Hepatic adrenal ectopia is a common clinical diagnosis, whereas adrenal tumors developed from hepatic adrenal ectopia are rare. Hepatic adrenal tumors are easily misdiagnosed as hepatic carcinoma and frequently treated by unnecessary operations.A 50-year-old female patient was hospitalized due to B-ultrasonic detection of “right focal liver lesions.” After hospitalization, enhanced CT examination was performed. A 2.2 cm × 1.8 cm tumor was found in the seventh section of the right liver, as indicated by obvious enhancement of the arterial phase and low density during the portal vein and delay stages. Enhanced MRI examination detected a 2.0 cm × 1.8 cm tumor on the right liver, which was considered a “primary hepatic carcinoma”. The patient was treated by open hepatectomy and recovered well after the operation. The postoperative pathological diagnosis was hepatic adrenal adenoma. No relapse was observed through the 1-year follow-up visit.According to imaging manifestations, pathological immunohistochemical treatment, alpha fetoprotein (AFP) and clinical features, hepatic adrenal tumors should be considered in the diagnosis of hepatic carcinoma to prevent misdiagnosis. Hepatic adrenal tumors should be ruled out during the diagnosis to avoid unnecessary operation. Heterotopic adrenal tissue is commonly diagnosed in the clinic. According to Vestfrid MA , heterotIn 1935, Weller first reported hepatic adrenal ectopia . In 1976This study reports a case of a patient with rare hepatic adrenal adenoma, which was misdiagnosed as liver cancer and treated by tumor excision.A female patient was hospitalized for “B-ultrasonic detection of focal liver lesion for 1 month.” The patient had neither history of hypertension, diabetes, hepatitis B, or hepatitis C nor symptoms of stomachache, abdominal distension, nausea, dizziness, or change in stool properties. The patient had no family history of genetic diseases or tumors and had not taken drugs for a long period.The patient was diagnosed with “primary hepatic carcinoma” before hospitalization. Routine blood examination, biochemical tests, and analyses of alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen 125 (CA125) and cancer antigen 19–9 (CA19–9), three systems of hepatitis B, hepatitis C antibody, HIV, RPR, and coagulation function were conducted. The results showed no obvious anomalies. According to B-ultrasound reexamination, a 2.1 cm × 1.6 cm echo node was found on the right lobe of the liver, and an even internal echo and clear boundary was detected Fig. . These rAlthough hepatic adrenal ectopia is a common pathological state, cases where it causes adrenal tumors are rare. To date, only ten cases of hepatic adrenal tumors have been reported in English Table , and allHepatic adrenal adenoma has no unique clinical symptoms, except the presence of malignant or functional lesions. Patients are often diagnosed by imaging examination. However, no unique changes are detected in the imaging diagnosis of hepatic adrenal adenoma . AdrenalThe final diagnosis of hepatic adrenal adenoma requires pathological examination. Hepatic adrenal adenoma can be successfully diagnosed in terms of its morphology and the existence of residual normal heterotopic adrenal cortical tissues. Immunohistochemical examination is conducive to distinguishing hepatocellular carcinoma from metastatic cancer. In adrenocortical adenoma, synaptophysin, inhibin-α, and melan-A might be positive, and hepatocytes, which are generally related to liver cancer, are negative. In the present case, inhibin-α (+), synaptophysin (+), and hepatocytes (−) were detected on pathological immunohistochemical examination. However, few relevant cases have been reported, and a unified diagnosis standard has not been established. In particular, collecting relevant clinical information by fine-needle aspiration biopsy is necessary upon suspicion of adrenal tumors. Attention should be paid to the patient’s history of hypertension, chronic liver disease, and phymatosis. Examination results, such as AFP and CEA results, should be considered, and appropriate immunohistochemical staining should be applied for final accurate diagnosis.According to this study, the possibility of hepatic adrenal adenoma should be considered for patients diagnosed with hepatic carcinoma by imaging examination. Diagnosis should be made by combining data on disease history, blood examination, imaging characteristics, and biopsy if necessary. The diagnosis of hepatic adrenal adenoma should be ruled out to avoid unnecessary operation. Analysis of a large number of patients is required to establish standards for the diagnosis of hepatic adrenal adenoma. It should be pointed out that hepatic adrenal adenoma has malignant potential, it represent conditions requiring therapeutic intervention . We suggest performing hepatectomy through a laparoscopic access. However, laparoscopic surgery has higher requirements for the surgeons.


Congenital intrathoracic accessory spleen (CIAS) refers to a developmental anomaly resulting in the presence of splenic tissue within the chest. The differential diagnoses for the resulting mass are pulmonary malformations, or lesions with malignant potential. To our knowledge, only four cases of presumed CIAS have been described in literature to date, and no cases were reported in the United States.We report on a 14-year-old Caucasian female with a left chest mass discovered incidentally on a CT scan performed following an all-terrain vehicle accident. Following resection, the mass was diagnosed as a CIAS.From our review of literature, we found that CIAS can pose a diagnostic dilemma as it is rare, difficult to distinguish from pulmonary sequestration, or malignancy, and biopsy is often inconclusive. Resection is required to rule out malignancy and determine the diagnosis. Pediatric thoracic surgeons should consider CIAS in their differential for an intrathoracic mass with an inconclusive biopsy. The presence of splenic tissue in the thoracic cavity can be acquired or congenital. Acquired intrathoracic spleen (splenosis) commonly occurs following splenic and/or diaphragmatic injury that results in the seeding of splenic tissue in the chest . In contIn clinical practice, CIAS may pose a diagnostic dilemma . FurtherThe patient was a 14-year-old healthy female referred to us after an intrathoracic mass was incidentally discovered in the left hemithorax on a CT scan . A total of four ports were required -5 mm port in the left 5th intercostal space along the anterior axillary line, 12 mm port in the eighth intercostal space in the mid axillary line on the left , 5 mm port in the third intercostal space in the anterior axillary line, and 5 mm port in the fourth intercostal space in the posterior axillary line. The mass was extra-pleural and in the medial inferior portion of the left thoracic cavity. A LigaSure™ device was used to release the pleural attachments and adhesions along the borders of the mass. Small arterial and venous tributaries were encountered on the anteromedial surface heading towards the internal mammary vessels along the anterior border of the pericardium, as well as, inferomedial arterial vessels headed towards the diaphragm. All vessels were ligated using 5 mm hemoclips and the LigaSure™. Following this, the specimen was dissected fully from the extra-pleural space, the specimen was placed in a specimen bag, partially morcellated and removed through the 12 mm port incision that was extended into a 5 cm mini-thoracotomy by dividing the intercostal muscles and latissimus dorsi. A portion of the sample was sent for frozen section analyses and pathology returned as “Lymphoid and spindle cell lesion, no overt features of malignancy”.A 20-French chest tube was placed intraoperatively, all port sites were closed, and she was extubated to room air in stable condition. Her hospital course was uneventful. Briefly, chest tube was discontinued on postoperative day (POD) 1, and she was discharged later that day. She was seen again in clinic 2 weeks following discharge and was doing well. Chest X-ray was unremarkable and we arranged for follow up as needed. She continued to do well without concerns 5 months following discharge.The specimen was sent to pathology for examination and was grossly described as a 169-g, 13 × 9.5 × 5.6 cm aggregate of solid, tan-pink, firm, and fleshy tissue with smooth cut surfaces Fig. . It had There are only four reports of CIAS to date. Patient characteristics in these cases included: age range of 7 months to 62 years, sex ratio of 3 females to 1 male, and laterality ratio of 3 left sided to 1 right sided chest mass (Table Similar to extralobar sequestration, blood supply to CIAS is often extrapulmonary with reports of intercostal vessels, and abdominal mesenchymal vessels being the most common . SequestThe pathogenesis/embryology of CIAS is unclear . NonetheTaken together, CIAS is a rare and benign presentation which cannot be distinguished from bronchopulmonary sequestration on CT alone. Pediatric thoracic surgeons should consider intrathoracic spleen as a possibility in lesions that have characteristics of sequestration on imaging. Furthermore, biopsies are often equivocal. Resection should be considered if malignancy is suspected, and to decrease the risk of relapse in patients undergoing splenectomy for hematologic disorders .


