Haemophilus influenzae. Several days into his course, he developed diplopia with leftward gaze. Brain imaging revealed an expansile, erosive PA cholesterol granuloma with associated contiguous dural and leptomeningeal enhancement. The patient improved with antibiotics and eventually underwent surgical intervention. This atypical presentation of GS with a rare complication of meningitis in the setting of a PA granuloma demonstrates the importance of early recognition of this syndrome, as well as consideration of added surgical intervention in patients with pre-existing petrous lesions at potentially higher risk of dangerous complications of GS.Gradenigo's syndrome (GS) classically involves a triad of ear pain due to acute or chronic otitis media (OM), facial or retro-orbital pain in the distribution of the trigeminal nerve, and an abducens nerve palsy. The simultaneous presentation of all three components has become less common in cases of GS reported in the literature, particularly in the era of antibiotics effective against typical organisms attributed to OM and petrous apicitis. In addition to infectious petrous apicitis arising directly from OM, more recent cases of GS are attributed to the compression of the same traversing cranial nerves in the presence of various expansile petrous apex (PA) lesions, both benign and malignant. We report a case of a 24-year-old male who presented initially with nausea, fever, photophobia, left-sided retro-orbital pain, and headache. He was diagnosed with bacterial meningitis by lumbar puncture and treated with empiric antibiotics, with CSF eventually revealing nontypeable  Gradenigo's syndrome (GS), first described in the literature by Giuseppe Gradenigo in 1907 . The undSimultaneous clinical presentation with all three components of the triad, however, is less common in the literature , particuHaemophilus influenzae meningitis in an adult presenting with a nonclassical Gradenigo's syndrome and a previously undiagnosed petrous apex cholesterol granuloma. While an expansile petrous apex cholesterol granuloma itself has been attributed to presentation with GS [In the majority of cases of bacterial meningitis, pathogenesis relies on an array of virulence factors that allow for mucosal attachment and survival within the bloodstream, followed by invasion through the blood-brain barrier . Bacteri with GS , we foun3. He was initiated on ceftriaxone and vancomycin empirically, and CSF culture and PCR revealed Haemophilus influenzae . Six days into his hospital course, he developed a horizontal diplopia and discomfort upon attempted left eye abduction, concerning for a left abducens nerve (CN VI) palsy.A 24-year-old male with a history of well-controlled asthma presented to an outside hospital with 3 days of headaches he described as deep, worst behind the left eye, and radiating posteriorly, with associated fevers, nausea and vomiting, photophobia, and phonophobia. He denied hearing loss, tinnitus, ear pain, or ear drainage. Physical exam was without concern for active ear infection. Lumbar puncture was performed and revealed a neutrophil-predominant leukocytosis with a white blood cell count of 1759 cells/mmCT scan of the head was obtained and revealed a 2.6 cm smoothly expansile left PA lesion with large areas of bone dehiscence around the margins . MRI demFollowing consultation with otolaryngology, ophthalmology, and neurosurgery teams upon transfer to our hospital, surgical intervention was deferred in favor of serial imaging along with antibiotic management. Steroid therapy was also initiated given the concern for cranial nerve compression related to the inflammation superimposed on his cholesterol granuloma. His retro-orbital pain and diplopia with left lateral gaze improved gradually with treatment, and he ultimately received an eight-week course of antibiotics  followed by a transition to oral antibiotics alone (amoxicillin-clavulanate) while awaiting repeat imaging and potential surgical intervention. Repeat MRI brain midway through his antibiotic course showed stable size of the cholesterol granuloma, a decrease in dural and leptomeningeal enhancement, and resolution of ICA vasospasm and the middle ear and mastoid inflammation . AudiogrFollowing clinical and radiologic resolution of his meningitis, he ultimately underwent a combined operation performed by neurosurgery and otolaryngology, with endoscopic transsphenoidal drainage of hemosiderin-stained brown motor oil contents from the left petrous apex. Following evacuation of the cyst contents, the left petrous apex defect was marsupialized using a right middle turbinate mucosal graft harvested earlier in the procedure. Tissue collected intraoperatively later demonstrated xanthogranulomatous inflammation consistent with the radiologically suspected cholesterol granuloma .Haemophilus influenzae meningitis. Despite a lack of clinical ear symptoms or physical exam findings concerning for OM, he was noted to have radiologic findings consistent with possible ipsilateral middle ear infection. The pathogenesis of petrous apicitis has been described by some as the spread of bacterial organisms from the middle ear to PA air cells (pneumatization of the petrous bone occurs in approximately one-third of the population), while others have suggested that vascular  channels may play a role, as petrous apicitis can rarely occur in those with non-pneumatized petrous apices [This patient presented initially with fever, deep retro-orbital pain potentially consistent with a trigeminal neuralgia, as well as eventual ipsilateral abducens palsy. He had no ear pain or discharge preceding these symptoms. Imaging confirmed an expansile PA cholesterol granuloma with smooth, chronic-appearing bone erosion and contiguous dural and leptomeningeal enhancement. His presentation was ultimately consistent with Gradenigo's syndrome occurring concomitantly with s apices , 19.PA cholesterol granulomas are rare lesions thought to form as the result of extensive PA pneumatization, which exposes marrow-filled spaces and triggers hemorrhage, obstructing the PA outflow tract and leading to degradation of hemosiderin and cholesterol and a resulting inflammatory granulomatous reaction . Most arH. influenzae serotype B (Hib) vaccine in the early 1990s, the unencapsulated group of nontypeable H. influenzae (NTHi) has increasingly been linked to invasive disease over Hib strains [Following the introduction of the  strains . While i strains . This paThis case demonstrates the impact of pre-existing petrous lesions on the risk for development of Gradenigo's syndrome, as well as of potential complications of petrous apicitis including meningitis, even in an era of antibiotics when advanced complications of OM are less common. While large-enough petrous lesions can eventually compress the same traversing nerves and can cause GS symptoms in the absence of recent symptomatic OM, it is reasonable to deduce that bone erosion associated with this patient's cholesterol granuloma made him more susceptible to the introduction of the bacterial organisms from his middle ear and mastoid cavity to his meninges. This patient reported no prior symptoms of a lateral rectus palsy until the superimposed inflammation presumably compounded the impact of this lesion on his abducens nerve.Surgical drainage for cholesterol granulomas is typically reserved for patients experiencing symptoms of the compressive effects of the lesion on adjacent structures . The lar


Osteochondroma is the most prevalent type of bone tumour, often arising in the long bones. Most are found in the third decade of life, and rarely in the axial skeleton of elderly patients. This case report aims to highlight the possibility of this differential diagnosis in an elderly patient with symptoms of radiculopathy, aside from degenerative cause.A 76-years-old woman presented to the authors’ hospital with complaints of pain and numbness of the left suboccipital and preauricular region. There was hypoesthesia of left C2 and C3 dermatome without any signs of myelopathy. CT-scan and MRI showed an expansile bone lesion from the posterior arch of C1 and lamina of C2. The patient underwent laminectomy of C1 and hemilaminectomy of C2. Postoperative histopathologic examination showed the features of osteochondroma. Radiologic follow-up after nine months showed no sign of recurrence. After eighteen months, the patient was ambulatory with complaints of fingers numbness and moderate neck pain.en bloc resection through posterior approach.Osteochondroma usually arises in long bone metaphysis. This lesion normally ceases to grow with growth plate closure, but other findings suggest it may continue to grow beyond skeletal maturity. About 29.5% of all osteochondroma of the spine would cause radiculopathy, and 27% would cause myelopathy. The cervical spine osteochondroma is usually treated by Osteochondroma of the cervical spine in the elderly is rare. However, this diagnosis could be considered as a possible cause of radiculopathy in this age group aside from other degenerative causes. This leSpinal osteochondroma frequently occurs in the third decade of life and rarely affects the elderly. The most common predilection of this benign neoplasm is on the cervical spine, followed by lumbar, thoracic, sacrum, and coccyx; it most commonly affects the posterior column of the spine ,4.We present an unusual case of symptomatic multiple osteochondromas in an elderly patient arising from the posterior arch of C1 and lamina of C2. This work is reported in line with SCARE 2018 criteria .2A 76-year old female presented to the authors’ hospital outpatient clinic with pain and numbness of the left suboccipital and preauricular region which persisted for the last six months. There was hypoesthesia of the left C2 and C3 dermatome; there were no signs or symptoms of myelopathy . The patient’s past medical and familial history was not remarkable; she never had any previous surgery, and she was not on any medication. The patient’s JOA (Japanese Orthopaedic Association) score was 16 out of 17  [Plain radiographs showed no abnormality. CT-scan and MRI showed expansile bone lesion arising from the left posterior arch of C1 and the left lamina of C2 , Fig. 3.Laboratory examinations did not show any abnormality. Based on the clinical features and pathological radiological findings, the authors suggested that the lesion most likely could be an osseocartilaginous benign tumor or known as osteochondroma.The authors decided to perform decompression through excision of the lesion. The lesion was explored through posterior approach, exposing level of C1 and C2. As C1 lateral mass was preserved, posterior arch osteotomy of C1 was performed. The osteochondral lesion of left lamina C2 was removed by left hemilaminectomy. The lesion excised is depicted in Diagnosis of osteochondroma was verified histopathologically. The patient could mobilize on the next day. There was no postoperative wound complication found. The clinical follow-up was performed up to seven days after surgery. The neck pain decreased, and the hypoesthesia of C2–C3 dermatome was significantly improved.Radiologic follow-up by MRI after six months showed no sign of recurrence . The lat3Osteochondroma is the most common benign lesion of the bone. It may be multiple or solitary; the former is caused by mutation of exostosin-1 (EXT1) and exostosin-2 (EXT2) . The latThe majority of osteochondroma arises in the metaphyseal region of long bone . It may The incidence of this lesion peaks during the third decade of life and usually cease to grow with the closure of growth plate during the adolescent . Thus, tAbout 29.5% of all osteochondroma of the spine would cause radiculopathy and about 27% would cause myelopathy. Moreover, the tumor growth may present as a progressive symptom not unlike degenerative changes of spinal stenosis . In the Other benign tumors of the spine which may occur in older patients includes neurofibroma and giant cell tumor (GCT) . The graThe imaging of spinal osteochondroma usually involves multiple modalities. Conventional plain radiograph is of low diagnostic value, especially for small lesion which is often obscured by adjacent structures . LikewisComputed tomography (CT) is the gold standard given the lesion’s major osseous component. CT could define its exact location and its connection to the central canal and neural foramen. On MRI, the cortex would be low intensity in any sequence. The marrow would show high intensity in T1 and intermediate intensity in T2. On the other hand, the cartilage cap would show variable intensity according to its degree of calcification .en bloc resection from the posterior approach (80.5%) due to its location propensity [The treatment of this lesion usually involves the opensity . In thisSince 1987, 13 cases of cervical spine osteochondroma had been reported  [4,15,2. The ageSymptoms duration and characteristics are variable. The shortest presentation was two months, ranging up to ten years. Most cases presented as radiculopathy or myelopathy. There are three unusual presentations of vertigo, obstructive sleep apnea, and dysphagia ,23,24. S4Osteochondroma of the cervical spine is quite rare, especially in elderly patients. However, this diagnosis could be considered as a cause of progressive radiculopathy in the elderly. Precise diagnosis through careful history taking, physical examination, and multimodal radiologic examinations should be made to solve this problem.All authors declare that there is no conflict of interest regarding this study.This study is solely funded by the authors.This study has been reviewed by the authors’ Institutional Review Board, and the patient had given a written consent.The patient had given a written consent. All identifying details have been omiited from the manuscript.This case report is not registered.Andhika Yudistira.Not commissioned, externally peer-reviewed.Andhika Yudistira: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing - original draft, Writing - review & editing. Yasushi Fujiwara: Data curation, Formal analysis, Project administration, Resources. William Putera Sukmajaya: Conceptualization, Formal analysis, Investigation, Methodology, Software, Writing - original draft, Writing - review & editing. Ray Asaf Hexa Pandiangan: Writing - review & editing. Muhammad Abduh: Writing - review & editing.


