and denied any history of fever or contact with tuberculosis patients. However, he had an episode of upper respiratory tract infection before he developed otalgia. Examination of the patient revealed multiple tender, enlarged bilateral cervical lymph nodes measuring up to 1 cm in size. Otoscopy examination revealed an intact tympanic membrane with no evidence of inflammation. No enlarged lymph nodes were palpable elsewhere, and there was no hepatosplenomegaly. Patient then proceeded with contrast-enhanced computed tomography (CECT) neck .


The novel Coronavirus (COVID-19) is one of the most recent Pandemics that invaded the earth and is still active. It caused and is still causing hundreds of thousands of patients high morbidity and mortality rates, with no definitive cure at this moment. COVID-19 has been proven to be associated with pathologic changes in coagulation, characterized by either thromboembolic or bleeding events. We describe this case of a 44-year-old male patient who walked into our emergency department with flank pain and was later discovered to have had renal angiomyolipoma (AML) rupture during his COVID-19 infection, ultimately requiring admission for hemorrhage control via interventional radiology (IR) drainage. Here, we discuss the role of front-line physicians and how they should keep a low threshold for the different presentations that could be associated with COVID-19 infection, such as what was found in this case. Renal angiomyolipoma (AML) is an uncommon benign tumor of the kidneys. Histopathologically, it consists of blood vessels, smooth muscle, and adipose tissue . Along wA 44-year-old gentleman presented to the emergency department with complaints of sudden onset of left flank pain lasting four hours. The pain was progressive in nature, radiating to the back with a severity of 10/10. There were no exacerbating factors for the pain, and it was not relieved by analgesia. The patient also complained of symptoms of vomiting, coughing, and an upper respiratory tract infection. No history of dysuria, hematuria, irritative urinary symptoms like frequency, urgency, or nocturia, no obstructive urinary symptoms, and no sensation of incomplete emptying of the bladder were noted. He is not a stone former. There have been no similar illnesses in the past and no relevant family history. His vitals were stable. On examination, the abdomen was soft and lax. Severe left flank tenderness was noted. Laboratory examination revealed a positive COVID polymerase chain reaction (PCR) with a cycle threshold of 20.7.A CT of the urinary tract was done, which demonstrated a large retroperitoneal hematoma in the left perinephric space that extended caudally to the left lower abdomen. No renal calculus or evidence of obstructive uropathy was seen. The right kidney appeared unremarkable. The rest of the upper abdominal solid organs appeared within normal limits. These findings were suggestive of a large left perinephric hematoma Figure .An abdominal CT scan with contrast was done to further evaluate the lesion, which showed a sizable left perinephric hematoma extending inferiorly in the retroperitoneum, reaching the left iliac fossa. The hematoma was displacing the left kidney anteriorly and compressing the renal parenchyma, suggesting a page kidney. An ill-defined, partially exophytic, heterogeneously enhancing lesion was noted at the interpolar region of the left kidney, approximately 45 mm × 45 mm × 40 mm. Multiple prominent vessels were seen at the periphery of the lesion, raising suspicion of minimal contrast extravasation at the site of the lesion. A prominent vessel was seen adjacent to the inferior pole of the left kidney, with active IV contrast extravasation noted in the delayed study. No sizable radio-dense urinary calculi or hydronephrosis were seen. No pneumoperitoneum or other obvious acute abnormalities were noted in the abdomen and pelvis. These findings gave the impression of a ruptured angiomyolipoma Figure .The patient was kept at nil per mouth and started on intravenous ceftriaxone, 2 g daily for seven days, and intravenous fluids. The patient was posted for left renal angioembolization by the interventional radiology (IR) team. Selective digital subtraction angiography (DSA) showed highly abnormal vascular structures in the mid-pole of the left kidney with no extravasation. The feeding vessel was closed with a vortex coil, and gel foam was used to close the remaining feeding vessels. At the end of the procedure, DSA showed complete occlusion of the feeding vessels Figures -4.Post-procedural days were unremarkable, and he tested negative on the 10th day of admission. An ultrasound of the urinary tract was done, which showed an ill-defined left renal outline with a 7 cm × 5 cm heterogenous cortical lesion at the interpolar region. A perinephric hematoma measuring 116 mL was also noted (Figures The hypervascular structure needs to be investigated later to exclude oncocytoma, and he was advised to follow up after six weeks with an MRI.Angiomyolipomas are benign mesenchymal lesions of the kidney comprised of mature adipose tissue, dysmorphic blood vessels, and smooth muscle. As with other renal tumors, the increased use of cross-sectional abdominal imaging has led to a rise in the diagnosis of these lesions. About 80% of AMLs are sporadic and not associated with any genetic syndrome. The remaining cases are associated with TSC and sporadic LAM . Renal AThe patient initially presented with flank pain that was out of proportion and not relieved with analgesia, which is the usual presenting complaint . A CT scDespite the difficulty in establishing causality between COVID-19 infection and renal AML rupture, there have been many reports linking the two incidents. The only other risk factor in our patient was the size of the AML. Other spontaneous bleeding complications have been described after infection with COVID-19, such as retroperitoneal hematoma, gastrointestinal bleeding, hemopneumothorax, and cerebral hemorrhage .COVID-19 can participate in bleeding as well as thrombosis. It has been proven that COVID-19 is associated with higher rates of thrombosis and bleeding in hospitalized patients with similar illnesses. This dysregulated coagulation is suggested to be due to endothelial disruption and autoimmunity induced by the coronavirus infection. Therefore, we feel that this case is worth reporting given the fact that COVID-19 was an important contributor to this patient’s AML rupture.


Intraventricular meningiomas are rare tumors, mainly localized in the lateral ventricle trigone. Several microscopic surgical approaches have been proposed according to the location of the tumors in the atrium. The authors present the case of a 68-year-old woman who had an increscent medically resistant headache with a left trigone meningioma. In the video, they demonstrate the four-hands surgical technique through a minimally invasive fully endoscopic retractor-less transcortical approach. They also discuss the background of these tumors and the technical nuances of the procedure, including the differences between an endoscopic surgical and a microsurgical one.https://stream.cadmore.media/r10.3171/2023.1.FOCVID2296The video can be found here:  We presented the case of a 68-year-old woman who suffered of a persistent headache resistant to medical therapy. She underwent an MRI, which showed the presence of an intraventricular lesion in the left trigone, with the main suspicion of a meningioma.According to the size of the tumor and the symptoms’ onset, surgery was indicated to avoid an acute hydrocephalus, intracranial hypertension, or development of neurological deficits. The risks of this procedure include eventual damages at the optic radiation, language areas, motor deficits, and Gerstmann’s syndrome for the subcortical parietal areas. Gamma Knife and radiosurgery are rarely indicated except for patients who can’t undergo general anesthesia or refuse surgery.To avoid damages at near-eloquent areas, we performed a full endoscopic inferior parietal lobule transcortical approach with a lateromedial/superoinferior direction, based on the preoperative tractography.The patient was placed in a lateral position with the head turned three-quarters on the right side, fixed with Mayfield head holder. The equipment was made by the surgical endoscope, microsurgical tubular instruments, ultrasound aspirator, and neuronavigator, which allowed us to study the surgical trajectory.Four-hands surgical technique was performed, consisting in two surgeons as first operators, of which in this case one holds the endoscope and spatula, the other one the surgical instruments, such as US aspirator, suction, bipolar, dissector, and microscissor. Both hands of the surgeons move in a coordinated way to guarantee a complete surgical vision by reducing the dynamic retraction.A minimally invasive linear skin incision was performed centered on the mini-craniotomy, followed by the corticectomy. A retractor-less transcortical approach was made with the only use of a spatula and dissector, to make gentle dynamic retraction of the interested parenchyma to avoid iatrogenic cerebral contusions.Considering the minimally invasive approach and the surgical site, it’s important to first debulk the lesion to easily find then its pedicle. Therefore, a mild debulking was performed through ultrasound aspirator. Usually, these lesions are characterized by a dura-like layer on the surface, which we could appreciate with some adherences between the ependyma and the tumor, already identified through the preoperative MRI, which have been gently detached.A first pedicle of the lesion was then seen, attached to the choroidal plexus in its cranial aspect, facing the anterior part of atrium, toward the middle sella and more anteriorly to the frontal horn. The vascular pedicle of the tumor should be identified and coagulated at the earliest possible time to avoid excessive bleeding from the ependymal surface, which can be challenging to control. We used bipolar forceps to coagulate and then cut it with microscissors to initially mobilize the tumor.After having partially moved the lesion, we could find the choroidal plexus on the occipital side, going downward to the temporal horn with the lateral-posterior left choroidal artery. Thanks to the endoscope surgical view, we could also appreciate the column of fornix in white, which turned around the thalamus on the anteromedial aspect.After having detached the lesion from the ependyma and rolling it on the surgical site, avoiding any retraction, we could appreciate the choroidal plexus still kept the lesion adherent to this area. This kind of surgical vision was possible only thanks to the endoscope.We continued then to debulk the tumor to better expose its base of implant, which we finally cauterized, avoiding the rupture of the small cicatricial synechiae and choroidal vessels associated; otherwise, there may be small bleedings, which, although minimal, could be compromised the ventricular system. The choroidal plexus was completely cauterized and cut with microscissor.We moved finally on the parieto-occipital portion of the choroidal plexus to completely detach the meningioma. An exploration excluded any other portion of attachment; the lesion was rolled in the surgical cavity to allow the surgeon to see if beyond the lesion any vessels were attached. Then we gently removed the tumor, appreciating the corticectomy was smaller than the lesion itself.1 They usually origin from the meningothelial inclusion bodies in the tela choroidea or the mesenchymal stroma of choroid plexus,2 often surrounded by a dura-like layer, as seen in this case. Because of their size they usually become symptomatic due to block the CSF and their proximity to eloquent areas.Intraventricular meningiomas are rare tumors, mainly located in the trigone of the lateral ventricle.4 The endoscopic approach gives a wider viewing range compared with the microscope and may reduce damage to normal brain tissue, facilitating total resection of the lesion and improving the surgical outcome.5 Surgical trajectory is based on the trigone tumor’s relationship with near white matter fiber tracts involved in the vision, language, motor functions, and integration of information.6Surgery is indicated when symptomatic, and in literature are described different approaches according to the tumor position in the trigone and to avoid the nearby white matter fiber tracts with a microscopic view.A postoperative CT scan excluded any complications. The patient underwent a postoperative MRI within 48 hours from surgery, which confirmed the gross-total resection of the lesion. She was discharged in her 6th postoperative day without neurological deficits.She repeated the MRI during the follow-up, 2 months after surgery. The patient was in perfect condition without headache. The final diagnosis was grade I meningioma, according to the WHO classification.We are extremely grateful to Dr. Valeria Coppola, Neuroradiologist at Regional Hospital San Carlo, for her passion and extreme accuracy in helping us with the preoperative planning, creating specific tractography.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.Primary surgeon: Cecchini. Assistant surgeon: Di Biase. Editing and drafting the video and abstract: Gelmi. Critically revising the work: Gelmi, Cecchini, Vitale. Reviewed submitted version of the work: Gelmi, Cecchini. Approved the final version of the work on behalf of all authors: Gelmi. Supervision: Cecchini, Vitale, Di Biase.The necessary patient informed consent was obtained in this study.