When ileal conduit construction is performed for urinary tract drainage during radical cystectomy, the conduit is usually constructed in the right lower abdomen. However, no reports have described ileal conduit construction in the left lower abdomen when it cannot be performed on the right side. In addition, some ingenuity is necessary for construction on the left.A 75‐year‐old woman visited our hospital with chief complaint of gross hematuria. Computed tomography and cystoscopy showed a huge bladder tumor, and blood analysis showed anemia. The patient was treated by radical cystectomy with ileal conduit construction. An ileal conduit was constructed in the left lower abdomen; it was impossible to construct in the right lower abdomen because of the abdominal wall scar hernia due to the past open surgery.We herein reported a patient who underwent ileal conduit for urinary diversion on the left side of low abdominal wall. We reported a patient who underwent radical cystectomy followed by ileal conduit on the left side of low abdominal wall. In this case, no perioperative complications, including ileus, were observed after surgery. We herein reported a patient who underwent ileal conduit on the left lower abdomen and described the surgical technique.Radical cystectomy remains the gold standard procedure for patients with muscle‐invasive bladder cancer.A 75‐year‐old woman visited our hospital with chief complaint of gross hematuria. Computed tomography and cystoscopy revealed a huge bladder tumor. Laboratory evaluation revealed a hemoglobin concentration of 7.2 g/dL . The patient was treated by radical cystectomy and ileal conduit construction. The patient had a history of open surgery for appendicitis and the presence of an abdominal wall hernia in the surgical wound , and written informed consent was obtained from the patient.The authors declare no conflict of interest.


Ewing’s sarcoma family of tumors consists of small round cell neoplasms, inclusive of primitive neuroectodermal tumor (PNET), Askin’s tumor, and PNET of the bone. Extraosseous Ewing’s sarcoma occurs commonly at bones of lower extremities and paravertebral region of the spine. It rarely presents as a primary intracranial lesion. When intracranial, it can be misdiagnosed as central PNET , other intracranial lesions, or even as an epidural hematoma.We report the case of a 20-year-old patient who presented to the emergency department with complaints of drowsiness, headache, and fever for 1 day. On initial computed tomography (CT) scan of the brain, a right temporal biconvex epidural lesion involving squamous-temporal bone with periosteal reaction was noted.The patient underwent urgent craniotomy, and a tumor was found and excised. Biopsy report confirmed Ewing’s sarcoma.Ewing’s sarcoma is a rare intracranial malignancy with only a few cases reported in literature. In a young patient with a biconvex epidural lesion, in the absence of trauma or ongoing infection, the possibility of Ewing’s sarcoma should be considered as well. Small round cell neoplasms, including Ewing’s sarcoma, primitive neuroectodermal tumor (PNET), Askin’s tumor, PNET of the bone, and extraosseous Ewing’s sarcoma, together constitute the peripheral primitive neuroectodermal (pPNET)/Ewing’s sarcoma family of tumors . Ewing sCommon sites of occurrence of extraosseous Ewing’s sarcoma include soft tissues and bones of the lower extremity, paravertebral, and retroperitoneal regions . ExtraosHerein, the authors report a case of a young patient with an intracranial extradural extraosseous Ewing’s sarcoma diagnosed on histopathology without t  translocation. This case is atypical, as the presentation of the case was acute and the initial neuroimaging revealed a lentiform epidural lesion, catching the neurosurgical team off-guard while performing an emergency decompressive craniotomy.A 20-year-old patient presented to the emergency department with complaints of drowsiness, headache, and fever for 1 day. There was no antecedent history of trauma or any infection focus, especially in the head and neck. On clinical examination, he was vitally stable and oriented to time, place, and person but appeared lethargic. There was a focal neurological finding of decreased muscle strength (4/5) in the left lower limb. These features were worrisome for a sinister etiology, such as raised intracranial pressure (ICP) and/or an acute central nervous system (CNS) infective process. The rest of the systemic examinations was unremarkable, and laboratory reports were within normal limits.On initial non-contrasted head computed tomography (CT) scan, a biconvex epidural lesion was noted over the right temporal lobe, involving the squamous-temporal bone with burst-type periosteal reaction Fig. . The axiGiven the acute presentation and obvious midline shift on the CT scan, the patient underwent an urgent decompressive craniotomy. Unexpectedly, intraoperatively, it was noted that a tumor that appeared malignant was arising from the dura mater and extending to the bone, with evidence of bone invasion. Thus, tumor excision and cranioplasty were performed.Histopathology report of the biopsy sample described the presence of bone and fibro-collagenous tissue exhibiting an infiltrating neoplastic lesion arranged in sheets, nests, and rosettes. Neoplastic cells had pleomorphic hyperchromatic to vesicular nuclei, variable prominent nucleoli along with moderate to scant cytoplasm. Areas of necrosis and vascular proliferation were also seen. Prominent mitotic activity was seen as shown in Fig. Immunohistochemistry showed reactivity pattern as in Table A diagnosis of small round blue cell tumor was made with the morphological and immunohistochemical features confirming it as Ewing’s sarcoma/primitive neuroectodermal tumor (PNET).On fluorescent in situ hybridization (FISH), t was not detected.Work up for metastasis, including CT scan of the chest, abdomen, pelvis, and whole spine MRI, was done and did not yield any metastatic lesions.The patient was arranged a follow-up visit; however, he defaulted his follow-up. Three months later, he presented again with complaints of a headache and bilateral complete loss of vision and a right temporoparietal mass. He was admitted, a