Echinococcus is a worldwide zoonosis, primarily causing liver lesions. Accidentally detected, these lesions enter the differential diagnosis of a tumor, including metastasis. This situation is especially challenging in patients with colorectal cancer, as both diseases affect mainly the liver.We report two patients with a newly diagnosed colorectal cancer. Pre- and intraoperatively radiological imaging revealed hepatic lesions which were resected on suspicion of colorectal cancer metastasis. Histology showed granulomatous lesions with characteristic parasitic membrane consistent with an echinococcal cyst. The diagnosis was confirmed by specific polymerase chain reaction.Focal hypoechoic liver lesion in patients with colorectal cancer should be primarily considered as a liver metastasis and resected whenever feasible. Other uncommon etiologies, including parasitic lesion as echinococcal cysts, should be taken in consideration, as this could lead to major changes of the management and prognosis of the affected patients. Echinococcosis is an unusual but clinically relevant infectious disease caused by helminthic parasites. Although the disease can become manifest by local symptoms due to the parasitic cyst, echinococcal lesions often remain asymptomatic for a long time and are accidentally detected by radiological imaging performed for unrelated clinical symptoms , 2. In tIn this report, we present two patients with colorectal cancers with hepatic echinococcal cysts, primarily considered being liver metastasis.A.An 83-year-old man consulted his family doctor due to dyspnea. The dyspnea increased in the last weeks and occurred mainly during physical activity. No other symptoms were reported. Apart from impaired hearing, the patient’s history was uneventful. So far, no colonoscopy was performed. Furthermore, the patient had no previous abdominal surgery. Although he was a retired farmer, he continued to work on his farm and in former years, he regularly went to the forest.Physical examination of the patient was inconspicuous. Laboratory analysis revealed a microcytic, hypochromic anemia. For further assessment of the anemia, a colonoscopy was performed and revealed a non-stenosing carcinoma of the ascending colon. No distant metastasis were found by staging computer tomography scan. During primary surgical resection, routine intraoperative ultrasound showed a 10 mm hepatic lesion in segment V  and Echinococcus granulosus (E. granulosus)- DNA in the lesion of the male and female patient, respectively.The pathological workup of both colorectal cancers showed a moderately differentiated pT3 adenocarcinoma with no lymph node metastasis. The examination of the two liver resection specimens revealed a central necrotic cystic lesion with a granulomatous and lymphocytic rim Fig. . FurtherFollowing consultation with the infectious disease specialist, no anti-helminthic treatment was initiated in the male patient due to advanced age, complete resection of the parasitic cyst and lack of vital scolices in the surgical specimen. The female patient was treated with albendazole 400 mg twice per day . Both coIn the cases presented, a single pre- and intraoperatively observed hepatic lesion of unknown origin in patients with colorectal cancer were described, which were initially interpreted as a metastatic disease. The histological examination revealed a cystic granulomatous lesion with a characteristic PAS-positive parasitic membrane. Scolices were not detected, however, the parasite is degraded and not visible in more than 50 % of all echinococcal cysts . TherefoEchinococcosis is a worldwide zoonosis encompassing different strains with major epidemiological variations . The incE. granulosus and E. multilocularis causing cystic echinococcosis and alveolar echinococcosis, respectively [For human, mainly two types of Echinococcus are clinically relevant: ectively . In the ectively . Due to ectively .E. multilocularis and E. granulosus [Echinococcus multilocularis is mainly restricted to the liver and shows a tumorous, infiltrating growth. In rare cases, the parasite may grow into adjacent structures or even affect distant organs. Based on these characteristics, the WHO has developed a classification specifically for E. multilocularis, the so-called PNM stages, analogous to the TNM classification [E. multilocularis, therapy is generally indicated, primarily a surgical resection. Prior to surgery, benzimidazole therapy is administered, which is continued postoperatively. In contrast, E. granulosus is usually limited to the liver; however, other organs can be affected including lung, kidney and the brain. A disease with E. granulosus is not an absolute treatment indication and a wait and watch strategy may be an acceptable option [There are some major differences of the clinical presentation between anulosus . Echinocfication . Due to e option , 15.In summary, we present two patients with suspected metastatic colorectal cancer finally diagnosed as parasitic cysts. Metastatic colorectal cancer implies tumor stage IV with a 5-year survival of less than 10 %, whereas survival in stage II colorectal cancer is in the range of 85 % . On the


Endometrial polyps are the benign localized overgrowth of endometrial tissue composed of a variable amount of gland, fibroblast-like spindle cells stroma, and thick-walled blood vessels. They develop as a result of unbalanced estrogens and progestin. Polyps greater than 4 cm are considered giant polyps. We report a case of giant endometrial polyp in a postmenopausal woman who presented with postmenopausal bleeding without any history of hormone or drug intake. However, the possible cause may be the age and use of phytoestrogens in the daily routine diet for a long time. Endometrial polyps (EPs) are the benign localized overgrowth of endometrial tissue protruding into the uterine cavity, affecting approximately 25% of women ,2. EP coA 67-year-old female, P4L4, presented in the gynecology outpatient department with a history of bleeding per vaginum for one month which was associated with spasmodic abdominal pain not relieved by medication. No history of prolonged illness, drug, or hormonal intake was elicited. The patient was of normal built for age with a body mass index of 20.1. Gynecological examination was unremarkable. Routine hematological and biochemical parameters were within the normal limits. On ultrasonography (USG), a homogenous hyperechoic mass measuring 48.4 × 38.2 mm with a central anechoic area attached to the fundus occupying the uterine cavity was detected. A diagnosis of submucosal fibroid was made on USG. Total abdominal hysterectomy was done, and the specimen was sent for histopathological examination. We received the total hysterectomy specimen. The uterus with cervix measured 11 × 7 × 5 cm with 1.5 cm long cervical canal. On cutting, a pedunculated polypoidal mass with a thin stalk attached to the fundus area, measuring 7 × 4 × 4 cm, was seen in the endometrial cavity. The external surface of the mass was smooth. The cut surface was grayish white with multiple small cystic spaces filled with altered blood. Microscopically, the cervix showed features of chronic non-specific cervicitis. The endometrium showed simple endometrial hyperplasia for age. The polyp showed variable-sized glands lined by cuboidal-to-columnar cells with variable spindle cells stroma and several blood vessels (Figure No atypia was noted in all the sections examined. A histopathological diagnosis of simple endometrial hyperplasia for age with benign hyperplastic EP was made. Further history was elicited from the patient for the possible etiology. She gave a history of daily intake of turmeric, garlic, ginger, onion, and the occasional intake of thyme and soybean in her diet, which are rich in PEs. Based on the clinical and histopathological findings, a final diagnosis of benign hyperplastic EP probably caused by the long-term dietary intake of PEs was made. The postoperative period was uneventful and the patient was doing well after six months of follow-up.EPs are a common benign endometrial pathology that affects approximately 25% of women . They arThe origin and pathogenesis of EPs are still not fully understood. However, in our case, we assume that aging and use of PEs in the daily routine diet for a long time may be the cause of the giant EP.