Testicular tumors in the intra-abdominal undescended testis are rare in children, and their management remains challenging. The aim was to present a case report and review of the literature about diagnosis and treatment of testicular tumors arising from undescended intra-abdominal testis in children.In this study, we retrospectively analyzed the clinical records of a 1-year-old male patient admitted to pediatric surgery in March 2022 with a testicular tumor originating in the intra-abdominal undescended testis. Furthermore, medical literature published in English during the last three decades was systematically searched through the databases of Medline, PubMed, and Google Scholar.The patient underwent laparoscopic orchiopexy and tumor excision. The operation was uneventful, and the patient recovered well without complications. An 8-month follow-up showed no recurrence of the teratoma after postoperative pathology. The literature search resulted in the retrieval of 16 non-duplicate articles, and 16 patients were included in this review. The cases included six cases of left cryptorchidism and 10 cases of right cryptorchidism, with an average age of 15.3 months. The largest transverse diameter of the tumors ranged from 1.8 to 12.5 cm, with an average tumor length of 6.7 cm. All patients underwent surgical treatment, including three cases of laparoscopic orchiectomy, a sole case of a conversion of inguinal incision to laparotomy and orchiectomy, and 12 cases of laparotomy and orchiectomy. Postoperative pathology revealed 12 cases of mature teratoma, two cases of immature teratoma, one case of yolk sac tumor, and a single case of embryonic carcinoma combined with yolk sac tumor. 11 patients were followed up, and one of them recurred.Abdominal ultrasound (US) or abdominal computer tomography (CT) should be performed in cases of undescended testis suspected to have testicular tumors on clinical findings. The most common type of intra-abdominal testicular tumor is mature teratomas. Early diagnosis and prompt surgical intervention resulted in an excellent outcome. Undescended testis also called cryptorchidism, is the most common reproductive congenital anomaly in pediatric urology . UndesceA 1-year-old boy, born with a non-palpable undescended testis on the right side, was admitted to our hospital. Four months ago, the first ultrasound (US) examination revealed a nonpalpable undescended testis in the abdomen near the internal ring and no mass was found in the testis. The preoperative ultrasound showed that the testis was still in the abdomen near the internal ring. The US simultaneously showed a hyperechoic mass of approximately 3 mm in the testis . Howeverβ- hCG (<0.1 mIU/ml). It was necessary for the child to undergo laparoscopic surgery. During the operation, we discovered that the right testicle was within a few centimeters of the internal ring but that there was no visible tumor , le tumor . Using ale tumor . We perfle tumor . The tesMedical literature published in English during from 1990 to 01-01 to 2022-12-31 was systematically searched through the databases of Medline, PubMed, and Google Scholar. The publication type was limited to article, case report and case series. The main search terms were set as “testicular tumor”, “undescended testis”, and “non-palpable testis”. After excluding patients older than 14 years of age and those children's cases without full-text articles, a total of 16 cases were retrieved from English literatures. Clinical data were counted, including age, clinical manifestations, location, preoperative examination, tumor diameter, surgical method, pathological diagnosis, follow-up time, and recurrence. The clinical characteristics of the patients are shown in Studies have found that 20% of undescended testis were non-palpable, and 25%–40% were non-palpable intraabdominal testes , 24.UndeA typical clinical presentation is absent in patients with undescended testis or testicular tumors. Most patients were hospitalized for cryptorchidism, and testicular tumors were discovered unexpectedly during the preoperative ultrasound. Clinical symptoms are less apparent when the patient is young, even asymptomatic. This may be due to the children's inability to express symptoms and the fact that symptoms are ignored, leading to late detection. Cryptorchidism with testicular tumors has only been diagnosed in a few patients due to abdominal mass or abdominal pain. Testicular tumors in the abdominal cavity are difficult to detect without imaging examination. The abdominal US is sensitive to testicular tumors, with hyperechoic changes often indicating tumors. An abdominal CT examination plays a vital role in confirming an intraperitoneal undescended testis with testicular tumor .β-HCG, and CA-125  must be guaranteed . RadicalIn conclusion, abdominal US or abdominal CT should be performed in cases of undescended testis suspected to have testicular tumors on clinical findings. The most common type of intra-abdominal testicular tumor is mature teratomas. Early diagnosis and prompt surgical intervention resulted in an excellent outcome.


Ovarian adrenal rest tumors (OARTs) are very rare. We describe a case of a young woman with uncontrolled classical congenital adrenal hyperplasia (CCAH), presenting with bilateral OARTs, successfully treated with steroid replacement. A 20-year-old woman, known to have 21OH-CCAH, presented with severe abdominal pain, vomiting, diarrhea, and fever. As a result of poor compliance, 6 months before her admission hirsutism worsened and amenorrhea, hyperpigmentation, and weakness developed. ACTH levels were 278 < pmol/L and 17OHP 91.3 nmol/L. She was admitted for parenteral antibiotics and high-dose hydrocortisone treatment. CT revealed bilateral juxta-ovarian masses (6.2 x 3.6 x 7.4 cm left and 5 x 2.2 x 3.2 cm right) that on MRI were iso-intense in T1 and hypointense in T2, with early enhancement and rapid washout. One week of high-dose hydrocortisone resulted in significant clinical and laboratory improvement and the patient was discharged with 2 mg dexamethasone/day. One month later US revealed shrinkage of the masses and dexamethasone dose was decreased. At three months from discharge, she has resumed regular menses, and a repeated MRI revealed the para-ovarian masses have shrunk. One year after the diagnosis, the para-ovarian masses have shrunk more to 2.8 x 1.9 x 4.3 on the left and 2.1 x 0.9 x 1.2 on the right with less contrast enhancement in comparison to previous test possibly due to fibrotic changes of the tissue. OARTs are rare tumors with a poorly known natural history, and surgery has been the first option in the few reported cases. We demonstrate that medical treatment is a good alternative, leading to significant tumor shrinkage over a short period. The development of gonadal adrenal rest tumors is a benign complication of congenital adrenal hyperplasia (CAH). They probably derive from adrenal cells that migrate with the gonad during fetal development . Their gA 20-year-old woman presented to the emergency room with severe abdominal pain, vomiting, diarrhea, and fever. She was known to have salt losing classical CAH treated with mineralocorticoids (fludrocortisone 0.1) and glucocorticoids . Biochemical data leading to her diagnosis of salt-losing classical CAH at birth were lacking. Moreover, virilization caused clitoromegaly and congenital labial adhesion, separated by urologic surgery at the age of 3. The patient’s menarche was at 13 years old, and she was graded Tanner Stage 5 and had hirsutism  and acne. She reached a final height of 161 cm.CYP21 gene. Genetic screening was carried out many years ago, with only a few mutations found . A deletion of the second allele could not be ruled out given the assays available at the time. Since the test did not correlate with the severity of the phenotype, the patient was advised to repeat genetic counseling several times as follow-up but did not proceed with the tests. A phenotype-genotype discordance was found in previous studies exploring the spectrum of disease severity in CAH, and although rarely, V281L mutation has been associated with salt-losing CAH (when sequencing of the entire gene was not performed)  and 2.1 x 0.9 x 1.2 on the right (down from 2.5 x 1.6 x 3.9) with less contrast enhancement in comparison to the previous test, possibly due to fibrotic changes of the tissue. In addition, multiple enlarged follicles were seen in both ovaries, implying hyperstimulation, possibly secondary to the long-lasting ovarian depression. Oral contraceptives were added to the pharmaceutical regimen.TARTs are benign tumors that histologically and functionally resemble adrenal tissue and are suspected to arise from aberrant adrenal cells that descend during fetal life with the gonads . They arWnt4 gene is downregulated in males to allow for the coelomic vessel formation in the testis; hence, steroidogenic cell migration remains possible  and secondary sex cords develop . WNT4, apossible .The imaging findings in TARTs are well described . The sonClinically significant OARTs have been reported mostly as case studies. No guidelines for the diagnosis or management of OARTs exists. We found only 17 case reports of OARTS in English language literature -27, docu