decompressive craniotomy and debulking of a tumor were performed, and he was referred for radio-chemotherapy.Ewing’s sarcoma was first described by James Ewing in 1921 .Extraosseous Ewing’s sarcoma rarely presents as a primary intracranial lesion (CNS-EES). Typically, CNS-EES presents as a solitary lesion and is associated with the dura  4, 5]., 5.4, 5]T1-weighted imaging while isointense and hyperintense signal on T2-weighted imaging. Post-contrast MRI scan usually reveals a heterogeneous contrast enhancement within the Ewing’s sarcoma [Epidural/extradural EES, which may present as a biconvex extradural lesion, can be confused with epidural hematoma , 3. This sarcoma .Intracranial primary Ewing’s sarcoma is commonly associated with mild to severe headaches (the most common presenting complaint) . Nausea,The incidence of intracranial hemorrhage in patients with intracranial extraosseous Ewing’s sarcoma is remarkably high. Of the 17 cases reviewed by Ramon et al. , 7 (41%)Accurate diagnosis and differentiation between CNS-EES and cPNET is particularly important because the clinical behavior, the treatment, and the course of either tumor vary significantly . In moreCNS-EES is usually treated with multimodality treatment including surgery, focal radiotherapy, and chemotherapy. Surgery is also indicated for cPNET, but radiotherapy and chemotherapy guidelines and protocols are remarkably different from those of CNS-EES . For epiThe 5- and 10-year survival rates for extraosseous Ewing’s sarcoma are 69.7% and 65.2%, respectively . Due to This case is about a young patient, who presented with acute neurological symptoms, suggesting raised ICP or CNS infection. Initial neuroimaging revealed a biconvex intracranial extradural lesion that was eventually diagnosed as extraosseous intracranial Ewing’s sarcoma.Although, this presentation is exceedingly rare, yet in the right context, Ewing’s sarcoma can be considered as one of the differential diagnoses of Epidural brain lesion.


Congenital diaphragmatic hernias rarely present after 2 months of age and are typically diagnosed in the perinatal period. Moderate to severe diaphragmatic hernias present with respiratory symptoms, while late-onset hernias have a more varied presentation, depending on the age and content of the hernia. Very rarely, such hernias are found on incidental imaging, in which surgical repair is frequently recommended. A young girl with Loeys-Dietz syndrome and prior abdominal surgeries presents with 1-year history of increasingly severe, intermittent, abdominal and left shoulder pain. Prior imaging incidentally revealed a left diaphragmatic hernia with omentum protruding into the thoracic cavity. This was managed expectantly due to her other medical and surgical issues. Serial imaging revealed that the herniated omentum was increasing in size and symptoms began to develop. An uncomplicated primary thoracoscopic repair was performed. We report the first case of a congenital diaphragmatic hernia in a patient with Loeys-Dietz syndrome. Congenital diaphragmatic hernias (CDHs) arise from a malformation of the pleuroperitoneal membrane during embryogenesis and are usually diagnosed by fetal ultrasound in over 73% of cases . If not A young girl presented to the emergency department at our children’s center with 1 year of increasingly severe, intermittent, abdominal and left shoulder pain. Medical history included a diagnosis of Loeys-Dietz syndrome at the age of 5 months, complicated by aortic enlargement. Detailed abdominal surgical history included Ladd’s procedure for malrotation, Nissen fundoplication and gastrostomy tube placement at 5 weeks of age, exploratory laparotomy at 3 months of age due to spontaneous intraperitoneal hemorrhage of a wandering spleen, incisional and bilateral inguinal hernia repairs at 9 months of age and a gastro-cutaneous fistula repair at 5 years of age.At age 5, a magnetic resonance imaging of the thoracolumbar spine was obtained in the setting of scoliosis, in which a small incidental diaphragmatic hernia was diagnosed on the left, posterolateral aspect of the diaphragm. The contents of the hernia initially appeared to be retroperitoneal fat, and the patient was asymptomatic. Given her other medical and surgical issues, the hernia was managed expectantly. Surveillance imaging for her aortic enlargement at ages 10 and 11 revealed a 5 cm × 3 cm herniation of retroperitoneal fat into the left hemithorax.In the setting of the patient’s new symptoms and her history, a chest radiograph  and compDuring repair, a large hernia was immediately apparent, protruding from the posterolateral aspect of the diaphragm, consistent with a Bochdalek hernia . The herCDH is a potentially fatal defect that generally presents perinatally and is repaired within the first month of life , 3, 4. VIn our case, frequent surveillance imaging required by our patient’s underlying genetic disorder offered assistance in diagnosing the etiology of her vague but chronic pain. Such an incidental finding is reported to occur in as little as 7 in 10 000 patients [In addition, our patient was without a spleen since early life. In some cases, the spleen may be well positioned to occlude a small Bochdalek hernia , howeverin utero, resulting in a diaphragmatic hernia for our patient.Our patient also had Loeys-Dietz, a clinical syndrome included within the Marfan spectrum known to cause multiple developmental anomalies including aortic and arterial aneurysms, hypertelorism, bifid uvula/cleft palate, arterial tortuosity, craniosynostosis, brain anomalies, mental retardation and spine deformities . The affLate-onset CDH can be repaired via thoracic or abdominal approaches. While the abdominal approach is more traditional, there has been increased evidence to suggest that thoracic approach can be just as effective . Our decIn summary, we report a rare case of incidental late-onset CDH in an adolescent patient with Loeys-Dietz syndrome and extensive history of abdominal surgery, repaired thoracoscopically. The genetic mechanisms underlying Loeys-Dietz may be associated with the formation of a diaphragmatic hernia, and, to our knowledge, this is the first case report of a CDH in a Loeys-Dietz patient.None declared.