Intracardiac tumors in children are relatively rare, but their clinical consequences may include severe outflow tract obstruction, embolism, cardiac insufficiency, or rhythm disturbances. In some cases, the tumor may constitute part of a genetic condition and prompt additional investigations, as well as a modification of therapeutic management. Herein, we present a molecularly confirmed familial case of Gorlin syndrome with an early cardiac tumor as a presenting sign. We provide detailed clinical characteristics of the affected individuals and a useful review of syndromic causes of pediatric cardiac tumors in clinical practice. Cardiac tumors are benign or malignant neoplasms that may originate in all the three layers of heart tissue  gene, which is part of the Hedgehog (Hh) molecular pathway  (OMIM:109400) Gorlin . NBCCS iHerein, we show a molecularly confirmed familial case of Gorlin syndrome consisting of an infant proband presenting with intracardiac tumor, polydactyly, and macrocephaly and the father with features of macrocephaly, mitten-type syndactyly of fingers, polydactyly, and maxillary cysts. We describe current and future targeted treatment options in our familial case and provide a review of syndromic causes of pediatric intracardiac tumors.We present a case of an infant girl with multiple dysmorphic features and a cardiac tumor of unknown origin diagnosed postnatally. The girl was born preterm at 36 weeks’ gestational age with the birth weight of 4000 g by caesarean section due to maternal hypertension. The Apgar score was 3 and 5 at 1 and 5 min after birth, respectively. After initial resuscitation, the transthoracic echocardiography was performed revealing a tumor in the left ventricle. The neonate was referred to the department of pediatric cardiology for subsequent diagnostics.On admission, the child was in a serious but stable condition with normal resting heart rate of 150 beats per minute (bpm) and arterial blood pressure of 81/68 mmHg. Blood oxygen saturation was 92–94%, and capillary refill time was normal. Macrocephaly with head circumference of 38.5 cm (> 97th centile), bilateral polydactyly of fingers with unilateral polydactyly of toes, and a natal tooth on lower gingiva were observed Fig. . DyspneaLaboratory testing revealed anaemias (hemoglobin concentration of 10.8 g/dL) and significantly increased NT-proBNP level   attached to the posterolateral wall of left ventricle with the areas of hyper- and hypodensity Fig. . ModeratCardiac magnetic resonance confirmed echocardiographical findings and revealed possible diaphragm and parietal pericardium invasion. Contractility of left ventricle wall was impaired by presence of the tumor mass. Peripheral contrast enhancement suggested the presence of tumor capsule, and the lack of central enhancement suggested necrosis. Additionally, oval mass  localized between the anterior and lateral wall of left ventricle with peripheral contrast enhancement similar to the main tumor was described; however, the connection between them could not be excluded. Imaging studies suggested rhabdomyoma, fibroma, or sarcoma.Subsequent treatment included administration of spironolactone, furosemide, and captopril. Hemodynamically significant PDA was closed with PDA occluder. Signs of dyspnea decreased. Because of the high risk of thromboembolic events, cardiac tamponade, arrhythmia, and possible presence of metastases, the biopsy during the procedure was not performed.Magnetic resonance imaging of central nervous system showed no tumors. Rhabdomyoma associated with tuberous sclerosis could still not be excluded; thus, therapy with sirolimus was started. After 4 weeks, no significant changes in tumor size were observed, and sirolimus therapy was discontinued. Pericardial drainage due to fluid accumulation was performed. Subsequent specimen cytology was negative for tumor cells.Additionally, wide QRS extra beats were observed during hospitalization in the standard ECG monitoring. Twenty-four-hour Holter monitoring revealed a few episodes of ventricular tachycardia up to 200 bpm. Metoprolol was administered, and during subsequent tests, only single premature ventricular beats were observed. Pending genetic test results the infant was discharged in a good general condition.The 29-year-old father of the proband girl presented with macrocephaly  and frontal bossing, mitten-hand–type bilateral syndactyly, and unilateral postaxial hand polydactyly Fig. . He had Nextera Flex for Enrichment sample preparation kit combined with TruSeq DNA Exome (45 Mb) probes  according to the manufacturer’s instruction. Library was pair-end sequenced (2× 100 bp) on HiSeq 1500 (Illumina) to the mean depth 83×, 98.7% of target was covered ≥ 10×, and 94.4% was covered ≥ 20×. Bioinformatics analysis of raw ES data and variant prioritization were performed as previously described  was performed using ASH1L, CDKN2A, SIX4, and PTCH1 genes for verification and family study. Variants in ASH1L, CDKN2A, and SIX4 were inherited from the healthy mother, while the variant in the PTCH1 gene ) was inherited from the affected father. The p.(Leu923Pro) variant in PTCH1 was absent from the proband’s grandparents’ blood. Therefore, we concluded that this variant occurred de novo in the proband’s father and was transmitted to the proband in an autosomal dominant manner of inheritance  is the most frequent syndromic presentation of cardiac tumors, and mTOR inhibitors are effective in treating CNS and kidney neoplasms of TS (Curatolo and Moavero PTCH1 gene creating a substitution p.(Leu923Pro). According to Varsome, most missense changes in PTCH1 are of uncertain significance. However, this particular variant is absent from GnomAD or our in-house databases of variants, and in silico analyses are predictive of its pathogenicity. Moreover, the variant was excluded in healthy paternal grandparents of our proband. Thus far, somatic mutation p.Leu923Pro has only been found in childhood medulloblastomas as the Sonic Hedgehog (SHH) pathway is likely involved in progression of these tumors (Parsons et al. In the described proband and her affected father, we have identified through ES a missense variant NM_000264.4:c.2768T>C in the In summary, we present a familial case of Gorlin syndrome characterized by the presence of a rare intracardiac tumor in the proband. Clearly, the syndromic diagnosis enabled optimization of therapeutic management, and it may support introduction of specific prophylactic measures. Similar personalized management should be introduced once the diagnosis of any of the genetic syndromes presenting with primary intracardiac tumors and discussed here is reached.


As chordomas are slow growing and locally invasive with high recurrence rates, initial recommendations include complete surgical resection with or without radiation therapy. A large proportion of recurrences occur years after initial resection necessitating lengthy follow-up. The novel biomarker brachyury and the repurposing of pharmaceutical products have the potential to substantially impact long-term recurrence rates.A 43-year-old woman presented with an isolated, cervical extraosseous intradural extramedullary chordoma attached to a nerve root underwent a C3-5 laminectomy, C3-5 lateral mass screw instrumentation, and mass resection. All symptoms resolved by the 12-month postoperative follow-up visit.This is the first report of an isolated, cervical extraosseous intradural extramedullary chordoma attached to a nerve root, and this case adds to the previous six Type IV chordomas in the literature. Unfortunately, the very rare form of extraosseous intradural chordoma is poorly understood: the lack of detailed knowledge in how they are differentiated from other forms of chordoma confounds the development of optimal treatment strategies and follow-up guidelines. Chordomas are rare, locally malignant neoplasms with high recurrence. Novel biomarkers enable definitive diagnosis, and pharmacotherapies are being studied in advanced disease. The paucity of research of a rare type—extraosseous intradural—prevents complete application of breakthroughs to these patients.A 43-year-old African American woman with no significant history presented with 2 years of worsening, bilateral arm numbness whose intensity waxed and waned daily. She developed bilateral foot numbness without gait difficulties, weakness, or trauma. Her examination was notable only for bilateral 3+ biceps, brachioradialis, patellar and Achilles reflexes, and Hoffmann signs.Cervical spine MRI Fig.  demonstrThe patient was positioned prone with the head slightly flexed. A midline incision with subperiosteal dissection then a C3-5 laminectomy with C3-5 lateral mass screw instrumentation was performed. The tumor adhered to the right C5 nerve root. The tumor was completely resected Fig. .Fig. 2aThe tumor stained positively for S100, pan cytokeratin, and vimentin, but negatively for CD10. Multiple institutions deemed routine stains definitive for chordoma, so brachyury stains were omitted Fig. .Fig. 3aHer hospital course was uneventful. Radiation oncologists choose to not radiate as there was no specific target. By 10 months, all symptoms resolved except for a small area of minor numbness in the right upper extremity. Though annual MRI surveillance was recommended, she was lost to follow-up.Chordomas are slow-growing, locally invasive tumors arising at the cranial 32%), spinal (32%), and sacral (29%) sites occurring in 8.4 per 10 million patients [%, spinalSigns and symptoms reflect the lesion’s location and include pain in the neck, shoulders, and upper extremities with weakness and occasional myelopathy . AlthougLocal aggressiveness necessitates surgery to minimize destruction of bone and surrounding structures. Excision is recommended except in patients with a history of radiotherapy where palliative resection is more appropriate based on a higher complication rate . RecurreThough biomarkers including S100 and cytokeratin are diagnostically useful, brachyury is specific to notochord-derived tumors. These soft and tan tumors hemorrhage frequently and are highly cellular with a physaliophorous appearance . AdditioSince designing drugs is predicated upon identifying a specific target, some have proposed developing a therapy for brachyury while others have focused on repurposing existing medications. A study of 2800 drugs showed that digoxin, digitoxin, and bortezomib inhibited growth in chordoma cell lines and primary culture, and many other medications exhibited varying potency . ImatiniWhile biomarker and pharmacotherapy discoveries may impact chordoma patients, Type IV has only been reported in six patients so it remains very poorly understood . Two preChordomas exhibit high recurrence rates even years after resection. Biomarkers and repurposed pharmacotherapies have shown promise in diagnosis and treatment. The rarity of Type IV chordomas prevents understanding of their unique characteristics as distinguished from other types—information required for prognostication and guidelines. Further studies may reveal differences between chordoma variations that would enable appropriate development of personalized treatment plans.


Contrast-enhanced ultrasonography (CEUS) is a relatively new imaging method for use in children. It is recognized as a safe and easily performed problem-solving method.A premature 10-day-old female infant experienced unusual persistent anemia. The diagnostic workup for the anemia included an abdominal ultrasound examination, which showed pathological formation in the left middle quadrant. MRI was used to further asses the lesion and showed a hypervascular lesion with necrotic areas rising from the left hepatic lobe, mainly showing the pattern that indicates an infantile hepatic hemangioma. Main differential diagnosis, hepatoblastoma, could not be excluded. The crucial examination used to differentiate was CEUS. Contrast-enhanced ultrasound (CEUS) features of infantile hepatic hemangioma (IHH) are still not widely reported, since the method is relatively new for use in infants . In 2016Hepatic tumors in children are relatively rare, accounting for 1% to 4% of all pediatric solid tumors .IHH may undergo spontaneous regression, but it can sometimes be life-threatening due to congestive cardiac failure and/or consumptive thrombocytopenia and coagulopathy (Kasabach-Merritt syndrome). While in asymptomatic cases observation is the recommended course, optimal management strategy for symptomatic patients is still controversial . We repoA 10-day-old female infant, born prematurely after an uncomplicated 36-week pregnancy and delivery, was admitted to the hospital because of an unusual symptomatic anemia. A clinical exam revealed a palpable solid, painless abdominal mass, measuring up to 3 cm below the lower left rib. She was anemic at birth and had icterus. She received phototherapy for a few days, and was given an erythropoietin and iron supplement. Her hemoglobin remained constantly low, ranging between 80 and 90 g/L.Ultrasound (US) of the heart at birth showed persistently patent arterial duct and oval foramen without hemodynamic significance. An abdominal US with Doppler Figure   and MRIThe blood supply to this focal hepatic lesion came from two feeding arteries rising from the left hepatic artery. There were still some issues in differential diagnosis between HBL and IHH due to slightly elevated serum alpha-fetoprotein (AFP). Therefore, an intravenous CEUS of the focal hepatic lesion was performed. The UCA SonoVue with a dose of 0.15 mL (0.05 mL/kg) was used. On CEUS, a distinctive enhancement pattern of the rapid-filling hepatic hemagioma is shown; peripheral nodular enhancement starting immediately in arterial phase (eight to ten seconds after IV administration of UCA) with centripetal filling completed in eight seconds  Figure . The lesSerum AFP was slightly elevated at the beginning and decreased over time. Serum concentrations of tumor markers neuron-specific enolase and human chorionic gonadotropin were normal. Concentrations of vanillylmandelic acid and homovanillic acid in the urine were normal. Kasabach-Merritt syndrome was also ruled out since the platelet count was normal. The brain US showed bilateral lenticulostriate vasculopathy.Treatment with propranolol at the age of four weeks was started, after which an abdominal US showed a minor regression in the lesion size, but hemoglobin remained low even two months later.The diagnostic approach to infant liver focal lesions is challenging and requires a complete workup because of the symptoms and concerns about malignancy. Diagnostic imaging modalities may facilitate a differentiation between benign and malignant liver tumors, or may even be a crucial method for establishing the right diagnosis on the basis of the enhancement pattern .The first imaging modality commonly used for focal hepatic lesions is the abdominal US with a color Doppler to determine the origin of the lesion and its gross structure and vascularization ,9. The nSecond-generation UCAs are on the market now and consist of microbubbles composed by inert gas surrounded by a phospholipid or albumin coat. They are a blood pool agent, which means that microbubbles remain in the vessels and do not diffuse in extravascular space. The safety profile of UCA is high with very low incidence of side effects ,9. The fThe characterization of a lesion during different phases of enhancement improves diagnostic accuracy and treatment. Recently, El-Ali et al. described the CEUS pattern of five cases of infantile and five cases of congenital hemangioma . One shoAbdominal mass and anemia are common indicators of both HBL and IHH, with AFP being the most important clinical marker for HBL, and remains the key clinical marker of malignant change, response to treatment, and relapse. However, there are some variants of both HBL and hepatocellular carcinoma that have low or normal AFP levels . AFP levIn our case, there were certain doubts about differential diagnosis after MRI, and due to the slightly elevated serum AFP and persisting anemia, CEUS was performed. Since the results showed the typical pattern of rapid filling hemangioma, we could confirm the MRI findings and conclude with certainty that the diagnosis is IHH, rather than HBL.Diagnosis of a neonate abdominal mass is challenging due to the urge to begin with therapy, and possible complications that may suddenly occur if left untreated. CEUS should be taken into account as an equally reliable method as MRI for diagnostic differentiation of focal hepatic lesions in infants, sparing time, money, and complications tied to gadolinium contrast adverse effects and general anesthesia, which is required for MRI. IHH should be considered in the differential diagnosis of infants with an abdominal mass in the newborn period as it could be associated with significant morbidity and mortality, requiring aggressive treatment and meticulous supportive care.