Chondroblastoma is a benign cartilaginous tumour that usually presents in the epiphysis of long bones in patients aged 10–20 years old. Only 4 % of primary chondroblastoma occur in the talus. Recurrence is rare, especially in the foot and ankle and there is no consensus regarding how it is best managed. This unique case and literature review add to a limited evidence base.A 21-year-old male was referred to our elective orthopaedic clinic with persistent anterior ankle pain exacerbated by weight-bearing. Radiographs and MRI revealed a 2.5 cm non-homogenous mass in the anteromedial talus with expansion of overlying bone consistent with chondroblastoma-ABC. Our patient was initially managed by intralesional curettage and autologous bone grafting but had recurrence 4.5 months postoperatively. Subsequent en bloc resection of the talar neck with talonavicular and calcaneocuboid joint fusion resulted in excellent functional outcomes and disease-free survival at 2 years follow-up.There are few reports discussing treatment options for recurrence in the foot and ankle. Successful treatment of primary and recurrent lesions depends on complete local resection. Repeat curettage or en bloc resection are effective options depending on tumour size and location. Type of bone graft or void filler should be considered on a case-by-case basis. Novel therapies (e.g. phenol instillation) may be beneficial.This case details successful management of recurrent chondroblastoma with en bloc resection of the talar neck and hindfoot reconstruction. We review the efficacy and outcomes of all previously reported recurrent chondroblastoma in the foot and ankle. We highlight multiple potential treatment options. •Only 4 % of primary chondroblastoma present in the talus.•This case describes recurrent chondroblastoma of the talus managed by en bloc resection and joint fusion.•There is no consensus regarding the management of recurrent lesions in the foot and ankle.•Recurrence of chondroblastoma is 10–35 %.•Novel adjuvant therapies have a potential role in preventing chondroblastoma recurrence. This case is the first to report successful management of recurrence in the talus by en bloc resection and hindfoot reconstruction. Our literature review amalgamates the outcomes of previously reported recurrences of CB in the foot and ankle.This case report meets SCARE criteria 2A 21-year-old male was referred to our orthopaedic clinic for persistent anterior, right ankle pain. Twelve months previously, he had rolled his ankle for which he attended physiotherapy for a presumed sprained ankle. However, the pain intensified, prompting a presention to the emergency department and then our clinic. His chief complaint was ankle pain exacerbated by weightbearing.He also reported intermittent ankle swelling, especially after strenuous exercise. No other joints were affected and his activities of daily living were not limited. He denied systemic symptoms such as weight loss and fatigue. He had no background medical or surgical history, he denied smoking and any family history of cancer.Clinical exam revealed point tenderness anteriorly. His gait was smooth and symmetrical, he was fully weight-bearing and had full range of motion in his ankle. There was no lymphadenopathy in the groin or popliteal fossa and he was otherwise neurovascularly intact.Radiographs showed a lucent lesion within the talar neck without fracture or periosteal reaction. Overall alignment of the ankle mortise was normal . MRI repOver the next 2 months, our patient became gradually unable to weightbear to the point where he required crutches. He subsequently underwent intralesional curettage and bone grafting via a single anterior approach to the talus. A cortical window was used to expose the tumour cavity before an aggressive curettage was performed. The remaining void was filled with autologous iliac crest bone grafting. Our patient reported immediate relief of symptoms. Post-operative radiographs were satisfactory . He was Histological examination of the intraoperative samples revealed mild cytological atypia with moderate numbers of multi-nucleated giant cells and scattered epithelioid cells. A significant cystic component was present which was noted to be more cellular than the usual fibrotic wall of an ABC. Areas of chondroid differentiation and necrosis were present throughout the lesion. Immunohistochemistry demonstrated weak positivity for S100, CD-68 staining histiocytes, and the MIB1 proliferation index was 5–10 %. The mitotic count was 1–2/10HPF. After multidisciplinary discussion the lesion was diagnosed as a benign chondroblastoma with secondary aneurysmal bone cyst formation.At routine follow-up, 4.5 months post-operatively, repeat plain radiographs identified a persistent focal lucency within the talus (2.2 cm) . Chest XThe revision procedure was performed through dual incisions, a curvilinear dorsolateral approach and a single anterior approach to the talus as before. Anteriorly, the talar neck was resected as far back as the talar dome and the articular surface of the talonavicular joint was excised. The remaining interval was prepared using a birr, drill and curettage before the defect was filled with a block of femoral head allograft. Graft fixation and talonavicular fusion were achieved using a 6.5 mm cannulated compression screw and 18 mm fixation staple. Next the calcaneocuboid joint and sinus tarsi were exposed through a dorsolateral approach. This joint was prepared with a birr and drill before it was fused using two 18 mm fixation staples .Fig. 5 score was 30/30, and American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot score was 94/100.3Chondroblastoma typically presents as chronic, non-traumatic arthralgia Primary foot and ankle involvement is rare, most commonly involving the calcaneus and talus 3.1Recurrence rates are reported between 10 %–35 % Surgery remains the gold standard of CB treatment 3.2While there are several reports of long bone recurrence, our literature review demonstrates a total of 18 reported cases of recurrent chondroblastoma in the foot and ankle. Including this case, 4 involve the talus. The calcaneus was the most common bone involved. The mean time to recurrence was 20.4 months and patients were predominantly male .Table 1SThere is no current consensus on how to treat these lesions. Treatment modalities for recurrence included revision intralesional curettage, wide local/en bloc resection and amputation. Our literature review suggests a trend towards revision curettage although each case was highly individual. Seven patients were treated in this manner with variations in void-filling technique. Six patients had no re-recurrence and one was lost to follow-up. Recurrent chondroblastoma is thought to be more aggressive than primary lesions and should be treated with a high degree of vigilance The effectiveness of revision curettage have been demonstrated in small case series of long bone recurrence although limited published data exists on chondroblastoma recurrence in general. Suneja et al. reported results of seven local recurrences, five in long bones and two in the foot and ankle. The mean time to recurrence was 10 months. Four patients were managed with revision intralesional curettage, one patient with endoprosthetic replacement of the humerus and both foot and ankle recurrences were managed by amputation. Three patients were successfully managed by revision curettage, but one patient underwent two further failed curettages before resection and endoprosthesis 3.3Revision surgery often involves more aggressive curettage or en bloc resection with wider margins and the need for subsequent reconstruction Autograft, allograft, and demineralised bone substitutes have all been show to be effective in small foot and ankle lesions While polymethylmethacrylate cement is widely used with good outcomes, it has been associated with growth arrest in immature skeletons Extensive curettage adjacent to articular surfaces is associated with joint degeneration Recently, denosumab treatment for chondroblastoma has been suggested due to CB's similar profile to giant cell tumours, including RANK L expression and how it responds to this human monoclonal antibody 4Chondroblastoma is a benign lesion with recurrence potential. There remains no consensus regarding most appropriate treatment. Our case report describes successful management of rare, recurrent chondroblastoma of the talus with en bloc resection and hindfoot reconstruction. Our literature review describes treatment modalities for recurrent disease.Written informed consent was obtained from the patient for publication of this case report. Evidence of this can be provided to the Editor-in-Chief of this journal upon request.Ethical approval is exempt/waived by the authors institution.N/A.Conceptualization: Alan Molloy and James WalshData curation: Olivia Jagiella-Lodise, Timothy McAleese, Mark Curtin, Alan Molloy, and James WalshSupervision: Timothy McAleese, Alan Molloy, and James WalshWriting:Original Draft: Olivia Jagiella-LodiseReview & Editing: Olivia Jagiella-Lodise and Timothy McAleeseJames Walsh.Not applicable.N/A.


Benign esophageal tumors are rare, occurring at an incidence of <5%.A 36‐year‐old woman presented with a 1‐month history of an asymptomatic left neck mass. She had been previously diagnosed with a thyroid nodule. Her thyroid function test results were normal, and ultrasonography showed a well‐defined hypoechoic mass behind the left thyroid lobe. Computed tomography (CT) showed a 2.5‐ × 3.6‐cm enhanced mass at the left tracheoesophageal groove with suspicion of esophageal involvement Figure . TransnaA transcervical approach was performed. The tumor was found after deflection of the left thyroid lobe, and the recurrent laryngeal nerve was successfully preserved Figure . IntraopBenign esophageal tumors are considered rare compared with the higher incidence of esophageal carcinoma. In 2003, Choong and MeyersThe diagnosis relies on multiple modalities. In our case, physical examination led to an initial misdiagnosis of a thyroid lesion. Ultrasonographic findings provided more information regarding the esophagus, leading to more precise investigations (CT and TNE). Cytology was needed to rule out malignancy, and the result was clearly a spindle cell tumor. According to the 2005 World Health Organization oncopathology and genetics criteria, esophageal mesenchymal tumor can be diagnosed if spindle cells are found microscopically.Our patient's initial pathological report suggested leiomyoma, but the histological pattern alone was not sufficient to differentiate other types of mesenchymal tumors; therefore, IHC was needed. Schwannomas are positive for S‐100 and SOX‐10 (characteristic markers for Schwann cells) and negative for CD117, CD34, and desmin. By contrast, GISTs are positive for CD117 and CD34, and leiomyomas are positive for actin, desmin, and caldesmon.The treatment options for esophageal schwannoma are based on many factors. Patients with asymptomatic schwannoma can undergo periodic surveillance with endoscopy, ultrasonography, or EUS. Most cases of symptomatic schwannoma warrant complete resection without further adjunctive treatment.The prognosis of esophageal schwannoma is promising because of its very low recurrence rate after complete excision. However, if histopathology shows a high degree of mitosis, the prognosis might be worse in terms of malignant potential.Nilnetre Mahathanaruk, surgeon, first author, corresponding author; Phurich Praneetvatakul, surgeon, coauthor, senior author.None.None.None.