Acute gastric dilatation (AGD) leading to gastric necrosis and perforation has been reported to be a rare but fatal complication in young patients with eating disorders, particularly anorexia nervosa.We report a case of a Canadian female patient presenting with mild abdominal pain, with a history of anorexia nervosa, the binge/purge subtype, who was found to have severe acute gastric dilatation on subsequent computed tomography imaging. Her clinical course was uncomplicated after gastric decompression. The cause of her AGD was thought to be secondary to dysmotility disorder caused by her anorexia nervosa.Our case report demonstrates the importance of clinical identification of AGD and subsequent diagnosis and management. Because of the urgency to rule out obstruction or perforation through consultation or additional imaging modalities, recognition and correct diagnosis of this condition is necessary for appropriate patient management. In addition, our case report adds to an underreported but important complication of anorexia nervosa. Anorexia nervosa confers a high degree of mortality and morbidity, including gastrointestinal disturbances –3. WhileA 21-year-old Canadian female, with known anorexia nervosa binge/purge subtype, and no other medical conditions, was admitted with mild abdominal pain following an episode of binge eating. The patient reported 5 days of constipation and abdominal distension. She was able to pass flatus but could not vomit. There was no other relevant family or social history.On initial physical examination, her vitals were stable. She appeared severely underweight with a body mass index less than 18. She did not have signs of purging such as Russell’s knuckles. On abdominal examination, she had a distended abdomen, with no peritoneal signs. She had no signs of chronic liver disease. Cardiopulmonary examination was unremarkable.Abdominal x-ray revealed a large soft tissue density displacing the transverse colon inferiorly, seen in Fig. The images showed return of normal caliber small bowel within the pelvis, with gas and a very large volume of stool present throughout the colon. The mesentery was compressed posterior to the stomach, and evaluation of small bowel loops was limited by the absolute absence of intraperitoneal fat. There was no free air or free fluid. The hepatobiliary and genitourinary systems were unremarkable Figs. , and 4.FGeneral surgery and gastroenterology were consulted. Obstruction and perforation of the small bowel were ruled out by esophagogastroduodenoscopy; the stomach was noted to be mildly irritated, but the small bowel was widely patent, and the mucosa was normal.Her gastric distention was thought to be secondary to reduced gastric dysmotility in the setting of anorexia with frequent binge/purge episodes , 4. SupeThe medicine team worked with the patient, the psychiatry team, and the dietician to increase her oral intake until she was medically stable for transfer to the inpatient eating disorders program. However, clinical challenges arose related to her worsening anorexia symptoms, which included refusing refeeding and intention to leave hospital, despite not being medically fit. A full interdisciplinary team approach was utilized in order to ensure standard of care for the patient.Acute gastric distention is caused by a myriad of etiologies which may cause ischemic injury to the stomach , 7. ThesClinically, symptoms tend to be non-specific but may include vomiting, nausea, and mild to severe abdominal distention. Rupture may lead to more pronounced symptomatology including peritoneal signs . HistoryRadiographically, abdominal x-ray may reveal a dilated stomach, and in the presence of gastric perforation may show pneumo-peritoneum on erect chest x-ray. A CT scan will show a dilated stomach; furthermore, CT can reveal alternative causes of AGD including superior mesenteric artery syndrome, although arteriogram may be necessary if the diagnosis is unclear. Further diagnostic clarification can be made with upper gastrointestinal endoscopy which can detect gastric outlet obstructions and early signs of ischemia , 9. If dThe definitive treatment of AGD largely depends on the etiology and may include surgery for patients with perforation or extensive ischemic injury. First-line acute treatment of AGD consists of nasogastric decompression and fluid resuscitation.One of the most common mechanistic theories for acute gastric dilation in patients with anorexia is gastroparesis (delayed gastric emptying), which develops frequently due to food restriction with weight loss. Typically, this phenotype presents with bloating postprandially –12. HoweOur case report adds to the literature of rare occurrences of AGD in patients with anorexia nervosa. It highlights the importance of diagnostic steps in patients who present with a psychiatric condition and a concurrent potentially catastrophic medical situation. More importantly it demonstrates the complexities of the underlying pathophysiology of AGD, as our patient had no obvious obstructive cause of her AGD, and the underlying reasons for anorexia-associated AGD remain unclear.


The liver and lungs are the most sites to occur. Incidence in muscles is exceptionally rare.We report a case of a 36-year-old female presented with an uncomfortable mass in the upper medial of her right thigh without any presence of other symptoms. She lived in a rural area in Manbij, which is an endemic area of hydatid cysts in Syria. She was a shepherdess; therefore she had direct contact with sheep and dogs. Ultrasound examination showed a cyst located between adductor longus muscle and gracilis muscle closed to the deep femoral artery. The patient was treated with pharmaceutical therapy for a week before cystectomy, which was done under general anesthesia. The cyst was dissected between the fibers of adductor longus muscle from the lateral side and fibers of the gracilis muscle from the medial side. The cyst with all its layers was resected.Musculoskeletal Echinococcosis is a rare disease, because of intramuscular growth of cysts is restricted by muscle's contractility, the muscles are undesirable habitat for Echinococcus granulosus and because of the hepatic barrier role. Many cysts are revealed by complications such as nerve compressions, infections simulating an acute abscess or a malignant tumor.Hydatid cyst present as mass of soft tissue, particularly in endemic areas, as a result of contaminated water. MRI considered the best technique in the diagnosis. •Incidence of Hydatid cyst in muscles is exceptionally rare.•MRI considered the best technique in the diagnosis.•Confirming the final preoperative diagnosis of muscle hydatid cysts is important.•Hydatid cyst should consider as a differential diagnosis for masses of soft tissue. The liver and lungs are frequently the most infected sites; the muscles are rarely infected and count about 2.2% [The presence of the hydatid cyst in the thigh is rare and counts about 0.35%–15% .Human Hydatid disease is a zoonotic infection. Humans are infected by consumption food and water contaminated with Echinococcus's eggs .These cysts manifest as slow-growing masses of soft tissue and can be associated with fistulization and signs of inflammation ,6.The clinical manifestation is insidious and nonspecific, frequently causing tardiness in diagnosis. The nonspecific clinical symptoms can be concise as a painless non-inflammatory tumescence increases progressively in size over many years while maintaining the patient's good general health. However, a particular number of cysts are revealed by complications such as nerve compressions or infections simulating an acute abscess or a malignant tumor .Here we present a rare case of hydatid cyst located between adductor longus muscle and gracilis muscle of a 36-year-old female.The work in this case report has been reported in line with the SCARE 2018 criteria .2Clinical findings: A 36-year-old female with a body mass index (BMI) of 26, 4 kg/m2, presented to the surgical clinic with a one-year history of an uncomfortable mass in the upper medial aspect of her right thigh. The patient suffered from heaviness in the thigh without any presence of other symptoms. She lived in a rural area in Manbij, which is an endemic area of hydatid cysts in Syria. She was a shepherdess; therefore she had direct contact with sheep and dogs. The patient had no family, surgical, or medical history. Physical examination showed an unpainful mobile mass in the upper medial aspect of the thigh without any features of acute inflammation or bruise. No erythema or any sign of lymphadenopathy.Diagnostic assessment: Laboratory tests, including serum chemistries, complete blood cell count, erythrocyte sedimentation rate (ESR), coagulation profile, and C - reactive protein (CRP) showed normal results. Weinberg test was carried out, and it was negative. Initially, an ultrasound examination “US” was performed, which showed a double-wall cyst with pure liquid in adductor longus muscle and