Spontaneous intracranial hypotension (SIH) is rare but can lead to life-threatening complications including cerebral venous thrombosis (CVT). The concurrence of CVT and SIH raises questions regarding priority.We present the case of a 52-year-old woman who developed sudden left-sided hemiparesis and generalized tonic-clonic seizures. She experienced progressive orthostatic headaches over the prior 2 weeks. Imaging showed thrombosis in the left transverse and sigmoid sinuses, bilateral subdural hematomas, and a cervicothoracic cerebrospinal fluid leak. Low molecular weight heparin was administered, but it was discontinued 2 days later due to subarachnoid hemorrhage. She was transferred to our hospital where an epidural blood patch was applied immediately, which resulted in complete symptom relief.CVT is a rare complication of SIH that may result in devastating consequences. Treatment of SIH should be the primary focus. Prompt diagnosis and EBP application can result in a good outcome. Spontaneous intracranial hypotension (SIH) is an uncommon entity, resulting from spontaneous cerebrospinal fluid (CSF) leak. Although its primary clinical feature is orthostatic headache, other reported symptoms include cervical pain, dizziness, nausea and vomiting, hearing loss, tinnitus, diplopia, vision loss, and cranial nerve deficits –3. CraniAlthough generally benign, SIH can cause life-threatening CVT, which can result in subarachnoid hemorrhage and seizures . ApproxiAn unconscious 52-year-old woman with a history of hypertension presented to the emergency department of an outside hospital after acute onset left-sided hemiparesis and generalized tonic-clonic seizures. She experienced progressive orthostatic headaches during the prior 2 weeks. There was no history of major trauma or lumbar puncture, and she was not taking oral contraceptives or hormonal replacement agents. Emergency cranial computed tomography (CT) showed cerebral microbleeds in the right frontal lobe Fig. a. CraniaTwo days later, the patient’s left face and left arm became numb. Cranial CT showed subarachnoid hemorrhage; thus, heparin was discontinued. She then developed left-sided involuntary movements and acute worsening of the hemiparesis the next day. Heparin was initiated as worsening thrombosis was suspected.At this point, the patient was transferred to our hospital for further treatment. On arrival, her neurologic examination was unremarkable except for left-sided muscle weakness. Cranial MRI with contrast showed diffuse pachymeningeal enhancement, enlarged pituitary gland, and diffuse cerebral edema Fig. a–c. AlthAn EBP was placed via multiple interlaminar injections using a 22-gauge Tuohy needle  under fluoroscopy. After successful loss of resistance, a small volume of contrast medium  was injected to fluoroscopically confirm epidural spread. It was difficult to identify the leakage site; approximately 52 mL of contrast medium and sterile autologous blood mixture (1:4) was injected separately under fluoroscopy at the T1–T2 and T12–L1 levels, which are considered as the most frequent sites. The injection was stopped when the patient began to note tightness in her shoulder. Epidural blood dissemination was subsequently evaluated by spinal CT Fig. . The EBPThe association between SIH and CVT was first reported in 2005 . Since tAlthough CVT affects only approximately 5 persons per million (0.0005%) in the general population , the preSecond, the downward sagging of intracranial structures due to the loss of CSF buoyancy  causes tBoth SIH and CVT are frequently misdiagnosed, which results in treatment delay and increased risk of complications. The present case highlights the importance of prompt imaging and aggressive treatment. However, in our literature review (including this case), many patients received an incorrect initial diagnosis despite MRI results evidencing SIH in 38 patients (90%) and CVT in 36 patients (86%) Table . In addiIn most reports, CVT was treated with anticoagulation Table . The curThe mainstay of SIH treatment is EBP placement; however, its effect on venous thrombosis development and recanalization is unknown. We hypothesized that the primary treatment focus should be SIH, given that CVT development is closely related to SIH-induced pathophysiologic changes in the brain. Thus, we prioritized EBP placement, even though the present patient had anticoagulation initiated at another hospital. In our literature review (including the present case), of the 34 patients who received anticoagulation therapy, 14 of 21 (67%) who did not receive an EBP had a complete neurologic recovery; in contrast, 11 of 13 (85%) who received an EBP recovered completely. Seven patients underwent EBP without anticoagulation, and all completely recovered. These data suggest that EBP application might be warranted for consideration as first-line therapy.There are several limitations of this literature review. It was retrospective in nature and examined only 42 cases due to the low prevalence of SIH and CVT. Moreover, anticoagulation therapy and EBP application were not performed in the same manner across studies, although treatments likely improved over time.We report a complex case of SIH associated with CVT, a rare complication with potential severe neurologic and life-threatening consequences. It is difficult to prevent sudden seizures before diagnosis; if seizures occur, immediate advanced diagnostic imaging should be performed along with supportive neurologic care. We believe that the primary focus of treatment should be directed at SIH, given that the underlying CVT cause is closely related to the pathophysiologic changes that occur after SIH. Prompt diagnosis and treatment with EBP application can result in a good outcome, as in the present case. Although the prevalence of SIH with CVT is low, rendering case-controlled studies impractical, additional studies are needed to determine an algorithm for early diagnosis and treatment.


Eccrine poroma is a benign adnexal neoplasm originating from epidermal sweat ducts mainly affecting the palmoplantar skin, buttock as a location of origin of poroma has rarely been reported, it is the first reported case of recurrent poroma in this site.We report an unusual case of eccrine poroma in the gluteal region of a 62 years old female associated with gluteal abscess, surgically excised with histologically clear margins, then recurred after one and half year with a given history of mild trauma.Given the uncommonness of these neoplasms, there stays a general lack of data on pathogenesis, atypical presentation, atypical sites, recurrence and risk of malignant transformation into porocarcinoma.Gluteal skin is an unusual location for a benign poroma. Early recognition and appropriate treatment at the initial presentation by complete resection with histopathology confirmation and follow-up are crucial to ruling out other diagnoses, such as lesions of malignant transformation. EP is lThe pathogenesis is unclear, but its etiology is associated with a history of trauma, radiation exposure, viral infection, or actinic damage . The typAs EP is a benign adnexal neoplasm, treatment is curative, simple excision is the current treatment of choice for the deep lesions . However2We report a case of a 62-year-old female presenting with clinical features of a left-side gluteal abscess. Upon physical examination, a firm nodule was palpated; the white blood cell count was 9500/μL, and a random serum glucose level was measured to 140 mg/dL. Surgical drainage and excision of the nodule were conducted. Microbiological examination based on culture and sensitivity testing of the drained fluid revealed E.coli organism susceptible to amikacin and cefepime. The resected nodule was sent to the histopathology laboratory and cefepime medical treatment was advised.Gross pathological examination revealed a fibro-fatty tissue piece measuring 6.5 × 2.5 × 1.2 cm covered by a skin piece, with an underlying, relatively circumscribed soft-to-firm yellowish nodule measuring 3.5 × 2 cm with a least surgical margin of 0.2 cm. Microscopic examination showed downward growth attached to the epidermis and reaching into the deep dermis, composed of cords and nests of small keratinocytes; the nests were sharply delimited from the adjacent epidermis; also duct-like structures and occasional islands of squamous epithelium were seen. Dermal reactive vessels and mixed inflammatory cells with neutrophil collections were present A and B. Staphylococcus aureus susceptible to amoxicillin/ clavulanic acid which was advised to the patient. The specimen received in the histopathology laboratory was partially fragmented revealing a fairly defined nodule measured 1.2 × 1.2 cm. Microscopic examination showed the same histological features as the first specimen  cysts, and eccrine porocarcinoma .4Gluteal region skin is an unusual location for a benign poroma. Early recognition and appropriate treatment at the initial presentation by complete resection with surgical margins of the EP and with histological confirmation and follow-up are crucial to ruling out and limitation of other diseases, such as recurrent lesions of malignant transformation.None declared by all the authors.No any funding sources for this article.Local Research Ethics Committee approval was done.Written informed consent was obtained from the patient for publication of this case report-Abdulkarim Hasan: Histopathology interpretation, study design, work administration, participation in writing and final revision.-Khalid Nafie: Lab data collection, imaging edition, abstract preparation and final revision.-Khaled Monazea: Performing the procedure, study concept and writing the paper.-Alsayed Othman: Data collection, writing the paper and final revision.-Abdoh Salem: Performing the procedure of the first operation and data collection.-Amal Ismail: writing the paper, Images editing, proofreading and final revision.NA (No human participants).Abdulkarim Hasan.Not commissioned, externally peer-reviewed.