BSCL2 gene (p.Thr109Asnfs* 5). Ultrasound revealed a hypoechoic solid nodule measuring 1.8 × 1.0 × 1.0 cm, and fine needle aspiration biopsy suggested malignancy. Total thyroidectomy was performed, and a histopathological examination confirmed PTC with vascular invasion and parathyroid lymph node metastasis (pT3N1Mx stage). This is the first report to describe a case of differentiated TC in a child with CGL. Severe insulin resistance that is generally observed in patients with CGL early in life, especially in those with type 2 CGL, may be associated with this uncommon presentation of aggressive PTC during childhood.Thyroid carcinoma (TC) is rare in children, particularly in those aged < 10 years. Several studies have demonstrated a correlation between neoplasms and hyperinsulinemia and insulin resistance, which are often associated with a higher risk for and/or aggressiveness of the neoplasm. Congenital generalized lipodystrophy (CGL) with autosomal recessive inheritance is a rare disease and is characterized by the lack of adipose tissue, severe insulin resistance, and early metabolic disturbances. Here, we reported a rare case of a type 2 CGL in a girl who presented with a papillary TC (PTC) at the age of 7 years. She had no family history of TC or previous exposure to ionizing radiation. She had a generalized lack of subcutaneous fat, including the palmar and plantar regions, muscle hypertrophy, intense acanthosis nigricans, hepatomegaly, hypertriglyceridemia, severe insulin resistance, and hypoleptinemia. A genetic analysis revealed a mutation in the  Thyroid carcinoma (TC) is rare in children, particularly those aged < 10 years, and accounts for 1.5%–3% of all childhood cancers in North America and Europe; however, its incidence has been increasing by 1.1% each year . The behSeveral studies have revealed the correlation between neoplasms and hyperinsulinemia and insulin resistance (IR), which are frequently associated with a higher risk for and/or aggressiveness of the neoplasm –6. HowevCGL is a rare disease with autosomal recessive inheritance characterized by a lack of adipose tissue, hypoleptinemia, severe IR, and early metabolic disturbances such as dyslipidemia and diabetes mellitus ,10.Here, we report a rare case of type 2 CGL in a girl who presented with PTC at the age of 7 years and who had no family history of TC or previous exposure to ionizing radiation.A 9-year-old girl with a clinical and molecular diagnosis of CGL was being followed at our center, . Based on the generalized absence of adipose tissue, she was clinically diagnosed as having CGL in her first year of life.2. She had a generalized lack of subcutaneous fat, including in the palmar and plantar regions, muscle hypertrophy, intense acanthosis nigricans, and hepatomegaly  of 20.5 kg/mtomegaly . The pattomegaly .BSCL2 gene mutation (p.Thr109Asnfs* 5), characterizing type 2 CGL.In her first year of life, hypertriglyceridemia (442 mg/dL) was detected. During follow-up, her clinical and laboratory work-up revealed IR . At 7 yeAt 7 years of age, thyroid gland ultrasound revealed a hypoechoic solid nodule measuring 1.8 × 1.0 × 1.0 cm in size, with partially defined margins and multiple foci of microcalcification located in the upper third of the right lobe. According to the clinical history, the patient had no family history of TC or previous exposure to ionizing radiation.Results of a cytological evaluation of the nodule, obtained through fine-needle aspiration biopsy, suggested malignancy (Bethesda V classification). Thus, total thyroidectomy was performed. Results of a histopathological examination confirmed a classical variant of PTC, with the tumor measuring 1.2 cm  and having vascular invasion. Perineural infiltration was not performed. Extrathyroid extension and metastasis were observed in a parathyroid lymph node (pT3N1Mx stage) . The patThis is the first study to report about a differentiated TC (DTC) in a child with CGL. Although the patient did not present with other risk factors for TC, i.e., previous radiation exposure or a family history of TC, she had severe CGL-associated IR since early childhood. Furthermore, she had an aggressive presentation of PTC (pT3N1Mx stage).AGPAT2 and BSL2 genes, respectively, which express proteins that are critical in triglyceride and phospholipid biosynthesis, lipid droplet formation, and adipocyte differentiation  are overexposed in most DTC cases ,22. In aIGF-1 plays a role in various human malignancies and possibly in DTC ,22. IGF-Some studies have described the presence of high leptin levels in patients with DTC . Cheng aAlthough our patient had no clinical diagnosis of diabetes, she had altered glycated hemoglobin levels. Most studies have demonstrated the correlation between diabetes and DTC. In their case-control study, Bae and cols. observed that Korean women in the upper quarters of HOMA-IR had an odds ratio of 4.07  for DTC. These data were adjusted for age, BMI, history of smoking, hypertension, thyroid disease, other cancers, cholesterol levels and TSH .In the meta-analysis conducted by Yeo and cols., women with pre-existing DM had an increased risk for TC  . A similHowever, it is unlikely that the association reported here is a random occurrence. The occurrence of DTC in children aged < 10 years is rare and is usually associated with the presence of identifiable risk factors such as a family history and exposure to ionizing radiation during childhood; however, this was not observed in our patient. Our patient had IR since her first year of life, which was related to the most severe subtype of CGL. Our case findings reinforce the hypothesis that IR is a trigger for CGL, independent of BMI or leptin levels.In conclusion, this is the first report to describe DTC in a child with CGL. The severe IR usually observed in this disorder early in life, especially type 2 of CGL, may be associated with the uncommon presentation of aggressive PTC during childhood. Future prospective studies are needed to better define the association between TC and severe IR and demonstrate the possible benefit of thyroid evaluation in patients with CGL.