gracilis muscle closed to the deep femoral artery. Then magnetic resonance imaging (MRI) was performed, which showed a cystic mass approximately 124× 80 × 110 mm closed to the deep femoral artery [l artery . The cysTherapeutic Intervention: The patient was treated with Albendazole (300) mg for a week before surgery was done. Cystectomy was performed under general anesthesia. A medial longitudinal incision was done, and the deep femoral artery was isolated. The cyst was injected with a stramid 15% (cetrimide–chlorhexidine combination) to reduce the risk of recurrence, after that, the cyst was dissected between the fibers of adductor longus muscle from the lateral side and fibers of gracilis muscle from the medial side [ial side . The cysial side . The patFollow-up and outcomes: Postoperatively, the patient was followed up for a month without any recurrence manifestations.3Hydatid disease which also called cystic Echinococcosis is a parasitic disease caused by the larval level of Echinococcus .There are two species of Echinococcus “E. Granulosus and E. Multilocularis” cause cystic Echinococcosis and alveolar Echinococcosis in humans. This disease prevails principally in Asia, North and East Africa, South America, Australia, and the Middle East. The most common sites of echinococcal cysts are in the liver 62%) and lungs (20%) but can affect any part of the body [% and lunDifferential diagnosis of hydatid disease should be considered for every soft cystic mass in any anatomical location, especially in endemic areas of the disease .Musculoskeletal Echinococcosis is an infrequent case counting for only 3–5% of all cases. Many factors explain the rare occurrence of muscular participation: First, the muscle is classified as an undesirable habitat for the Echinococcus because of the high levels of lactic acid, which makes the muscle an inconvenient growth environment. Second, the intramuscular growth of cysts is restrained by the muscle's contractility. Third, the consideration of the hepatic barrier role, where the implantations at this site requires a passage through the filters of the liver and lung .Computed tomography has superiority over ultrasound because of having better documentation of site, size, and structure of the cyst. The differentiating sign of hydatid disease may show on MRI as an intensive rim .To confirm the diagnosis, several popular tests are usually applied, such as Sero-logic tests, indirect immunofluorescence antibody test, ELISA, immunoelectrophoresis, and immunoblot test .Weinberg test or Complement Fixation test (CF) is one of the serological methods commonly used to diagnose the hydatid disease, the sensitivity of CF test ranges from 36% to 93%, This method also has a prominent role for postoperative evaluation .In general, MRI has a higher specificity and sensibility than ultrasound for hepatic hydatid cyst .It also allows a better characterization of anatomical relations and helps surgical management of cyst. It is essential to confirm the final preoperative diagnosis of skeletal muscle hydatid cysts. This contraindicates confirm treatment options like marginal excision or incisional biopsy due to the likelihood of dissemination and anaphylactic shock on spillage .Pericystectomy remains the treatment of choice in musculoskeletal hydatid cysts. Percutaneous aspiration, infusion of scolicidal agents like chlorhexidine gluconate, and re-aspiration PAIR, under imaging ultrasound or CT guidance, can be used as an alternative to surgery in inoperable cases .Supplementary chemotherapy with anthelmintic for skeletal muscle hydatid disease is debatable, and currently, no evidence provides sufficient backing on the benefit of its association with conservative treatment. Albendazole remains the gold standard drug administered in adjuvant therapy . However4Hydatid cyst incidence is extremely rare in muscle, and most occur in the liver, lungs, or both. The disease is zoonotic, the result of contaminated water, via Echinococcus granulosus. Hydatid cyst should be considered as a differential diagnosis for masses of soft tissue, especially in endemic areas. MRI considered the best technique in the diagnosis.The patient participated in the treatment decision and she was satisfied with the results of the treatment. Her perspective on this treatment was to get rid of the uncomfortable mass without complications.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.Not required for case reports at our hospital. Single case reports are exempt from ethical approval in our institution.There are no sources of funding.Aya Zazo: data collection, revising critically, wrote the manuscript.Rama Zazo: patient care, revision, corresponding author.Mohammad Nour Shashaa: review and editing, data analysis, wrote the manuscript.Mohamad shadi Alkarrash: design of the study, revision, validation.Muhamad Zakaria Brimo Alsaman: patient care, data collection, wrote the manuscript.Ammar Niazi: managed the patient and did the surgery, the supervisor, patient care, revising critically.All authors read and approved the final manuscript.None.Dr.Ammar Niazi.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The authors declare that they have no conflict of interest.


Chronic proctalgia can have a major impact upon quality of life. There are many potential aetiologies however, in some patients no cause can be identified.We present a patient post liver transplant with intractable proctalgia, despite multidisciplinary management including opioids, nerve blocks and surgical intervention. An underlying rectal arteriovenous malformation (AVM) was subsequently identified and successfully treated with embolotherapy. The onset of symptoms coincided with the development of inferior mesenteric vein stenosis, likely leading to engorgement of the malformation due to impaired venous outflow. Neovascularisation secondary to the liver transplant procedure may also have contributed to growth of the lesion.This is a rare presentation of rectal AVM. These lesions can be treated with minimally invasive embolisation/sclerotherapy and should be considered in cases of unexplained proctalgia. Proctalgia is a difficult clinical challenge which can cause significant impairment of quality of life. Common causes include malignancy, haemorrhoids, cryptitis and fissures. If no cause is found, it may be classified as a functional disorder, however it is important to thoroughly investigate and outrule treatable causes prior to this diagnosis.We present a case of proctalgia secondary to rectal arteriovenous malformation (AVM). This is an unusual presentation for this condition, which more commonly causes gastrointestinal (GI) bleeding. We discuss the probable aetiologies for this patient’s symptoms, based upon review prior literature and describe our successful approach to endovascular management.A 54 year old man attended Liver Transplant clinic with severe proctalgia. He had undergone two liver transplant procedures for liver failure due to autoimmune hepatitis. Severe rectal and perineal pain, faecal urgency and intractable pruritus ani began two months after his second transplant. His pain persisted despite high dose opioids. Two nerve blocks were performed under fluoroscopic guidance by our local pain service, targeting the Ganglion Impar, a sympathetic ganglion located anterior to the sacrococcygeal joint which is involved with innervation of the coccyx, perineum and distal rectum  demonstrated two regions of abnormal, engorged vessels; at the antimesenteric border of the splenic flexure of the colon and adjacent to the rectum. There was arterial hypertrophy and arteriovenous shunting, compatible with arteriovenous malformations (AVM). The lesions did not have dominant draining veins, consistent with type IIa ‘Typical AVM nidus’ according to the Yakes’ Classification System Yakes . Upon reHe was referred to Interventional Radiology (IR) and underwent angiography Fig.  and scleAVMs are tangles of poorly formed vessels where blood flows from arteries directly to veins, without an interposed network of capillaries. They can form anywhere in the body and may be congenital (sporadic or hereditary) or acquired (post trauma or iatrogenic). Small focal AVMs of the GI tract are often referred to as angiodysplasia. Reported population prevalence of small colonic AVMs on colonoscopy range from 0.8-3%, although they are uncommon in the rectum , immediate peri-nidal venous outflow occlusion with coils or other mechanical embolic devices is the recommended therapy, which may be performed alone or in addition to sclerotherapy Yakes . This waThis case highlights a rare but important cause of proctalgia. AVM should be considered in cases of unexplained proctalgia because, if diagnosed, these lesions can be effectively treated by minimally invasive embolization. This case also demonstrates an interesting temporal association between the development of venous outflow stenosis and the onset of symptoms in AVMs, which is supported by prior literature in cerebral AVMs.