Postsurgical necrobiotic granulomas present a diagnostic challenge and have been described in organs such as the urinary bladder, prostate, and uterus. However, occurrence of these granulomas is rare in the bowel.In this report, we present the case of a 28-year-old woman with recurrent multifocal colonic adenocarcinoma 3 years after sigmoidectomy. Intraoperatively, the ileum was suspicious for tumor deposits. Total colectomy with segmental small bowel resection was performed, and the histopathological findings of the small bowel specimen were consistent with necrobiotic granulomas with no evidence of malignancy. Infectious disease workup was negative. The patient was administered adjuvant chemotherapy and had no negative outcomes at 8 months after the surgery.This is a rare and challenging case of postsurgical necrobiotic granulomas of the bowel.Granulomas with “active” necrobiosis can occur as late as 3 years after colon cancer surgery and can be a diagnostic pitfall that significantly affects the management. The e2A 28-year-old woman was admitted to our hospital with complaints of constipation, hematochezia, and symptoms of iron deficiency anemia since one month. History revealed that the patient had undergone sigmoidectomy for management of colon cancer before 3 years and was asymptomatic until the last month. On physical examination, the patient was pale and there were no palpable abdominal masses. Biological tests revealed normal results except for low hemoglobin level of 8 signifying anemia. Tumor markers in the blood were within normal limits. CT scan revealed ileal wall nodules and left colon wall thickening . Endosco3Postoperative necrobiotic granulomatous reactions have been described in the prostate, bladder, female genital tract, and thyroid ,8,9. The4In conclusion, granulomas with “active” necrobiosis can occur as late as 3 years after colon cancer surgery and can be a clinical and microscopic diagnostic pitfall that significantly affects the management. The current case is an unusual presentation in a young woman with colorectal adenocarcinoma. Further molecular and biomarker studies are needed.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Not applicable. This case report is exempt from ethical approval in our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images.NA.Ali Al Khader.Not commissioned, externally peer-reviewed.Ali Al Khader: Conceptualization, Data curation, Investigation, Methodology, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Esra Nsour: Investigation, Methodology, Validation, Writing - original draft, Writing - review & editing. Raed Aldabbas: Data curation, Investigation, Methodology, Writing - review & editing. Anwar Alneweiri: Data curation, Resources, Writing - review & editing.The authors declare that they have no conflict of interest.


Octodon degus), rodents native to South America, have been becoming increasingly popular as pet animals. Data about neoplastic diseases in this species are still sparse and mainly limited to single-case reports. The aim of this study was to present neoplastic and non-neoplastic proliferative changes in 16/100 pet degus examined at the Veterinary Faculty University of Ljubljana from 2010 to 2015 and to describe the clinic-pathological features of these lesions. Twenty different lesions of the integumentary, musculoskeletal, genitourinary and gastrointestinal systems were diagnosed: amongst these were 13 malignant tumors, six benign tumors, and one non-neoplastic lesion. Cutaneous fibrosarcoma was the most common tumor (7/16 degus). It was detected more often in females (6/7 degus) and lesions were located mainly in hind limbs. The gastrointestinal tract was frequently affected, namely with two malignant neoplasms - an intestinal lymphoma and a mesenteric mesothelioma, four benign tumors – two biliary cystadenomas, an oral squamous papilloma and a hepatocellular adenoma, and a single non-neoplastic proliferative lesion. In one animal, two organic systems were involved in neoplastic lesions. In recent years, degus ( Octodon degus) is a rodent of the Octodontidae family endemic to Central Chile, where it inhabits the open savannah [The common degu  presented neoplastic or non-neoplastic proliferative lesions. The age of these degus ranged from 3 to 9 years (mean 6 ± 1.9 years). A complete necropsy was performed on twelve subjects and biopsy samples taken from the other four degus. Tissue samples were fixed in 10% neutral buffered formalin and routinely processed for paraffin embedding. Four-micrometers thick sections were stained with Hematoxylin and Eosin, Goldner’s Trichrome and Periodic-Acid Schiff. Immunohistochemistry was performed on the selected sections using mouse monoclonal antibodies anti-human vimentin , anti-human cytokeratin AE1/AE3 , desmin  and anti-human c-kit CD117) . Antibody binding was detected by EnVision Detection System Peroxidase/DAB +, Rabbit/Mouse . Tumours were classified according to the WHO classifications of tumors of domestic animals ,16,17,18  or 8/20 . Cutaneous fibrosarcoma was detected in seven degus  (degus # 1–7). The age of animals with fibrosarcoma ranged from 3 to 9 years with the mean age of 6 ± 1.9 years. Grossly, these tumors were firm masses measuring from 1 to 3 cm in diameter and with a grey-white cut surface. The most common localization was hind limbs (N = 4/7) A, but thBone tumors were observed in two 5-years-old degus (degus # 8 and # 9), while non-neoplastic lesions were not observed. Chordoma was diagnosed in a male (degu # 8) presented with a firm mass on the tail measuring 1 cm B. HistopGenitourinary neoplastic lesions were detected in two female degus. Degu # 10 had two asynchronous genitourinary tumors, and degu # 11 also had also renal haemangioma concomitant with a mesenteric mesothelioma and a hepatic nodular hyperplasia. A uterine leiomyosarcoma measuring 2 cm in diameter was detected in a 4-year-old female (degu # 10). A well circumscribed, grey-white, firm, non-encapsulated neoplastic mass composed of spindle cells resembling normal smooth muscle cells was observed. Neoplastic cells showed moderate nuclear pleomorphism and anisokaryosis with bi- and multi-nucleated cells and multifocal areas of dystrophic calcification. The mitotic index was low. The animal died 2 years later and in the urinary bladder wall a round occluding, neoplastic mass measuring 1.5 cm in diameter was observed at necropsy. The histological examination revealed an infiltrative and poorly demarcated spindle cell tumor with marked nuclear pleomorphism, anisokaryosis and multifocal areas of dystrophic calcification and a diagnosis of a urinary bladder leiomyosarcoma was performed C. A renal cavernous hemangioma was diagnosed in an 8-year-old female (degu # 11) concomitant with mesenteric mesothelioma. Two dark red well circumscribed nodules located in the renal cortex and measuring 2 mm and 3 mm in diameter were composed of large vascular spaces lined by one layer of thin endothelial cells. Gastrointestinal lesions were frequently detected in the examined degus. Neoplastic lesions were observed in six animals, three males and two females . Non-neoplastic proliferative lesion was observed in one female animal (degu # 11) only. Mesenteric mesothelioma and hepatic nodular hyperplasia were diagnosed in degu # 11, euthanized due to persistent weight loss. At the necropsy, a large grey-white, firm neoplastic mass, infiltrating and accreting intestinal loops was found. Histologically, an infiltrative, non-encapsulated, dense cellular mass composed of spindle cells resembling fibroblast was detected. Neoplastic cells, which exhibited anisocytotosis and anisokaryosis, showed intense positive immunohistochemical reaction for CK AE1/AE3 D and vimHepatocellular adenoma was diagnosed in a 7-year old male (degu # 14) with inappetence and reluctance to move. At necropsy, round, brown-red, firm hepatic mass, measuring 3 × 2 × 2 cm in diameter was detected. A well circumscribed, non-encapsulated lesion consisting of cords of well-differentiated neoplastic cells resembling hepatocytes, without portal triads and interlobular biliary ducts, was observed histologically. Biliary cystadenoma was diagnosed in two 8-year-old male degus (degus # 15 and 16). Solitary, well-circumscribed cystic lesions, measuring 3 mm and 7 mm were detected as incidental findings at necropsy. Microscopically, multifocal cystic structures lined by well differentiated cuboidal or columnar biliary epithelium were detected. The tumor prevalence in pet degus is reported to be low ,14. OnlyIn our examined sample, tumors and proliferative lesions were found in several organic systems, but integumentary lesions prevailed, representing more than one third of diagnosed lesions. With the exception of one chordoma, mesenchymal tumors were detected our study, leading to the conclusion that degus are more prone to the development of cutaneous and subcutaneous mesenchymal tumors. To the author’s knowledge, epithelial tumors have not been reported in the integumentary system of degus. Cutaneous fibrosarcoma was the most common neoplastic integumentary lesion and the most common tumor type diagnosed in the present study. To date, only one case of fibrosarcoma has been reported in degu . In our In our study, other tumors and non-neoplastic lesions were found as a single case. The morphology of these lesions resembles that described in other domestic animals . ChordomIn conclusion, our study demonstrates that neoplastic lesions in degus, especially in older animals, can be very frequent. The most common are lesions of the integumentary system, and cutaneous fibrosarcoma is the most common neoplastic integumentary lesion and the most common tumor type diagnosed in the present study.


Calcium pyrophosphate dehydrate deposition (CPDD) disease very rarely affects the temporomandibular joint (TMJ). It may resemble synovial chondromatosis, chondrosarcoma, chondroblastoma, or a parotid tumor. Clinical examination, CT, and MRI are important in making the correct diagnosis. Surgical removal of CPDD is necessary with or without excision of the TMJ. Calcium pyrophosphate dehydrate deposition (CPDD) disease very rarely affects the temporomandibular joint (TMJ). It may resemble synovial chondromatosis, chondrosarcoma, chondroblastoma, or a parotid tumor. Clinical examination, CT, and MRI are important in making the correct diagnosis. Surgical removal of CPDD is necessary with or without excision of the TMJ. It usually affects other joints, and patients are usually over the age of 60.The etiology of CPDD still remains unclear. However, it has been reported that advanced age, rheumatoid arthritis,The clinical picture of CPDD in the TMJ may be unspecific, patients may present with reduced mandibular motion, swelling, and pain in the TMJ and surrounding structures.2A 40‐year‐old woman with a medical history of asthma, hypertension, and psoriatic arthritis with involvement of both TMJs diagnosed over 20 years ago. She was on the following medications: selective immune suppressor (Araba), Angiotensin II receptor blocker (Diovan), leukotriene receptor antagonist (Singulair), antihistamines (Arius tablets and Livostin eye drops), corticosteroid , estrogen replacement (Progynova), proton pump inhibitor (Pantoprazole), sedative (Zolpidem), and analgesics . The patient presented with a swelling in the left preauricular region. She had a long past history of TMJ pain and limitation of jaw movements and had, 14 years earlier, undergone bilateral discectomy and synovectomy. Three years previously an arthroplasty and synovectomy in the right TMJ was done because of severe pain and significantly reduced TMJ function. A diffuse swelling over the right preauricular region was observed  was undertaken. The MRI examination showed a well‐defined encapsulated lesion related to the TMJ, possibly an inflammatory pseudo‐tumor, parotid tumor, synovial cyst, or postoperative changes. There were no findings typical of parotid tumors, and the FNAC was nonspecific. A new MRI dedicated to the TMJ was taken, which showed progressive bilateral calcification around the TMJ. A diagnosis of calcium pyrophosphate dehydrate deposition disease was suggested. CT scans showed extensive progressive calcification in both TMJs with deformation and arthrosis Figure  were rem3Calcium pyrophosphate dehydrate deposition may occur as a generalized disease or localized to a specific joint. Localized CPDD is believed to occur secondary to trauma or following surgical procedures.Treatment of CPDD varies according to the presentation and clinical findings. Calcium pyrophosphate crystals cannot be dissolved; therefore, management of crystal‐derived inflammation is important.In conclusion, we report a case of CPDD of the TMJ in a patient with psoriatic arthritis with tophaceous pseudogout presentation, deformation, and bilateral arthrosis. Tumoral CPDD can be confused clinically and radiographically with TMJ neoplasms, biopsies are necessary for the diagnosis. Treatment is by surgical excision in tumor cases and cases with erosion of the TMJ. Total TMJ prosthesis may be necessary to restore function and avoid ankylosis.None declared.Both authors have contributed equally during the treatment of the patient and in the process of writing of the manuscript.