Our objective was to report the use and results of 68Ga-DOTATOC PET in suspected ONSM. Twelve subjects who underwent 68Ga-DOTATOC PET for suspected ONSM in our department were retrospectively included. Standardised clinical and radiological data were collected. The PET examination results were classified as positive or negative, and lesion standardised uptake values (SUVmax) were recorded. 68Ga-DOTATOC PET confirmed positive uptake in six cases (SUVmax > 5), leading to ONSM diagnoses followed by radiation therapy in patients with vision loss. Six 68Ga-DOTATOC PET scans were considered negative (SUVmax < 5); these comprised one case of neurosarcoidosis, one cavernous malformation, and four uncertain diagnoses, leading to further investigation. 68Ga-DOTATOC PET was helpful in tumour volume delineation before radiation therapy, leading to a decrease in dose exposure. Noninvasive 68Ga-DOTATOC PET should be performed before treating nonhistologically proven meningiomas with radiotherapy or stereotactic radiosurgery, particularly in cases of uncertain diagnosis with MRI, which characterises most ONSM cases. PET SUVmax thresholds to distinguish meningioma from nonspecific uptake in other lesions need to be adapted to ONSM. 68Ga-DOTATOC PET improves the intraorbital lesion diagnostic approach and therefore impacts therapeutic management. Optic nerve sheath meningiomas (ONSMs) are benign tumours that arise from meninges around the optic nerve. The optic nerve sheath is a rare meningioma location, accounting for 1–2% of meningiomas [ONSMs most frequently occur in adults between 30 and 50 years of age and most often in females, with a sex ratio of 3:1 . HoweverONSMs’ clinical presentation can vary from no symptoms to ocular motility disturbance, proptosis, exophthalmos, and progressive vision loss via compressive optic neuropathy, as specified in ophthalmologic examinations. Papilledema might also be observed. Prognosis varies and is essentially functional, depending on location, the main risk being definitive vision loss if left untreated.Clinical management depends on functional impairment. Some ONSMs remain asymptomatic and only need observation, whereas others need appropriate therapies. Progestin intake should always be assessed as it increases the risk of meningioma, especially if taken over a long period of time or in high doses, and should be discontinued when possible. Therapeutic management includes surgery, which comprises delicate, stereotactic radiotherapy and intensity-modulated radiation therapy (IMRT) with a risk of radiation-induced retinopathy or neuropathy. Currently, radiation therapy (RT) is the preferred treatment in cases of visual impairment.Diagnosis relies mainly on clinical and imaging features since biopsy in this location can be deleterious and is avoided as much as possible. Typical MRI findings are the following: optic nerve enlargement with thickening of the meninges surrounding the optic nerve that can be tubular, globular, fusiform, or focal, and isointensity on T1- and T2-weighted sequences . After gHowever, MRI findings can be nonspecific and sometimes fail to differentiate meningiomas from their other main differential diagnoses, which include tumours such as gliomas, lymphomas, and metastases; granulomatosis such as neurosarcoidosis or tuberculosis; and optic perineuritis. In MRI, optic nerve glioma typically presents as uniform enhancement of the optic nerve, but in some cases, the nerve sheath is thickened, mimicking ONSM. In ONSM, the meningioma can sometimes invade the optic nerve and not be confined to the sheath. Furthermore, the typical tram track sign visible in ONSM may be observed in many other diseases that represent the main differential diagnoses of ONSM, such as perioptic neuritis, orbital sarcoidosis, lymphoma, and metastases .68Ga-DOTA-conjugated somatostatin analogues can differentiate meningiomas from their other main differential diagnoses [Noninvasive PET imaging with iagnoses  with hig68Ga-DOTATOC uptake, with maximum standardised uptake values (SUVmax) between 4.3 and 68.7 for all types of meningiomas [max was 14.3 ± 15.4 for optic pathway meningiomas, with a sensitivity and specificity of 100% for detecting ONSM [Indeed, meningiomas are known to intensely express somatostatin receptor subtype 2A (SSTR2A), which can be targeted with radiolabelled somatostatin analogues , even when they are aggressive. There has been rising interest in the use of positron emitters for the diagnosis of meningiomas, whereby a high tumour-to-background ratio is sometimes able to diagnose millimetric remnant lesions . MeningiIt is important to note that, unlike MRI, PET is a molecular imaging technique that identifies the molecular target SSTR2 in the case of DOTATOC PET. High uptake by a lesion of DOTATOC PET reflects that the lesion has high SSTR2 expression, as revealed through receptor binding. DOTATOC PET uptake in meningiomas is well correlated with SSTR2 expression in the lesions in anatomopathological studies .68Ga-DOTATOC PET in the diagnosis of ONSM have been reported [68Ga-DOTATOC PET in the follow-up for ONSM has been reported.Only a few cases of reported ,11,12. T68Ga-DOTATOC PET on the diagnostic strategy for and clinical management of ONSM.We report a series of 12 cases of suspected optic nerve sheath meningiomas and analyse the impact of 68Ga-DOTATOC PET in the Department of Nuclear Medicine, Marseille, APHM, between January 2020 and April 2022 for suspected ONSM were retrospectively included. 68Ga-DOTATOC PET was performed using an integrated PET/CT camera  after the intravenous injection of a 2.5 MBq/kg radiotracer. A protocol of 7 min of acquisition, 1 h postinjection, was used. Images were reconstructed on a 192 × 192 matrix using the ordered subsets expectation maximisation algorithm and were corrected for attenuation using a CT transmission scan.All patients who underwent max, to classify PET as positive or negative was chosen via discussion amongst the authors.Standardised clinical and radiological data were recorded. When MR images were available, PET images were fused with the MR images using alignment algorithms. Hence, images could be represented as PET/MRI fused images, even if acquired with a PET/CT camera, and secondarily fused with MRI. PET examination results were classified as positive if DOTATOC uptake was considered elevated and negative if DOTATOC uptake was considered low or null by two independent nuclear physicians. The maximum standardised uptake values of the optic lesion and pituitary gland were recorded. Initially, PET was classified as positive or negative based on visual interpretation. Subsequently, an optimal threshold, based on SUVNo biopsies were performed. All cases were discussed in multidisciplinary meetings with a neuro-oncologist, radiotherapist, neurosurgeon, and nuclear physician. Patients were followed up by physicians, and further examinations were performed when necessary . Follow-up visits and multidisciplinary meetings were employed to (i) validate the diagnosis of ONSM, (ii) give the case an uncertain diagnosis, or (iii) choose other diagnoses.68Ga-DOTATOC PET. The gross tumour target volume (GTV) was defined using MRI with at least T1-weighted gadolinium and T2 FLAIR sequences. The clinical target volume (CTV) was defined as the GTV expanded by a 3 to 5 mm margin to consider the microscopic extension of the disease. CTV could be manually modified by the radiation oncologist according to the MRI interpretation. BTV and CTV were compared in patients who were treated in our department.Preradiation therapy (RT) volume delineation was performed on all cases by the same radiation therapist. The biological target volume (BTV) was defined using This study was approved by the institutional review board of the French College of Neurosurgery . Retrospective observations required nothing other than informed consent according to French and European regulations.® Excel 2023.Mean values as well as ratios were calculated using Microsoft 68Ga-DOTATOC PET scans for suspected ONSM were analysed. All patients presented with a unilateral optic nerve lesion in MR images. Most MRI examinations showed an isointense T1-weighted lesion with peripheral enhancement. Six examinations were considered positive due to intense 68Ga-DOTATOC uptake, and six exams were considered negative. 68Ga-DOTATOC results.Twelve 68Ga-DOTATOC examinations by virtue of their intense radiotracer binding in the optic lesion, which is strongly suggestive of ONSM  with rapid vision loss. One patient (case 6) had already been treated with IMRT 6 years ago for a suspected ONSM and presented 1 year ago with visual impairment of the treated eye. One positive case had no vision loss case 4; . This 4168Ga-DOTATOC PET scans, the SUVmax values of the retained ONSMs ranged from 6.3 to 19.6, with a mean SUVmax = 10.8.Concerning the six positive max ONSM/pituitary ratios ranged from 0.4 to 1.1, with a mean ratio of 0.8.The SUV18F-FDG whole-body and brain PET scans were negative. High-dose corticosteroid therapy had no clinical effect.Case 5 was a 74-year-old woman first referred for right blurred vision. An ophthalmologic examination revealed disc pallor and diminished vision in the right eye. MRI showed a hyperintense T2 enlargement of the intraorbital and intracanalar right optic nerves, with peripheral enhancement shown in T1-weighted images. Neuritis, lymphoma, and ONSM were suspected. The results of the medullary MRI, spinal tap, and two 68Ga-DOTATOC PET showed moderate–high DOTATOC uptake with an SUVmax of 6.3, but the lesion/pituitary ratio was low (0.4). The absence of any FDG uptake by the lesion combined with radioclinical stable evolution and moderate 68Ga-DOTATOC uptake led to the diagnosis of ONSM. RT was discussed but not started for personal reasons.68Ga-DOTATOC uptake (cases 7 to 12). Four diagnoses remained unknown. In the absence of worsening vision loss, no biopsy was performed in these cases. One patient was diagnosed with sarcoidosis . This 67-year-old man was referred for brutal left retro-ocular pain and diplopia to the right lateral gaze one month before the examination. MRI showed a round heterogeneous lesion of the left orbit, with mixed signal intensity on T1- and T2-weighted images and no enhancement. 68Ga-DOTATOC PET and the CTVs obtained from MRI were compared. Both measures were defined by the same radiation therapist. The BTVs obtained for cases 2 and 3 were 2.5 cm3 and 1.1 cm3, respectively, whereas the CTVs were 6.8 and 2.5 cm3, respectively (see In two positive ONSM cases (cases 2 and 3), the BTVs obtained from 68Ga-SSTR ligand PET in the literature. Meningiomas usually have high SSTR2A expression and hence high 68Ga-DOTATOC uptake, in contrast with most tumours or inflammatory lesions that can show low, nonspecific 68Ga-DOTATOC uptake [The optic sheath nerve is a rare location for meningiomas, which explains the scarce cases with C uptake .Radiolabelled SSTR2A-PET is a noninvasive tool to identify the presence of SSTR2A. A high uptake by the lesion in PET reflects that the lesion has high SSTR2 expression that has bound the tracer, which has been confirmed in anatomopathological studies .Other tumours can exhibit high SSTR2A expression, such as pituitary adenoma or neuroendocrine tumours, but are not usually found in the optic pathway sheath or orbital location. Rare cases of NET metastases in the optic pathways have been described, but the primary tumour is usually noisy, and the clinical context helps to identify it.68Ga-DOTATOC uptake can be concluded to be meningiomas with a high predictive positive value. When we see a high uptake, we do not expect a false positive in the optic pathways. Klingenstein et al. reported 100% specificity in their study on optic pathway tumours [Hence, intraorbital tumours with high max values of lesions with a obtained diagnosis of ONSM ranged from 6.3 to 19.6 (mean SUVmax = 10.8), which are close to results found in the literature  [max of 5.6) [In the present case series, the SUV of 5.6) .68Ga-DOTA uptake that is not necessarily correlated with SSTR2A expression (tumour SUVmax = 2.25 ± 1.33 in a study consisting of 19 gliomas) [Low tracer uptake can be found in many tumours or inflammatory lesions, as illustrated in gliomas) .max has been suggested by some authors [max delineated meningiomas in PET before RT but did not seem able to differentiate meningiomas from other lesions or distinguish certain types of meningiomas, such as ONSM. In the same study by Rachinger and colleagues, 9/82 lesions with SUVmax > 2.3 were identified as not being meningiomas with a specificity of 73.5% [max values ranging from 1.7 to 3.6  and by the lack of histological confirmation, as in most ONSM studies.Even though this study is, to our knowledge, the largest study on Another limitation is that apart from biopsy, there is a lack of a clear gold-standard method for ONSM diagnosis.In the present study, high DOTATOC uptake led to a positive diagnosis of ONSM. This could be interpreted as a limitation and could indicate the presence of false positives. However, diagnoses were made in concordance with clinical and MRI data after multidisciplinary discussion and with a compatible follow-up. DOTATOC PET is a molecular technique that detects SSTR2A. Since other tumours that highly express SSTR2A are not found in the optic nerve, if the optic lesion presented a high SSTR2A level in PET, the PET was considered positive.Concerning negative examinations, two diagnoses of tumours other than meningiomas were made , while four diagnoses remained unknown. These four diagnoses could have been false negatives (ONSMs with low SSTR2).68Ga-DOTATOC PET for this indication, particularly for 68Ga-DOTATOC PET-negative lesions.Larger series and new tools for meningioma diagnosis are required to specify the desirability of 68Ga-DOTATOC PET is a noninvasive, powerful, and still underused tool in the diagnostic workup of intraorbital tumours, especially ONSMs.As illustrated in this study, 68Ga-DOTATOC uptake in contrast with other tumours or inflammatory lesions that can show low, nonspecific 68Ga-DOTATOC uptake. Previously reported SUVmax cut-offs to differentiate meningioma from non-meningioma are probably not adapted to ONSM and do not seem specific enough. Based on the present series, an SUVmax threshold of 5 seems most relevant for the diagnosis of ONSM.ONSMs are frequent primary optic nerve tumours, but their diagnosis is challenging due to nonspecific clinical or MRI findings and a lack of histology on this specific location. Meningiomas usually have high SSTR2A expression and, hence, high max ratio should be specified. In this case series, 68Ga-DOTATOC PET improved the intraorbital lesion diagnostic approach and therefore impacted therapeutic management, identifying 6 ONSMs out of 12 intraorbital lesions. Negative 68Ga-DOTATOC PET should lead to an uncertain diagnosis of meningioma and the possibility of differential diagnosis requiring complementary investigations and possible biopsy. Moreover, 68Ga-DOTATOC PET may be helpful in tumour volume delineation during radiation therapy planning.The role of the lesion/pituitary SUV