Case Report. A 69-year-old man presented with diffuse abdominal pain and vomiting over the last 12 hours. Clinical examination, laboratory, and imaging investigations showed small bowel obstruction, and after 12 hours of conservative management, surgical exploration was decided. During surgery, a dilated terminal ileum bowel loop was found densely adhered to the sigmoid colon, attached to an inflamed epiploic appendix. The small bowel was mobilized and freed, and the inflamed epiploic appendix was resected. The postoperative course was uneventful, and the patient was discharged on the 5th postoperative day.  Epiploic appendagitis is a rare cause of acute abdominal pain, mimicking acute diverticulitis or appendicitis. Epiploic appendagitis causing small bowel obstruction is highly unusual, and only a handful of such cases have been reported so far.  Epiploic appendagitis, although a rare clinical entity, may explain small bowel obstruction symptoms. Small bowel obstruction (SBO) is a common cause of hospital admission, caused mostly in adults from previous surgery adhesions, neoplasms, or abdominal wall hernias . On the th postoperative day.A 69-year-old man presented with colicky abdominal pain, flatulence, vomiting, and abdominal distension developed over the last 12 hours. The patient had arterial hypertension from his past medical history, while from his surgical history, he had underwent laparoscopic cholecystectomy 10 years earlier, and his BMI was 34. On clinical examination, he was mildly febrile with a temperature of 37.8°C, hemodynamically stable, and with marked abdominal distension and elevated inflammatory markers: white cell count 15000/78% neutrophilic type and CRP: 9. Otherwise, his laboratory tests were unremarkable. Abdominal X-ray showed dilated small bowel loops with air-fluid levels. Abdominal computed tomography (CT scan) followed and revealed SBO, showing a transition point in the terminal ileum . AbdominEpiploic appendages are pedunculated fat-containing structures arising from the large intestine wall, mostly developed on the transverse and sigmoid colons . The sizClinical presentation resembles acute diverticulitis or acute appendicitis, with left or right lower quadrant abdominal pain, which is more acute in onset though, with concurrent nausea, anorexia, and mild peritonism signs . LaboratAs mentioned above, 90% of SBO cases are caused by adhesions, hernias, and neoplasms , while uIn conclusion, EA should be included in the differential diagnosis list of unusual SBO causes.


Intraosseous epidermoid cyst (IEC) is a rare, non-neoplastic, pathology in animals and humans that most commonly affects the distal phalanx. In dogs, it is important to differentiate this lesion from malignant digital tumours causing bone lysis. In previous reports, IEC has been described to affect only a single digit at the time of diagnosis which is usually based on histopathology. This is the first case report to describe immunohistochemically confirmed IECs affecting simultaneously multiple digits.A 4-and-a-half-year-old female spayed Great Dane was presented with a 2-month history of progressive swelling of the distal phalanx (PIII) of digits IV and V of the right pelvic limb. Eleven weeks prior to presentation, the dog had a low-grade cutaneous mast cell tumour completely excised from the craniolateral base of its left pinna. A history of trauma to 1 of the nails of the same pes 4 years prior to referral was also reported. Examination of the right pelvic limb identified firm non-painful swelling of PIII of digits IV and V, with concurrent deformation of the nails. Radiographs of the right pes obtained by the primary veterinarian identified an expansile lesion of PIII of digits IV and V. Computed tomography identified large expansile lesions of PIII of digits IV and V, with associated cortical thinning and soft tissue swelling. Neoplasia was considered the most likely radiographic diagnosis. Histopathology of Jamshidi bone biopsies was consistent with intraosseous epidermoid cyst, which was confirmed with immunohistochemistry. Amputation of PIII of digits IV and V at the level of mid-PII was performed as definitive treatment. No recurrence of the lesion occurred during the 10-month follow-up period.Intraosseous epidermoid cysts should be included in the differential diagnosis for expansile lesions affecting the canine digit. It is important to differentiate them from other digital lesions, with bone involvement, such as malignant digital tumours, which often require more extensive surgery for definitive treatment. The case herein highlights that this lesion can affect simultaneously multiple digits. Definitive diagnosis can be achieved by identification of keratin-producing epithelial cells on histopathology and confirmed by pancytokeratin labelling. Echocardiography identified a normal left atrium:aortic ratio, normal left ventricular fractional shortening and no evidence of dilated cardiomyopathy. The dog was premedicated with methadone hydrochloride11 needle accidentally exited the opposite cortex of PIII and entered the interdigital skin. An intraoperative intravenous dose of cefuroximeStaphylococcus simulans and a very slow growing Granulicatella elegans. No fungal growth was identified. Histopathologic analysis of the 2 Jamshidi11 bone biopsies identified small foci of dense lamellar bone with frequent rows of plump osteoblasts lining internal surfaces. Focally within cavities in the bone were small haphazardly-layered keratin squames surrounded by a thin layer of stratified squamous cells (keratinocytes). On IHC, these cells stained positively for pancytokeratin.Complete blood count and serum biochemical analysis identified normal morphology of red and white blood cells, a mild increase in haemoglobin concentration (192 g/L RI: 120–180]), mild lymphopenia 0.76 × 100), mild RI: 1.00–.60), and0, mild R10 (2.0 mg/kg) via a cannula placed in a dorsal pedal vein after placement of a tourniquet proximal to the tarsocrural joint. The tourniquet was removed intraoperatively after 90 min. A skin incision was made over the dorsal aspect of PIII of digits IV and V extending from the region of the nail bed to the level of mid-PII. The skin and subcutaneous tissue were dissected from the bone (PIII), extending abaxially from dorsal to plantar. Amputation was performed using bone cutters at the level of mid-PII. The ostectomy site was rasped to remove sharp bone edges. During dissection around PIII of digit IV, pale brown-coloured flocculent fluid emanated from an approximately 5–6 mm diameter subungual circular defect in the lesion. A swab of this fluid was obtained for microbiologic culture. Both surgical sites were copiously lavaged with sterile saline. The digital pads of digit IV and V were preserved for closure, which consisted of a simple interrupted suture pattern with 2–0 polydioxanone4 (0.1 mg/kg intravenously), and acetaminophen16  and meloxicam1  for 