Palliative short-course radiotherapy may be considered as an alternative to abdominoperineal resection in elderly patients with advanced rectal cancer.A 92-year-old woman was diagnosed with a rectal prolapse after short-course radiotherapy; 2 months before she was diagnosed with advanced lower rectal cancer. A curative approach was declined. Therefore, a palliative short-course radiotherapy followed. Two weeks after termination of radiotherapy, a symptomatic rectal prolapse has been observed. Endoscopy confirmed a tumor completely included in the prolapsing rectum. A rectal prolapse resection by Altemeier’s technique was performed. Histological examination downgraded the tumor staging to ypT1 M0.This case discusses whether the prolapse was preexisting and led to overstaging the tumor or whether the prolapse is a new-onset complication of the radiotherapy.It seems of paramount importance to detect preexisting rectal prolapse to avoid overstaging. If presumed rectal prolapse was not present before therapy, rectal prolapse may represent a new-onset adverse event of short-course radiotherapy. Abdominoperineal resection for rectal cancer in frail patients is associated with a mortality up to 18% in short course and up to 51% within 1 year . CombineIn this case a symptomatic rectal prolapse was observed early after palliative short-course radiotherapy in an elderly woman. The question is whether the rectal prolapse was preexisting and led to overstaging of the tumor or if the prolapse was a sequela of the radiotherapy. This work has been written in accordance with the SCARE criteria .A 92-year-old woman, with known dementia and no previous history of anorectal surgery, was referred to the emergency department with a full-thickness rectal prolapse. Two months before she was diagnosed with advanced lower rectal cancer. Initially treated for hemorrhoids, a colonoscopy was arranged when patient noticed a resistance while introducing suppositories. Comorbidities were coronary heart disease and bronchial asthma. Family history was bland regarding tumor diseases. The colonoscopy demonstrated a malignant polyp of 4 cm size . There was no clinical or endoscopic evidence of full-thickness rectal prolapse. The histology showed a moderately differentiated microsatellite-stable adenocarcinoma. A computed tomography and a magnetic resonance tomography (MRT) resulted in a cT3–T4 cN1 cM0, circumferential resection margin (CRM) positive (0 mm) staging . The mulTwo weeks after the radiotherapy the patient noticed severe perianal pain. The patient’s relatives observed a painful partially reducible perineal bulge; thus, a rectal prolapse was diagnosed. At presentation in the emergency room the prolapsed segment of the rectum appeared edematous. The endoscopy showed a residual tumor completely included in the prolapsing rectum. MRT confirmed severe edema in the entire rectum after radiation and prolapse with poor definition of the tumor . The indThe surgical site was adjusted using a Lonestar retractor and the prolapse was exposed further using Allis clamps . A monopThe patient recovered uneventfully and was discharged on the 11th postoperative day. The postoperative course was delayed due to the patient’s fragility and initial mild pain problems. The histological examination confirmed a moderately differentiated, microsatellite-stable intestinal adenocarcinoma with complete excision and no infiltration. Thus, the TNM classification could be downgraded to ypT1 pN0 (0/1) L0 V1 Pn0 R0 M0 G2. In respect of the multimorbidity and the dementia of the patient no further oncological treatment was recommended.There are several reported cases of rectal adenocarcinoma detected in a prolapsed rectum . No caseIncontinence and anal bleeding were noticed by the patient several months before the treatment and led to the diagnosis of rectal cancer. Although these symptoms are well explained by rectal cancer, they might also be associated with a rectal prolapse. Nevertheless, the patient’s relatives never noticed rectal prolapse before the radiotherapy.Before treatment the tumor was staged cT3–T4 and an infiltration of the puborectal muscle was suspected. The tumor infiltration into the pelvic floor could have prevented the rectum from prolapsing. The response to the radiotherapy though was very distinct, as the tumor was staged ypT1 in the specimen. A tumor regression grade 2 according to Dworak was seen by the pathologist. The rate of complete pathological response 4–19 weeks after short-course radiotherapy was reported to range between 4.4% and 25% in the literature. A downstaging is achieved in 46.8% of cases . The degOn one hand, the influence of the rectal prolapse on the initial staging and on the other hand, promotion of the rectal prolapse by the radiotherapy, must be discussed.If the rectal prolapse was present before the radiotherapy but not diagnosed, it may have contributed to an overstaging of the tumor in the MRT. Other cases of rectal prolapse associated with rectal or sigmoid cancer are reported . Some auIf we presume rectal prolapse occurring after radiotherapy, then this is a novel adverse effect by the radiotherapy. The prolapse of the rectum could be fostered by the strong downgrading of the tumor, thus dissolving the tumor attachment to the pelvic floor.Because of the acute presentation, the extensive edema that made it difficult to reduce the prolapse and the degree of suffering, a watchful waiting strategy was not possible. Perineal resection of the rectal prolapse according to Altemeier seems a safe and effective technique for this kind of situation.This work presents a case of newly diagnosed rectal prolapse after short-course radiotherapy for advanced rectal cancer. It is of paramount importance to detect preexisting rectal prolapse to avoid overstaging. If rectal prolapse is not present prior to therapy, promotion of the rectal prolapse may occur by radiotherapy.


Although myxofibrosarcoma (MFS) is the most common mesenchymal tumor, occurrence in the orbit is extremely rare. A characteristic clinical feature of MFS is its propensity for local recurrence (LR). Still, none of published literature has described the entire clinical course of multiple recurrences of MFS in the orbit. Here we present an unusual case in which a patient with multiple recurrences of MFS in the orbit followed-up for 5 years. We describe its clinical-pathological correlation, treatment, and prognosis.A 70-year-old woman sought treatment for a year history of right upper eyelid swelling in May 2014. Since then, she underwent three surgical procedures in the right orbit in the same region . The pathology analysis of the three surgical tissue samples was consistent with myxofibrosarcoma, characterized by spindle-shaped cells and variably myxoid stroma. In the 2 years follow-up after the third surgery, there was no evidence of tumor recurrence.Myxofibrosarcoma of the orbit is extremely rare. Since few reports are available in the literature, the diagnosis and management of the orbit myxofibrosarcoma is still a challenge to ophthalmologists. Histopathology is highly valuable in the diagnosis. As a clinical characteristic, the lesions have a high risk of local recurrence; therefore, aggressive resection and careful postoperative follow-up are paramount. Myxofibrosarcoma (MFS) is the most common malignant soft tumor of the elderly, previously known as myxoid malignant fibrous histiocytoma (MFH) . Since tA 70-year-old woman presented to our hospital with a one-year history of right upper eyelid swelling in May 2014. Her best-corrected visual acuities (BCVAs) were 0.6 in the right eye, 1.0 in the left eye. Binocular Intraocular pressure was normal. Physical examination revealed a palpable soft mass in the right upper eyelid with a size of 3 cm*2 cm. The exams of the right upper eyelid also presented with an increased volume. Complete resection of the tumor revealed a large oval encapsulated mass in close relation to the adjacent tissue. The histopathology examination revealed a spindle-cell tumor with a myxoid matrix, consistent with MFS. The Ki-67 proliferation index was 60%.Two years after the initial surgery, the patient was admitted to another hospital with a palpable mass at the same site and swollen right upper eyelid. She underwent surgery and pathological analysis confirmed the recurrence of MFS, with an invasion of the surrounding tissue. Immunohistochemical staining was negative for S-100, desmin, and positive for α-SMA and for Ki67 in 20% of nuclei. Unfortunately, no pathological section was available. Adjuvant radiation therapy was administered after surgery, but we were unable to collect information about the radiation therapy modalities.One year after the second tumor resection, she returned to our hospital with progressive swelling of the right eyelid for nearly half a year. Ophthalmological examination showed visual acuity as CF/40 cm OD and 0.6 OS. The upper eyelid was swollen and ptotic. There was a 1.5 cm*1.5 cm palpable, firm, and movable mass in the inner part of the right upper eyelid Fig. a. AnotheAfter the third surgery, the patient was followed-up for 2 years without tumor recurrence.Myxofibrosarcoma (MFS) is the most common mesenchymal tumor in elderly patients, which, most of the time, presents as a painless, slowly-growing mass, with typical potential for local recurrence (LR). It is characterized by variably myxoid stroma with a distinct curvilinear vascular pattern.MFS might develop in most parts of the body, but most commonly in the extremities, especially lower extremities, then the trunk. Orbital presentation of MFS is extraordinarily rare, and it was first described in 2008. Since then, only six cases have been published –8.MFS has a high incidence of LR, ranging from 50 to 60%. Some studies demonstrate locally recurrent MFS progressing to a higher-grade disease with an associated increase in metastatic potential , 10. HowThe diagnosis of MFS relies on the histopathology. Typically, the spindle-cells or stellate shaped cells populate in variably myxoid stroma and there are great differences in cellularity, polymorphism, and mitotic activity. A curvilinear vascular pattern can be remarkably found in most tumors , 11, 12.Since this kind of tumor is apt to recurrence and metastasis, margin-negative surgical resection is the most effective therapy. Insufficient tumor-free margins are associated with a high risk of local recurrence and, hence, a poor prognosis , 16. TheSummarizing, primary MFS of the orbit is rare and can present a high recurrence rate. Our report described an entire clinical course of multiple recurrences of orbital MFS, reinforcing the importance of complete excision of these lesions. Ophthalmologists should be mindful of this diagnosis and closely monitor these patients.