Jejunal diverticulum is a rare condition that affects less than 0.5 % of population. Pneumatosis is also a rare disorder marked by gas in the intestinal wall's submucosa and subserosa. Both the conditions are rare cause of pneumoperitoneum.A case of 64 years female presented with acute abdomen and upon investigation found to have pneumoperitoneum. Exploratory laparotomy was done and intraoperatively there was multiple jejunal diverticula and pneumatosis intestinalis in separate segments of bowel and closure was done without any resection of bowel segments.Small bowel diverticulosis was considered to be an incidental anomaly; however, it is now thought to be acquired. Pneumoperitoneum is a common complication of diverticula perforation. The occurrence of pneumatosis cystoides intestinalis or subserosal dissection of air around the colon or adjacent structures has been linked to pneumoperitoneum. Complications should be managed accordingly however, occurrence of short bowel syndrome should be considered before doing resection anastomosis of involved segment.Jejunal diverticula and pneumatosis intestinalis both are rare cause of pneumoperitoneum. Combination of both the condition giving rise to pneumoperitoneum is extremely rare. These conditions can give rise to diagnostic dilemma in clinical practice. One should always think these as differentials when patient with pneumoperitoneum are encountered. •Pneumoperitoneum rarely can be caused by jejunal diverticula and pneumatosis intestinalis.•Combination of both pneumatosis intestinalis and jejunal diverticular disease is extremely rare.•Proper clinical evaluation and investigation need to be done as these conditions may cause dilemma in diagnosis.•Surgical treatment may also depend on intraoperative findings. Males a2A 64 years female from kathmandu presented to our emergency department with chief complaints of pain in abdomen for 3 days and vomiting for 1 day. The pain in abdomen was generalized all over abdomen and was mild to moderate in intensity. She had undergone laparoscopic cholecystectomy one year back, since then she had abdominal distension and altered bowel habit. She had 3 episodes of vomiting one day back which was non-projectile and contained food particles. She had not passed stool and flatus for 2 days. She had chronic obstructive pulmonary disease (COPD) for one year. She was non-smoker and did not consume alcohol. She had no history of diabetes mellitus, hypertension, or pulmonary tuberculosis.She was conscious, co-operative, well oriented to time, place, and person. On general physical examination she had dehydration, however, she had no pallor, icterus, cyanosis, or clubbing. Her blood pressure was 102/78 mmHg, pulse 80 beats/ min, and respiratory rate 21 breaths/min. On abdomen examination, her abdomen was soft and distended, mild tenderness over generalized abdomen was present however there was no rebound tenderness or guarding, tympanic on percussion and liver dullness was obliterated. However, there was no organomegaly and bowel sound was not present.Her laboratory investigations are shown in Following this she was suspected to have hollow viscus perforation peritonitis with bowel obstruction and was planned for explorative laparotomy. The procedure was performed by above mentioned author team in our tertiary centre in emergency basis. However, intraoperatively there was pneumatosis intestinalis with jejunal diverticulosis , 4, 5 wiHistopathological examination showed fibrocollagenous tissue with mild chronic inflammatory infiltrates, vascular proliferation and edematous changes , 7.Fig. 3Pneumoperitoneum is a condition characterized by presence of free air in abdominal cavity. Various causes of pneumoperitoneum are perforated peptic ulcers, bowel obstruction, penetrating trauma, ruptured diverticulum, after laparoscopy. Pneumoperitoneum can be diagnosed by plain x ray chest erect showing both dome of diaphragm where free gas is seen below the diaphragm and computed tomography of abdomen and pelvis in doubtful cases. Treatment depends on the causes and all pneumoperitoneum cases do not need surgical treatment because it may be caused by conditions that do not need laparotomy.Small bowel diverticulosis is false diverticulum defined as thin-walled sacculations made of mucosa, submucosa, and occasionally a thin coating of serosa . These dClinical signs and symptoms include a bloating sensation after eating, as well as vague and chronic epigastric or periumbilical abdomen pain of varying severity. The clinical condition is usually asymptomatic if there is no complication arising from the same condition. Due to the disease's relative clinical rarity and diverse presentation, identification may be delayed or hindered. Diagnosis is frequently determined on the spur of the moment, either through radiographic inspection or laparotomy due to complications.Chronic stomach pain, malabsorption, bleeding, diverticulitis, blockage, abscesses in the mesentery, and perforation are all reported complications of jejuno-ileal diverticulosis, which affect 10 %–30 % of patients. Diverticulitis with or without perforation is the most prevalent acute complication of the jejuno-ileal diverticula, occurring in 2.3 %–6.4 % of cases ,7 and wiBefore an exploratory laparotomy or diagnostic laparoscopy, the diagnosis of complex or uncomplicated jejunal diverticulosis is rarely made. Ultrasound, computed tomography, endoscopy, capsule endoscopy, intraoperative endoscopy, deep enteroscopy , laparoscopy, radio-tagged erythrocyte bleeding scans, and selective mesenteric arteriography have been used with increasing success for detection. Many lesions, however, can go undetected. The diverticula can quickly empty and become invisible if the diverticular ostium is large. Small diverticula may not hold contrast medium as well as larger diverticula, or they may not be filled at all. For certain diagnosis of asymptomatic and complex diverticula, laparotomy remains the gold standard.Pneumoperitoneum is a common complication of diverticula perforation. Pneumoperitoneum without perforation or indications of peritonitis, on the other hand, is uncommon. The outcome of a rapidly closed leaking diverticulum or the transmural passage of air via a thin-walled diverticulum has been postulated as the cause of this spontaneous, generally asymptomatic pneumoperitoneum.Nonspecific therapies such as a high-protein, low-residue diet, vitamin supplementation, antispasmodics, antidiarrheal drugs, antacids, and analgesics are used in the conservative treatment of uncomplicated patients ,12, withPneumatosis intestinalis (PI) is an uncommon but important condition in which gas is found in a linear or cystic form in the submucosa or subserosa of the bowel wall and rarely muscularis layer is involved. It is common in jejunum followed by ileocecal region and colon. Overall incidence is 0.03 % based on autopsy series . PI has On literature review, there are case reported of both diverticular disease and pneumatosis intestinalis giving rise to pneumoperitoneum separately as well as both present in same patient involving same segment of bowel however in our case small bowel diverticulum and pneumatosis intestinalis involved different segment of bowel.4Finally, although jejunal diverticula with pneumatosis are uncommon, they should not be ignored. Jejunal diverticula and pneumatosis intestinalis both are rare cause of pneumoperitoneum. Combination of both the condition giving rise to pneumoperitoneum is extremely rare. These conditions can give rise to diagnostic dilemma in clinical practice. Conservative management is the first line of treatment for patients with uncomplicated symptoms such as chronic abdominal discomfort or malabsorption due to jejuno-ileal diverticulosis. Surgical resection, on the other hand, is the preferable option when the patient does not respond to conservative treatment or when complications arise. One should always think these conditions as differentials when patient with pneumoperitoneum are encountered.Ethical approval is exempt/waived at our institution .None.Milan KC, Suman Dahal, Laligen Awale, Prasan B S Kansakar: Study concept, Data collection, and surgical therapy for patient.Milan KC, Suman Dahal, Sangam Shah: Writing and original draft preparation.Milan KC, Suman Dahal: Editing and writing.Prasan B S Kansakar, Laligen Awale: senior author and manuscript reviewer.Not applicable.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer reviewed.No conflict of interest.