7 days. Postoperative radiographs of the right pes confirmed complete radiographic excision of both digital lesions. The limb was bandaged postoperatively to protect the surgical sites and was changed q 24 for the first 2 days, at which time the dog was discharged. Discharge instructions included exercise restriction for a further 2 weeks, maintenance of an Elizabethan collar, twice weekly bandage changes, suture removal at 14 days postoperatively and administration of meloxicam1  and acetaminophen16  for 7 days as well as amoxicillin clavulanic acidThe dog was re-presented 7 weeks following initial presentation to our institution for definitive surgery. It was not receiving any medication and demonstrated no lameness. On physical examination, the right popliteal lymph node remained moderately enlarged and firm on palpation. The firm, non-painful, bony swelling of digits IV and V remained static. Fine needle aspirates of the right popliteal lymph node were repeated and cytologic analysis was consistent with a reactive lymph node. The dog was re-anaesthetised and the right crus and pes prepared for surgery as previously described. Intravenous regional anaesthesia was performed using lidocaine hydrochlorideCulture of the fluid emanated intraoperatively from the subungual defect of digit IV yielded no bacterial or fungal growth. The excised phalanges were submitted for histopathologic analysis. Macroscopically, the excised lesions appeared unilocular with pale white/grey dense material filling the cavity Fig. . On IHC,Pseudomonas infection was identified on repeat culture and was treated with marbofloxacin3 and amoxicillin clavulanic acid2.Four days post-discharge, the dog was presented to its primary veterinary clinic for a bandage change and wound check. Dehiscence of both digital pads was identified, which required debridement and open wound management, with daily wound lavage and bandage changes. To the best of our knowledge, this is the first report of an immunohistochemically-confirmed IEC in the veterinary and human literature and the first to describe the simultaneous involvement of multiple digits in the dog and in humans.In a study involving 17 dogs with digital IECs , the thoA history of trauma to 1 of the nails of the affected right pelvic limb was reported in the dog of the present report. The significance of this is uncertain as it is possible that such trauma was completely unrelated to IEC formation. There are several reports of IECs affecting the phalanges of people with a history of previous blunt, penetrating or iatrogenic (e.g. previous surgery) trauma, supporting the traumatic theory for development of IECs , 34–36. Clinical signs of the case reported herein are similar to those previously described in dogs and in humans, and include firm bony enlargement of the PIII of the affected digits and nail deformation , 25, 34.Intraosseous epidermoid cysts in both humans and animals share common radiographic characteristics appearing as well-defined expansile radiolucent osseous lesions with distinct thin-walled sclerotic cortical margins , 31, 35.In the dog described herein, CT of the affected pes was performed in an effort to better define the nature and extent of the osseous lesions identified on radiographs obtained by the primary veterinarian. The main CT features of the dog of the present report included a large expansile lesion with associated cortical thinning and focal cortical loss. We are unaware of other reports describing the use of CT to diagnose IECs in small animals. In people, both CT and MRI are used to diagnose IECs , 27–30. Macroscopically, IECs lesions tend to be spherical, filled with thick semi-liquid, light-coloured cream-to-gray-tinged material , 33, 34.11 bone biopsy specimens in the dog of the present report. However, on the basis of the possibility of a non-diagnostic sample, histopathology of surgically obtained bone biopsy specimens was considered more likely to provide a definitive diagnosis. Being epithelial in origin, IECs exfoliate well, with the most common cytologic findings including anucleate squames surrounded by granular debris [Cytology of fine needle aspirates has been described as a minimally invasive method of obtaining a diagnosis in human patients but has not been described in the veterinary literature , 17, 22.r debris , 22.Pseudomonas aeroginosa and Staphylococcus aureus were isolated at the time of surgery, respectively [Staphylococcus simulans and Granulicatella elegans. However, both were considered to be contaminants due to inadvertent penetration of the interdigital skin during biopsy acquisition. In the human literature, the majority of IECs are sterile [Secondary infection of IECs is infrequently reported in both the veterinary and human literature , 23. In ectively , 23. Ini sterile , 26, 36.en bloc excision or amputation of affected phalanges [Treatment options that were discussed for the dog of the present report included curettage and autogenous cancellous bone grafting, mid-PII amputation and isolated PIII excision (declawing). Partial foot amputation has been reported in dogs for the management of malignant tumours of the digits; however, in light of the histopathologic diagnosis of benign IEC and the distal location of the lesion within the digits, this option was not considered appropriate. To the authors’ knowledge, curettage and bone grafting as is reported in people has not been described for the management of IECs in dogs , 23, 24.halanges , 34, 36.halanges , 23, 29.halanges  or isola11 bone biopsies, as definitive diagnosis was uncertain based on the histopathology. Pancytokeratin labelling confirmed the epithelial nature of the lining cells of the cyst further supporting the histopathological suspicion of IEC, which allowed the authors to consider less aggressive treatment options. Repeat IHC was performed after excision of the lesion to confirm the initial diagnosis.The use of IHC has not been previously described in veterinary and human literature in order to support the histopathologic diagnosis of IECs. In the case described herein, pancytocekeratin labelling was used on the initial JamshidiIn conclusion, IECs are a rare pathology in dogs but should be considered as differential diagnosis for expansile digital lesions. It is important to differentiate them from other digital lesions, with bone involvement, such as malignant digital tumours, which often require more extensive surgery for definitive treatment. We believe that knowledge of the characteristic expansile thin-walled radiologic nature of this lesion in a known predilection site  in dogs and in humans may expedite definitive treatment and potentially avoid the requirement for incisional biopsy as was required in the case herein. This report highlights that IECs can affect simultaneously multiple digits. Definitive diagnosis can be achieved with histopathology supported by immunohistochemical labelling for pancytokeratin.