Blunt abdominal trauma is a rare cause of small bowel obstruction thought to arise from either a sealed perforation of the small bowel or mesenteric injury resulting in adhesions. A 55-year-old gentleman presented with symptoms and signs of small bowel obstruction and a history of blunt abdominal trauma 14 months previously. Abdominal computed tomography showed a transition zone at the terminal ilium with proximal dilatation indicative of obstruction. At surgery, he had adhesions involving the terminal ilium with shortening and fibrosis of the supplying mesentery. Patients with a history of blunt abdominal trauma presenting with abdominal symptoms must be investigated to rule out bowel obstruction, with a low threshold for surgical intervention. Adhesions, masses, and hernias account for >80% of presentations of small bowel obstruction, with other less common causes including volvulus, intussusception, and inflammatory bowel disease . Blunt aA 55-year-old gentleman with no history of abdominal surgery presented to the emergency department with a two-day history of sudden onset, colicky abdominal pain of increasing intensity and abdominal distention. He had nausea and vomiting but there was no history of fever, rectal bleeding, or melena. On examination there was tenderness in the lower left quadrant but no peritoneal signs, and he was clinically stable.His history from another hospital reported trauma 14 months previously after being hit as a pedestrian by a car. He had sustained multiple facial and orthopedic injuries, which had been managed by the orthopedic team. Computed tomography (CT) of the abdomen at that time showed a small gastrocolic ligament hematoma, right adrenal hematoma, sub-capsular liver hematoma, and small sigmoid mesocolon contusions, which were managed conservatively. The patient was discharged after seven weeks in hospital. He had sought medical advice one month after discharge due symptoms and signs of bowel obstruction, with an abdominal CT performed at that time showing distal ileal obstruction with luminal narrowing and a transition zone suggestive of an adhesive band with surrounding fat stranding and mild intestinal wall thickening. The patient improved with conservative management and he was discharged after resolution of the obstructive symptoms.During his current admission, tumor markers were negative. Abdominal X-ray revealed dilated intestinal loops and multiple air-fluid levels, and an abdominal CT with oral contrast again showed luminal narrowing with a transition zone at the terminal ilium and proximal dilated bowel loops with contrast passing distally . The patAlthough small bowel injury after blunt abdominal trauma is rare, small bowel obstruction can occur after blunt abdominal trauma and account for 1% of small bowel obstruction cases . The preOne suggested mechanism of bowel obstruction after blunt abdominal trauma is mesenteric injury leading to ischemia of the supplied bowel segment and subsequently fibrosis and stenosis of the involved segment ; this maThe first CT at the time of the accident showed no significant bowel or mesenteric injury; however, he presented one and 14 months later with bowel obstruction and CT findings of distal ileal narrowing with a transition zone. Given the intra-operative finding of distal ileal adhesions associated with mesenteric fibrosis and scarring and intraabdominal contusions and hematomas noted at the time of the accident, the most likely cause of the obstruction was mesenteric injury at the time of trauma that led to ischemia of the supplied bowel segment and subsequent luminal stenosis. These specific mesenteric injuries can be missed during the first presentation after trauma and can be difficult to diagnose or even misdiagnosed as suspected malignancy or inflammatory bowel disease when presenting later with bowel obstruction . Hence, Patients with a history of abdominal trauma and symptoms of bowel obstruction should preferably be investigated with contrast-enhanced abdominal and pelvic CT scans and later colonoscopy . CriteriIn conclusion, patients with abdominal symptoms suggestive of bowel obstruction and a history of abdominal trauma should be thoroughly investigated, with a lower threshold for surgical intervention.


Background: Pheochromocytoma is a catecholamine secreting tumor that, in extremely rare cases, may develop over time from a non-functional adrenal adenoma. Catecholamine excess can lead to a kind of cardiomyopathy similar to that seen in tako-tsubo syndrome (TTS).Case report: A 69 years old female with a history of type 2 diabetes, hypertension, and a non-functional right adrenal adenoma diagnosed 3 years earlier was referred to our center for further investigations. During the evaluation, she had a hypertensive crisis with chest pain, tachycardia, and diaphoresis. Suspecting an acute coronary syndrome, she underwent coronary angiography, which showed the typical features of TTS. The high 24 h-urinary metanephrines excretion and abdominal MRI findings were suggestive of pheochromocytoma. Right laparoscopic adrenalectomy was performed, with the resolution of all symptoms. Pathology findings confirmed the diagnosis of pheochromocytoma. After 12 months, the patient was still asymptomatic, with the echocardiography displaying a complete recovery of the left-ventricular function.Conclusions: The development of a pheochromocytoma from an adrenal non functional adenoma is an extremely rare event, but potentially life-threating because of the catecholamine-associated cardiovascular toxicity. In particular, TTS is a form of cardiomyopathy that has been increasingly described as associated with catecholamine-secreting tumors. The exclusion of pheochromocytoma in a patient with TTS has important therapeutic implications, since the administration of β-blockers may be extremely harmful in patients with catecholamine surge in the absence of adequate α-blockage. An adrenal incidentaloma (AI) is an adrenal mass unexpectedly found during an imaging examination performed for reasons other than a suspected adrenal disease. In most cases, adrenal masses are non-functional at the time of diagnosis and don't develop hormone secretion over time. Still, a minority (~5%) have proved to be a pheochromocytoma, a rare neuroendocrine tumor producing catecholamines, originating from chromaffin cells of the adrenal medulla. When the tumor arises from extra-adrenal paraganglia is called paraganglioma (PPGL) . CardiacA 69 years-old woman, with a history of papillary thyroid carcinoma, type 2 diabetes mellitus (T2DM) treated with metformin, and hypertension on treatment with angiotensin II receptor blockers (ARB), calcium antagonists, and β-blockers, was diagnosed in October 2015 as having a right-sided AI during a routine abdominal ultrasound exam. A contrast-enhanced computed tomography (CT) scan of the abdomen showed a homogeneous right adrenal mass of 32 × 40 mm with density of 35 HU and relative contrast washout of 21% . Basal pWe reported the case of a pheochromocytoma presenting with TTS and originating from a non-functional adrenal adenoma diagnosed 3 years earlier. The prevalence of adrenal masses increases with age and is reported to be up to 10% in the elderly . While cAlthough it is unlikely that a non-functional AI may develop clinically overt hormone excess during its natural history, we described a rare case of non-secretory adrenal adenoma developing catecholamine secretion after several years of clinical, biochemical, and radiological follow-up. In selected cases, long-term follow-up may be necessary for early detection of these rare, unpredictable tumors, paying particular attention to the onset of new symptoms or worsening of comorbidities. In our patient, hormonal activity presented with a dramatic symptomatology and life-threatening TTS caused by the catecholamine surge. Based on the recently published consensus statement and increasingly reported cases, a diagnosis of pheochromocytoma should always be taken into account when echocardiography or ventriculography reveals the typical TTS appearance.All datasets generated for this study are included in the article/supplementary files.This study represents a case report. All the procedures in this case were conducted according to guidelines and according to clinical practice. All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethics committee of University Hospital of Pisa and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. A written informed consent was obtained from the patient for the publication of this case report and any potentially-identifying images/information.PF and MT wrote the manuscript. PF and FO followed the patient. All authors contributed to manuscript revision and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Adenomyosis is a benign gynecological condition caused by the presence of the endometrial glands within the uterine walls. This phenomenon occurs due to the breakdown of the inner lining of the uterus (endometrium) through the muscle wall of the uterus (myometrium). Usual symptoms are pelvic pain and irregular vaginal bleeding. As it is defined according to histological criteria obtained from a hysterectomy, diagnosis made based on only symptoms and imaging can be challenging. Discussed here is a case of a 30-year-old woman who presented with severe pelvic pain and irregular periods. Computing imaging (CT) and blood tests initially suggested malignancy but a review of magnetic resonance imaging (MRI) scans finally concluded adenomyosis. This clinical scenario elucidates for the utmost caution in the interpretation of investigations especially for the growing number of young women with this condition urging for more accurate diagnostic tools and effective communication between clinicians.  Uterine adenomyosis is a gynecological disease in which the endometrial glands and stroma are present within the myometrium, causing hypertrophy of the surrounding myometrium. The condition has more recently been discovered in young fertile women due to improvements in diagnostic tools. Women with symptomatic adenomyosis may display uterine enlargement, abnormal uterine bleeding (AUB), infertility, and/or painful menses negatively impacting their quality of life . The defA 30-year-old female presented to her general practitioner (GP) with a six-month history of severe non-cyclic pelvic pain, heavy periods, and bloating. The patient’s menarche was at 14, and subsequently, she had regular cycles. However, for the past couple of months, she has been experiencing irregular periods. She had never used any form of oral contraception and did not have any record of previous medical, obstetrical, or surgical history.Her symptoms were intermittent for the first five months and progressively became permanent. The pain originated from the lower abdomen and radiated to the lumbar area. She described the pain as dull and pulsating, feeling “two pinpoint pressures at the sides,” which indicated bilateral pelvic pain. Her discomfort intensified at night prompting the use of paracetamol to ease the pain. Her GP prescribed her progesterone tablets for the irregular menses and referred her to a specialist ordering blood tests, a pelvic ultrasound scan, and a CT scan. The radiologist noted on both the ultrasound and CT scan an enlarged uterus with endometrial hyperplasia (endometrium thickness with cystic areas) which he queried as being of possible malignant origin. Faced with these results, the gynecologist, decided to perform a hysteroscopy and a dilation and curettage (D&C). Pre-operative blood tests results revealed anemia with hemoglobin (Hb) at 8.4g/dL. During the procedure, some areas of endometrial hyperplasia were seen but no other intra-uterine abnormalities were noted. The histopathologic results of the D&C, however, showed benign tissue. After the operation, the patient was prescribed non-steroidal anti-inflammatory drugs (NSAIDs) for the pain and was recommended to continue taking paracetamol along with the progesterone tablets for her irregular periods. Due to the lockdown restrictions imposed by the current pandemic, the patient did not turn up for follow-ups post-surgery. Two months later, the patient came back to the gynecologist for a consult as the pain worsened. During her physical examination, it was noted that her uterus had become palpable abdominally. A second set of tests, this time including an MRI scan, was ordered and done by another radiologist revealing an enlarged uterus in the CT scan Figure .It was noted again that there was a centro-uterine lesion with endometrial hyperplasia; this radiologist also raised the possibility of malignancy but gave a differential diagnosis of necrosis of a submucosal fibroid. Bilateral ovarian cysts of 4 cm were also noted. Blood test results on this occasion showed elevated cancer antigen 125 (CA-125) levels at 285.5 u/ml. Consequently, given the discrepancies between the two radiologists’ reports, the patient self-referred herself to another gynecologist who decided to perform yet another hysteroscopy and D&C. The hysteroscopy failed to reveal any new findings and histopathology was again in favor of benign hyperplasia (complex hyperplasia without atypia). The second gynecologist submitted this case to a multidisciplinary team compromising of an oncologist, radiologist, and pathologist who had not yet been involved in the previous investigations. A careful review of the MRI scans revealed the disappearance of the endometrial lining and the presence of small cystic areas in both the axial Figure  and sagiDue to the patient’s reproductive age, the patient was prescribed Gonadotrophin Releasing Hormones (GnRH) analogs and is now much better. After two monthly injections, she described a net improvement in her symptoms with much less pain and reduced menses. What presented as a common complaint for a woman, turned out to be a more complex issue due to the initial difficulty in reaching a diagnosis after imaging and two diagnostic D&Cs. Further confusion arose when attention was given to the presence of bilateral ovarian cysts and raised CA-125 levels. CA-125 is a tumor marker that can be elevated in cases of serous cell carcinoma of the ovary, but high levels may also be found in benign conditions such as adenomyosis, endometriosis, fibroids, or pelvic inflammations, emphasizing its non-specificity. Discussion within the multidisciplinary team after reviewing the scans finally led to the conclusion that the bilateral ovarian cysts were benign in nature and that the elevated CA-125 level was most probably due to the presence of adenomyosis. Risk of Ovarian Malignancy Algorithm (ROMA) is a diagnostic tool increasingly being used to detect certain gynecological conditions eradicating the need for redundant procedures. It is a qualitative serum test that derives a numerical score from the results of CA-125 and human epididymis protein 4 (HE4) blood tests in addition to menopausal status, to identify patients presenting with an adnexal mass as having malignancy . In thisThis case also highlights how the lack of communication and collaboration between doctors hinders the progress towards a diagnosis. Adenomyosis is more commonly seen in women over the age of 40, with a history of prior cesarean section and/or uterine surgery, and who are multiparous . None ofUltimately, this condition requires a long-term management plan involving medical and/or surgical treatment. Treatment for adenomyosis is dependent on factors such as the woman’s age, reproductive status, and clinical symptoms. Due to potential risks affecting the option to conceive, conservative surgical approaches involve hysteroscopic endometrial and adenomyoma resection, endometrial ablation, high-intensity focused ultrasonography (HIFU), laparoscopic resection of adenomyosis, or uterine artery embolization. However, these treatments require further corroboration due to a lack of supporting evidence . Despite significant advancements and understandings in diagnostic techniques, potential medical treatments, and pathogenic mechanisms, a pressing need for a consistent diagnostic criteria profile of imaging and histologic examinations is required to accurately recognize all the variations in phenotypes of adenomyosis. This case study highlights the faulty interpretation of diagnostic investigations and lack of cooperation between physicians lowering the quality of care for the patient, with delay in diagnosis and appropriate treatment.