Intracardiac leiomyoma is a rare benign right heart tumor that usually extends from the intravenous system. The patient often has a history of uterine leiomyoma.We report a 46-year-old female patient who presented to us with exertional dyspnea, chest tightness, and shortness of breath for two weeks and had a history of uterine leiomyoma resection. Echocardiography showed a pedunculated solid mass in the right heart with the pedicle attached to the inferior vena cava. The surgery was performed under cardiopulmonary bypass established through the femoral artery and vein with a probable diagnosis of leiomyoma. The tumor was removed by ingenious surgical technique: a snare made of silk suture in which the tumor’s pedicle was trapped, and the tumor with its pedicle was carefully removed with the help of a scalpel along the silk suture. The histopathology report confirmed the diagnosis of intravenous leiomyoma. The postoperative course was uneventful and the patient was discharged a week later.Intracardiac leiomyoma is a rare benign smooth muscle tumor. Surgery is the mainstay of treatment with different surgical approaches available. It is possible to completely remove cardiac leiomyomas through sternotomy without the need for an abdominal incision if the leiomyoma is originated in the inferior vena cava not far from the right atrium. Intravenous leiomyomatosis (IVL) is a rare and special type of uterine leiomyoma encountered in clinical practice in which leiomyomatous tissue is formed within the uterine vessels and progresses through the vessels. The median age of occurrence is 44 years and patients present usually with abnormal uterine bleeding or abdominal mass etc. . IVL devA 46-year-old female patient presented to our hospital with exertional dyspnea, chest tightness, and shortness of breath for two weeks. She had a history of uterine myomectomy four years ago. On physical examination, her blood pressure was 116/70 mmHg, pulse 78 beats/minute, and RR was 20/minute. Inspection of the chest revealed no abnormal findings. There was no abnormality found on the auscultation of the chest as well. Routine blood and biochemical tests were normal. Echocardiography showed a pedunculated solid hypoechoic mass in the right heart with the pedicle attached to the inferior vena cava not far from its opening into the right atrium Fig. . The hisIntravenous leiomyomatosis is often seen in perimenopausal women, which is clinically rare and often associated with a history of uterine leiomyomas. It can grow along the vasculature in a very aggressive fashion. Uterine venous leiomyomas involving the right heart are extremely rare and available literature is mostly individual cases , 6.IVL confined to the inferior vena cava has no obvious symptoms, but at the time symptoms occur, most tumors have invaded the heart. There is lack of effective standards for etiology, classification, and treatment methods. Regarding the origin of the ICL, one view is that the tumor originates from the venous vascular wall in the uterus or pelvis. Other holds the view that the ICL is a further extension of the uterine leiomyoma to the vasculature . Most ICThe tumor is generally smooth and rubbery, with a greyish-white or rusty color, with or without an intumescent intracardiac head. In patients with a long course of this disease, the tumor may be calcified and extended more than 50 cm . ImmunohIn terms of ICL morphological characteristics, to achieve the goal of complete tumor resection, the general surgical procedure needs to involve the pelvic cavity, abdominal cavity, thoracic cavity, and great vessels. It requires multidisciplinary team cooperation involving cardiovascular surgeon, general surgeon, and gynecology and obstetrics surgeon. Generally, a combined thoracoabdominal incision under extracorporeal circulation is used to remove the tumor , 9, 10. Combined with medical history, echocardiography, CT, and other tools can help in diagnosis, and diagnosis is generally not difficult. Once ICL is diagnosed, curative care should be carried out, and the surgical plan should be fully evaluated as far as possible. Individual incisions should be formulated according to the scope and origin of the tumor, and multiple and large incisions should be avoided as far as possible. Follow-up and observation should be carried out to detect tumor recurrence at an early stage.Once ICL is diagnosed, it should be actively treated with complete surgical resection, if possible, which has a good prognosis. The tumor usually is widely invading and growing. The surgical plan should be formulated under a multidisciplinary team and should be fully evaluated and individualized as far as possible. Close follow-up and observation are required to improve the survival of patients and prevent tumor recurrence.


A 37-year-old male presented multiple times for abdominal pain with a persistent diverticular abscess on imaging that was managed previously with antibiotics and percutaneous drainages. Due to unrelenting abdominal pain and multiple presentations of unresolved acute complicated diverticulitis, the patient underwent an exploratory laparotomy. A colonic mass was discovered, and the patient had a colonic resection. Pathology revealed invasive transverse colonic adenocarcinoma with perforation and involvement of the stomach. Imaging showed no distant metastatic disease and chemotherapy was started. Months after treatment, the patient developed skin lesions and a palpable mass at the previous drain site. Biopsy showed metastatic adenocarcinoma consistent with colonic origin. Colonic adenocarcinoma with metastasis to the abdominal wall after drainage of presumed diverticular abscess is rare. Clinicians should consider malignancy when a patient has a recurrent diverticular abscess that has failed medical management and multiple drainages. Clinicians should remain vigilant of the risk of seeding colonic adenocarcinoma to the abdominal wall when repeated drainage is performed. Diverticular disease is an uncommon colonic disease estimated to be as low as 5% in ages 40 years or younger . DivertiColorectal cancer (CRC) is one of the most common cancers worldwide. Common initial presenting symptoms of CRC include abdominal pain, palpable abdominal mass, change in bowel habits, rectal bleeding, unexplained anemia, and weight loss. Abscess formation and perforation are less common presentations of CRC. A well-contained perforation and local abscess formation of CRC can resemble complicated diverticular disease both in terms of symptomatology and radiographic findings.A combination of antibiotics, bowel rest, and drainage is the usual approach to manage diverticular disease. However, in patients with unresolved and persistent diverticular disease, it is imperative for clinicians to consider perforated colonic carcinoma before draining the fluid collection due to possible risk of metastatic tumor seeding to the abdominal wall at the drainage site.A 37-year-old male with a past medical history of iron deficiency anemia and diverticulitis with diverticular abscess and fistulization presented for a third time to the emergency department for persistent left upper quadrant abdominal pain and constipation for the past week. The patient was previously hospitalized for management of his diverticular abscess with intravenous antibiotics and image-guided percutaneous drainages Figure . He was Patient’s laboratory results showed a leukocytosis, iron deficiency anemia, and normal carcinoembryonic antigen Table .Contrast-enhanced abdominal CT revealed redemonstration of the mesenteric fat stranding with unchanged air-fluid collection around the transverse colon, with prominent left upper quadrant mesenteric lymph nodes, and a new soft tissue density in the abdominal wall at the site of previous drain site Figure .With signs and symptoms of possible bowel obstruction, intractable abdominal pain, previous failed medical management with percutaneous drainage and antibiotics, surgical intervention with exploratory laparotomy and colonic resection was planned. There was a concern for underlying malignancy given features of perforated diverticulitis with fluid collection and inflammatory changes near the splenic flexure and transverse colon Figure . HoweverThe patient ultimately underwent exploratory laparotomy, with the discovery of a colonic mass. Patient had a right colectomy, gastric wedge resection, and partial omentectomy. Pathology revealed a 11-cm moderately differentiated invasive transverse colonic adenocarcinoma with perforation and involvement of the stomach. The lymph node and malignancy resection margin were negative and final tumor-node-metastasis (TNM) staged as pT4bN0. He was subsequently started on FOLFOX  for his colon cancer. After three cycles of chemotherapy, the patient noticed new blisters and skin lesions around the prior drain site of his abscess. He underwent a skin biopsy which showed metastatic disease to the abdominal wall with primary colonic origin. Magnetic resonance imaging (MRI) showed the progression of metastatic abdominal wall tumor with local invasion and the development of a palpable mass at the previous drain site , African American descent, and diverticulitis. CRC can present in a variety of ways with either suspicious or emergent symptoms of obstruction, perforation, or an acute gastrointestinal bleed. The rare and unusual complications of colorectal carcinoma include bowel obstruction, abscess formation, and perforation. The predominance of left-sided colorectal carcinoma is due to the common occurrence of obstructing colonic lesions that are found in the smaller diameter of the left colon. Right-sided colonic lesions can present with symptoms of abdominal pain, palpable mass, or anemia. CT imaging can be used to detect bowel obstruction that can identify transitional zones and obstructing lesion on imaging that appears as irregular circumferential thickening of the colon .Abscess formation with colon cancer is a rare complication in patients with colon cancer. The formation of an abscess can be due to perforation of the colon, fistula formation between the colon and adjacent structures, or direct tumor invasion . PossiblPerforation and penetration of adjacent organs with abscess formation as an initial presentation of colorectal carcinoma are uncommon, with the incidence of perforation less than 10% . PerforaAbdominal CT imaging or ultrasound is the most common technique to diagnose intra-abdominal pathologies. With abdominal CT, it has been reported that accurate diagnosis preoperatively of perforated colonic carcinoma is low . PreviouMetastatic abdominal wall seeding after percutaneous drainage of a presumed complicated diverticular disease is rare. De Filippo et al. suggest that percutaneous drainage of abdominopelvic collections has been an alternative technique to surgery with lower morbidity and mortality rates . PercutaAbdominal wall drainage tract tumor seeding is incredibly rare and a few cases have been reported with gastric adenocarcinoma and metastatic abdominal wall implantation after drainage of intraabdominal abscess with a right colonic adenocarcinoma ,17. TumoPatients with diverticulitis should be screened for CRC after an acute episode of inflammation has resolved . At six It is important to consider malignancy when a patient presents multiple times with unresolved symptoms of ACD after several attempts with medical management with antibiotics and percutaneous drainages. This case highlights the importance of recognizing the radiological similarities between very different intra-abdominal pathologies. For example, the common finding of fat stranding around an inflamed structure seen on CT can be due to pancreatitis, appendicitis, cholecystitis, pyelonephritis, and diverticulitis. Other key radiological findings can help distinguish between ACD with abscess and perforated colonic cancer. Both clinical entities will show pericolic fat stranding, abnormal bowel wall thickening, and enhancement patterns on CT imaging, making colonic cancer and complicated diverticulitis a diagnostic challenge. Our case stresses the importance of considering the possible risk of colonic metastatic tumor seeding to the abdominal wall before performing multiple percutaneous abscess drainage in patients with presumed complicated diverticular disease that mimics perforated colonic cancer. The survival rate is worse with patients that have obstructive or perforated CRC; thus, it is crucial for clinicians to identify and reliably diagnose a perforated colon cancer to initiate timely management and improve clinical outcomes. Close follow-up with general surgery and gastroenterology is imperative after the acute episode of management of diverticulitis for screening for underlying CRC. More research will need to be conducted to identify distinguishing CT imaging features between perforated colonic cancer and ACD.