A left maxillary sinus soft tissue mass was discovered on computed tomography in a 70-year-old woman who had been experiencing blood-tinged mucus for 2 years. The lesion demonstrated mild enhancement, and bony destruction. Magnetic resonance imaging displayed a cerebriform appearance of the mass, which mimicked the appearance of inverted papilloma. However, histology and staining identified the lesion as ameloblastoma. Resection of the tumor was successful with no recurrence 1 month later on follow-up computed tomography. This case represents an unusual imaging presentation of ameloblastoma, and an opportunity to avoid the misdiagnosis of inverted papilloma in similar future cases. Ameloblastoma is a benign tumor of odontogenic origin, but if not treated can cause significant morbidity or death ,2. CliniA 70-year-old woman was incidentally found to have a left maxillary sinus mass on a computed tomography (CT) scan of the facial bones performed for trauma. The patient was referred to Otolaryngology for further workup. She recalled having noticed intermittent blood-tinged mucus for over 2 years with episodes of epistaxis over the last month. She also reported 1 week of left facial numbness, and one day of drooling from her left oral commissure. Her medical history was notable for Human Immunodeficiency Virus, Diabetes Mellitus, Hypertension, and chronic sinusitis. There was no history of tobacco or alcohol use. On physical exam, a palpable mass was noted below the left zygoma, and on endoscopy, the left ostiomeatal complex was compromised secondary to adjacent soft tissue fullness. pathway dysregulation, which results in increased cell proliferation Epigenetic modifications help to further explain the origin of ameloblastomas. Alterations of DNA methylation, and resulting changes in expression of genes involved in apoptosis, and cell cycle regulation have been associated with ameloblastomas en bloc surgical excision with wide bone margin; nonetheless, the risk of recurrence is high in conventional ameloblastoma [Treatment consists of blastoma ,2,4. In blastoma . Peripheblastoma ,2,4. FutThe patient provided written informed consent regarding the publication of this case and the accompanying radiographic images. No identifiable patient information was included in the manuscript.


Nonfunctional bladder paragangliomas is a rare urological disease. It may present clinical, radiology and pathological features similar to bladder cancer, Only scarce reports have been reported. Urologist must identify this generally benign neuroendocrine neoplasm to avoid misdiagnosis.A 62-year-old female presented the outpatient department of our hospital with the symptoms of stomachache, frequent micturition, and urination pain for 20 days. Diagnosed with high blood pressure 1 year ago, administered Amlodipine besylate tablets 5 mg po qd occasionally, did not check blood pressure; denied any tumor observation in the family history. Color ultrasound of the urinary system showed a 38 mm × 34 mm hypoechoic mass on the right side of the bladder, CDFI: in the masses, blood supply was sufficient. Cystoscope showed bladder occupying lesion. Biopsy diagnosis: papillary polypoid cystitis was suspected as a malignant change . Then, the patient was admitted to our urological department. Further, computer tomography urography considered bladder cancer. Cystoscopy and biopsy failed to define the nature of the lesions in our outpatient department, which prompted a transurethral resection of the bladder tumor. histopathological and immunohistochemical results were diagnosed as bladder paragangliomas. For the reason, the tumor was removed by partial resection of the bladder. The postoperative recovery and follow-up were uneventful.Nonfunctional bladder paragangliomas are occasionally found on imaging studies with the symptoms of urinary tract infection or/and intermittent painless hematuria. It may present clinical, radiology and pathological features similar to bladder cancer, so knowledge of this generally benign neuroendocrine neoplasm is of great importance to avoid misdiagnosis. It should be accompanied by the clinical and pathological characteristics of the patient and image changes. Partial resection of the bladder can effectively treat this disease. Paraganglioma of the urinary bladder (PUB) is a rare disease, accounting for 0.06% of all bladder tumors . The PUBA 62-year-old female presented the outpatient department of our hospital with the symptoms of stomachache, frequent micturition, and urination pain.Patient’s symptoms started 20 days ago, She had no symptoms such as lumbago, dizziness, headache, palpitation, chest tightness, nausea, vomiting, fever, chills, or other symptoms.The patient was diagnosed with high blood pressure 1 year ago, administered Amlodipine besylate tablets 5 mg po qd occasionally, did not check blood pressure; terminal gross hematuria was observed once 4 months ago, the symptom disappeared, and no treatment was administered; denied any tumor observation in the family history.After hospitalization, the patient’s temperature was 36.5 ℃, 80 pulses/min, 20 breathing times/min, blood pressure was 159/108 mmHg and oxygen saturation in room air was 98%. no bulge, pressure pain or percussion pain in either of the kidney area; no pressure or percussion pain in both ways of the ureteral region; no bulge in the bladder area but light pressure-induced pain.Fasting venous blood glucose was 8.34 mmol/L, and other indexes were normal. Chest X-ray showed mild interstitial changes in both lungs, ECG: 102 times/min. Color ultrasound of the urinary system showed a 38 mm × 34 mm hypoechoic mass on the right side of the bladder with an uneven surface and a large bottom; multiple strong echo masses were observed. CDFI: in the masses, blood supply was sufficient. Cystoscope showed bladder occupying lesion  [Color ultrasound of the urinary system is the first line of investigative modality to detect the silent as well as functioning ectopic lesions. Doppler demonstrates the vascular nature of these tumors, which was also observed in our case. the tumor showed a low-density shadow mass with clear edge, calcium density shadow and uneven enhancement on CT. On magnetic resonance imaging (MRI), these tumors are markedly hyperintense on T2-weighted (T2W) images. In addition to the monitoring of catecholamine or its metabolites, echocardiography, CT, magnetic resonance imaging (MRI), and radiotracer molecular imaging in the clinical suspicion of PUB is essential. The functional imaging technology of the tracer molecular may confirm that the tumor is paraganglioma  . The hisalkali.) . The cas131I-MIBG and cytotoxic chemotherapy. The study found that MIBG treatment was beneficial to 67% of the patients’ biochemical reactions, and 89% of the patients’ symptoms were improved [131I-MIBG has a good effect on the local control and treatment of malignant paraganglioma [The PUB is not sensitive to radiotherapy and chemotherapy. The most common treatment is partial cystectomy. Other treatments include transurethral cystectomy and radical cystectomy. The symptoms can be controlled, and low incidence can be achieved by surgical resection. Adequate preoperative preparation can significantly reduce the risk of hypertension and the hazards of operation. In this case, the patient had been regularly taking phenoxybenzamine for 2 weeks. Her blood pressure was stable before, during, and after the operation. The surgical treatment of metastatic pheochromocytoma is rarely effective. Radical bladder surgery, bilateral pelvic lymphadenectomy, radiotherapy, and chemotherapy are feasible for the cases with wide pathological range, impossible bladder preservation, and lymph node metastasis. Reportedly, 76% of the patients with paraganglioma received > 40 Gy of external irradiation, and their clinical symptoms were significantly relieved for at least 1 year or until death [Nonfunctional bladder paragangliomas are occasionally found on imaging studies with the symptoms of urinary tract infection or/and intermittent painless hematuria. It may present clinical, radiology and pathological features similar to bladder cancer, so knowledge of this generally benign neuroendocrine neoplasm is of great importance to avoid misdiagnosis. In our study, the patient underwent open surgery to remove the tumor completely. The prognosis was good.