Giant goiters are still encountered in low-income countries where diagnosis and management remain challenging. The authors report a case of an endemic giant goiter, treated during a humanitarian mission. A 50-year-old female with no particular history presented during a humanitarian mission with a giant nontoxic goiter evolving for 30 years. She underwent a total thyroidectomy removing a 3 kg thyroid gland. The postoperative period was uneventful. Giant goiters are not exceptional in goiter-endemic areas. Diagnostic and surgical management do not require particular technology. Surgery remains feasible even in countries with limited resources. Thyroid diseases are one of the most common endocrine disorders worldwide. Endemic goiter due to iodine deficiency remains a public health concern in sub-Saharan Africa. In these areas, given the lack of available health care and socioeconomic issues, many patients often neglect their diseases and can present with enormous goiters. These massive goiters may result in significant pressure symptoms like dyspnea and dysphagia and sometimes be the cause of stigma and rejection. Surgical removal is the treatment of choice in such cases. It provides instant relief from the effects of pressure and ensures good cosmetic results.However, in developing countries, due to delayed diagnosis and lack of qualified human resources, surgical management of these goiters remains challenging -3. Here,During a surgical humanitarian mission in a low-income Sub-Saharan African country, a 50-year-old female, with no past medical history, who was not taking any medications, presented with a large cervical mass evolving for nearly 30 years. The patient complained of heaviness-like pain without dysphonia or dysphagia. She reported feeling moderate dyspnea when walking or during household activities. Aesthetic and social embarrassment was very important and associated with ostracism.On physical examination, she had a huge hypertrophy of the thyroid gland, occupying the whole neck, and overflowing laterally Figure  measurinTotal thyroidectomy was performed under general anesthesia after the identification and preservation of recurrent laryngeal nerves and parathyroid glands. It allowed the excision of a bulky, firm, multi-nodular thyroid weighing 3 kg Figure .Postoperative recovery was uneventful without dyspnea or muscle cramps. The patient was discharged three days later, with levothyroxine replacement therapy (100 micrograms per day), and placed under the supervision of the general practitioner.Giant goiters can still be encountered in goiter-endemic areas -3. TheseIn these places, the management of giant goiters often comes up against a diagnostic delay, a lack of qualified human resources, and an insufficient technical platform ,3,5,6. TTechnology to support medical decision-making is often lacking in these places . For ourTotal thyroidectomy is the best treatment modality for giant goiter . It doesGiant endemic goiters still exist in sub-Saharan Africa. Surgery is the main treatment modality in such cases. Subtotal thyroidectomy, with its long-term risk of recurrence, is an option but total thyroidectomy is the preferred one. The volume and the weight of these huge goiters might involve some surgical difficulties. However, the procedure does not require any particular technology and can be performed regardless of the work context.


Focal nodular hyperplasia (FNH) is a noncirrhotic tumor that is the second most benign tumor, accounting for 2% of all pediatric liver tumors.A 13‐year‐old Japanese girl developed a nodular hepatic lesion that was undetectable on ultrasonography 12 months ago. She was initially treated as an outpatient for obesity at 8 years of age. At 10 years old, she had obesity (obesity index 53.3%) and fatty liver confirmed by ultrasonography. Abdominal ultrasonography had been performed annually since then.Her medical history included successful treatment for Kawasaki disease with high‐dose immunoglobulin therapy. She had also occasionally received leukotriene antagonist for bronchial asthma as a 1‐year‐old and had received midodrine hydrochloride because of orthostatic dysregulation since she was 10 years old. No bleeding tendency was observed. Her parents had bronchial asthma and her brother had childhood obesity, but there was no family history of liver disease.On physical examination, her height was 158.8 cm (+0.8 SD) and weight was 81.6 kg (+2.9 SD). Her obesity index and body mass index were 61.0% and 32.4, respectively, indicating obesity. Her abdominal circumference was 113 cm and blood pressure was 112/70 mmHg. She had acanthosis nigerians on her neck and axilla and striae distensae on her abdomen, buttocks, and thighs.Blood examination indicated moderately increased aminotransferase levels due to fatty liver  and hyperinsulinemia with a normal HbA1c (5.2%), normal fasting plasma glucose (96 mg/dl), and elevated immunoreactive insulin level (45.2 mIU/ml). Her FIB‐4 index based on her age, AST and ALT levels, and platelet cell count  was 0.14, which was not indicative of liver fibrosis. Hepatitis B and C markers  and tumor markers  were within normal ranges.Ultrasonography revealed a hypoechoic nodule with clear boundaries in S7 and uniform internal and enhanced posterior echoes Figure . PerflubFocal nodular hyperplasia is most common in women aged 30–50 years with no liver disease, and often accompanies abnormal vascular morphology. Pediatric patients with FNH often have a history of anticancer drugs and radiation therapy.A definitive diagnosis of FNH is based on (1) absence of liver damage, (2) spoke‐wheel appearance of the vascular structure and a central scar on imaging, and (3) pathological findings of central scar‐like fibrous tissue, increased cell density, and hyperplasia.The Central Medical Journal has reported 73 cases of FNH and two of FNH‐like lesions in children <18 years since 1985, but no FNH or FNH‐like lesions in children with fatty liver. Epidemiological data also suggested that being overweight or obese was associated with liver cancer.We encountered a girl with an FNH‐like lesion and fatty liver. Follow‐up is necessary because the lesion appeared within 1 year and she has a fatty liver and hyperinsulinemia.M.M. was responsible for managing the patient, review of the clinical chart, perusing the potentially relevant literature, and drafting the initial manuscript, and conceiving the case report. M.M. and Y.N. were responsible for planning and implementing diagnostic imaging. Y.N., K.S., and T.I. supervised the draft manuscript. All authors read and approved the final manuscript.The authors declare no conflict of interest.Written informed consent was obtained from the patient's guardian for the publication of this manuscript.


Eublepharis macularius) was presented with distended coelom and cachexia. Examination of the faecal sample ruled out the presence of protozoan parasites. A radiographic examination confirmed the presence of radiopaque foreign material in the intestine. The conservative treatment with tramadol, butylscopolamine, famotidine, vitamin B complex, and supportive fluid therapy with Hartmann solution and Duphalyte, was performed for 14 days. Ultrasonographic examination revealed the presence of a large mass adherent to the liver (with hypoechoic regions), a thin-walled cystic structure close to the liver, and coelomic effusion. Surgical exploration revealed a large mass on the right ovary. The unilateral (right) ovariectomy was performed. Histologic examination of the mass revealed dysgerminoma with an invasion of the ovarian bursa and blood vessels. Nine months after the surgery the patient was active and doing well. In reptiles, dysgerminoma is an uncommon type of neoplasia. To the best of our knowledge, this is the first case of dysgerminoma tumour diagnosed intravitally and treated successfully in lizards.The 16-year-old female leopard gecko ( Based on their popularity as pets and the increased frequency of visits to veterinarians, lizards are over-represented in recent clinical case reports . They arThe standard protocol of reptile patient clinical examination consists of physical examination, radiographic and/or ultrasonographic examination, faecal samples examination, and analyses of haematology and plasma chemistry profiles .Surgically excised tissues should always be submitted for histopathologic analysis.Eublepharis macularius), with a body weight of 52 g and body condition score of 1/5, was presented at a clinic with distended coelom and a history of weight loss within the last 6 weeks. According to the owner, the patient had no problems with appetite, urination, or defaecation, and the animal was otherwise considered healthy. The female was kept individually, under 12 h light/12 h dark photoperiod, in a terrarium with sand as the substrate. The temperature within the enclosure was 25 °C to 28 °C. The diet consisted of crickets and occasionally mealworms.A 16-year-old female leopard gecko  and laterolateral (LL) projections by intraoral dental X-ray system Gendex expert DC . Radiographs revealed intestines filled with radiopaque content ,B. Haemath day, the patient started to eat spontaneously. Check-ups and suture removal were performed six weeks after surgery. Nine months after the surgery, the patient is active and doing well.Premedication before surgery consisted of me-loxicam  and tramadol  intramuscularly. Forty-five minutes later, alfaxalone  was administered intramuscularly. An endotracheal tube  was placed and anaesthesia was maintained with isoflurane  in oxygen 0.5 l/minute). A standard celiotomy was performed on the patient in dorsal recumbency. A relatively well-defined mass was attached to the right ovary, partially adhered to the hepatic lobe . The mas l/minuteThe excised mass was submitted for histopathological examination. A mass originating from germ cells was found. The cells were large, round to oval, and had an abundant amount of clear amphiphilic cytoplasm. Anisocytosis, anisokaryosis the mitotic index was moderate. Some blood vessels showed invasion of the tumour cells. The margins of the tissue were not clean, because the tumour cells invaded the organ capsule. Histological examination revealed dysgerminoma with the invasion of the ovarian bursa and blood vessels .Platycercus eximius; Chelydra serpentina; Trachemys scripta elegans; Leptodactylus fallax; Potamotrygon motoro; Micropterus salmoides; In old reptiles, neoplasia should always be considered a differential diagnosis . ClinicaTo the authors’ knowledge, this is the first report of ovarian dysgerminoma in lizards. This finding has a significant impact on the differential diagnosis of neoplasms of the reproductive system in reptiles.


Acute phlegmonous esophagitis is a rare life-threatening disease that often requires surgical intervention in case of complications, including esophageal abscess, perforation, or mediastinitis. We present a case of acute phlegmonous esophagitis, in which magnetic resonance imaging (MRI) proved useful in planning the treatment strategy. An 89-year-old woman was admitted to the emergency department with painful swallowing and respiratory distress. She was diagnosed with acute phlegmonous esophagitis and a hypopharyngeal abscess based on computed tomography (CT) findings. However, there was a discrepancy between the clinical course and CT findings. Given the improvement of the patient’s condition with conservative treatment with ampicillin/sulbactam, the CT findings suggested an apparent abscess due to increased esophageal wall thickness. However, MR diffusion-weighted images showed a slightly high-intensity signal, suggesting that the enlargement was due to edema rather than an abscess. The patient recovered successfully following conservative treatment. Thus, our findings demonstrate the utility of MRI in the treatment planning of acute phlegmonous esophagitis, especially in cases with unreliable contrast-enhanced CT findings. However, future studies are warranted to explore the utility of MRI in the management of such cases.