Lipomas represent the most common benign mesenchymal tumor. They are usually located subcutaneously and rarely become symptomatic. Occasionally pressure symptoms on adjacent neurovascular structures may be exerted, thereby causing functional impairment. Lipomas rarely grow larger than 5 cm, becoming the so-called giant lipomas, posing a real diagnostic and surgical challenge. We report an unusual case of a 43-year-old Caucasian female with an accidental pelvic ultrasound finding of a giant mass, which was also palpable over the right gluteal region. Interestingly the patient was free of any sciatic nerve compression symptoms. Magnetic resonance imaging (MRI) revealed a soft tissue tumor, partially located in between the external rotator muscles of the hip and the gluteus muscle. The tumor forced up and advanced through the great sciatic foramen into the pelvis. The patient underwent an uneventful complete and safe surgical excision of the gluteal mass, via a wide transgluteal approach. Pathology confirmed lipoma diagnosis. Patient is free from recurrence two years post operatively. Physicians involved in the diagnosis and treatment of gluteal masses should always consider in their differential diagnosis the presence of a sciatic hernia. Lipomas are benign mesenchymal tumors. They are the most common type of soft tissue tumor with an annually reported incidence of up to 0.5/1000 . Papen, A 43-year-old Caucasian female, during a regular office visit to her gynecologist underwent an ultrasound scanning and she was accidentally diagnosed with a pelvic mass. Patient was otherwise asymptomatic and well nourished. An easily palpable, reducible lump over the right gluteal area was revealed, consistent with a subcutaneous lipoma. Physical examination did not show any signs of sciatic nerve compression, such as pain radiating down over the buttock, the back of the thigh and calf. Past medical and surgical history was free of any malignancies and traumas in the hip region. No recent weight loss or malaise was reported. On palpation, the abdomen was soft, free of masses or peritonitis signs. Sphincter tone was normal during a digital rectal examination but a soft mass was found in the right ischiorectal fossa.Complete blood workup was ordered and all results returned within normal limits. Subsequently ordered magnetic resonance imaging (MRI) demonstrated a giant in size, well-defined intermuscular soft tissue mass homogeneously isointense with fat, next to the sciatic nerve Figure . InteresWe decided to perform a wide transgluteal approach, thus avoiding a combined abdomino-perineal approach, because the lipoma was mainly located in the gluteus muscles, according to the imaging study. Incision was made in the skin, parallel to gluteus maximus fibers, along a line in between the major trochanter of the femur and the mid-sacrum, projecting the course of the piriformis muscle. The mass was carefully removed with meticulous blunt dissection and enucleation from the adjacent structures. The herniated, through the sciatic foramen, intra-pelvic portion of the lesion, was possible to withdraw and totally resected. Sciatic nerve and gluteal vessels were identified and left intact. The mass was entirely removed in an extracapsular plane thus ensuring a complete resection Figure . The surWe reported on a rare case of an accidental ultrasound finding of a giant intermuscular gluteal lesion with intrapelvic extension, posing diagnostic and therapeutic dilemmas, since malignancy should be ruled out . SciaticThe exact etiology still remains uncertain, among other factors piriform muscle atrophy and neuromuscular disease have been also suggested as possible triggering factors, but intra-abdominal adhesions and elevated abdominal pressure should be also considered -8. In thSciatic hernias may expand via either the lesser sciatic foramen or the supra- or the infra-piriform space. Our patient was symptom free, but other patients may complain of pain radiating over the buttock, thigh, back, even the pelvis . Hernia’Preoperative diagnosis is mainly based on MRI and/or computed tomography (CT) scan since they depict size, extend and adjacent structures of the tumor. Depending on the presenting symptoms, other diagnostic modalities may include intravenous pyelography, plain X-ray, cystography, ultrasound . PhysicaIn our case, preoperative MRI delineated the lesion precisely, showing that it was an intermuscular lipoma, developed in between gluteal muscular fascicles, which favors complete resection of the lesion with digital dissection without resecting any muscles in order to achieve clear margins. Wide excision is regarded curative, since partial removal may lead to recurrence and further complications . To the Transabdominal approach is strongly suggested for patients with bowel symptomatology such as incarceration or strangulation . SkipworRight piriformis muscle was identified intact, without signs of atrophy or fibrosis and no patch was needed since sciatic defect was not found. Complete and uneventful surgical removal of the lesion was decided and achieved via a transgluteal approach, with careful digital dissection under constant visual control of both the pelvic and the gluteal portion of the mass. Surgeons involved in the treatment of such cases should always safely expose and preserve the sciatic and posterior femoral cutaneous nerve and assess the status of the piriformis muscle. The mass did not show any signs of infiltration during surgery and it was well delineated.A giant gluteal lipoma herniating through the sciatic foramen may accidentally be found during a pelvic ultrasound. Nowadays, MRI may suggest the diagnosis. Once the lesion is discovered, it should be completely resected. Surgeons involved in the treatment of such cases should keep in mind that an uneventful and safe surgical excision of a gluteal mass via a wide transgluteal approach still remains a reliable treatment choice.


Well-differentiated fetal adenocarcinoma (WDFA) of the lung is a rare disease that resembles fetal lung tubules. Most of previous reports concerning WDFA have focused on histological features, while there are few reports describing radiological features. In addition, there are no reports evaluating the difficulty of intraoperative diagnosis of WDFA with frozen section. We report a case of WDFA and review the radiological features of WDFA including the findings of F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) and assess the difficulty of intraoperative diagnosis with frozen section.3 segmentectomy was performed via thoracotomy, and a benign tumor that was possibly an adenoma was intraoperatively diagnosed based on frozen section analysis. The mass was a solid tumor measuring 2.9 × 2.5 cm in diameter. Microscopically, the tumor comprised abundant glands with single or double layers of nonciliated cells and bronchial structures resembling a fetal lung. Rounded morules of polygonal cells were frequently observed. Immunohistochemistry revealed that nuclei and cytoplasm of the tumor cell were positive for β-catenin. Finally, the postoperative pathological diagnosis was well-differentiated fetal adenocarcinoma of the lung, and completion right upper lobectomy and mediastinal lymph node dissection were conducted 1 month after the initial segmentectomy. No residual tumor or lymph node metastasis was identified, and the final pathological stage was pT1cN0M0 stage 1A3. The patient did not wish to receive any adjuvant therapy. At the 1-year follow-up, no evidence of recurrence was noted.A chest radiography performed in a 20-year-old female revealed a mass in the hilum of the right lung. Computed tomography revealed a well-defined mass measuring 3.5 × 3.0 cm in diameter in the right upper lobe, whereas PET showed a high accumulation of FDG. The most likely diagnosis was clinical T2aN0M0 stage 1B non-small cell lung cancer. A right SHere, we report a rare case of well-differentiated fetal adenocarcinoma of the lung that was difficult to diagnose based on radiological evaluations including FDG-PET and intraoperative diagnosis using frozen section analysis. Fetal adenocarcinoma was first described by Kradin et al. in 1982 as a subtype of pulmonary blastoma . Convers3 of the right upper lobe and that its surface facing the interlobular space was covered with visceral pleura. The mass had not invaded the middle lobe, but it was close to the hilar vessels. Thus, wedge resection with the mass was considered to be difficult, and right S3 segmentectomy was performed. Intraoperative frozen section analysis revealed that the tumor contained branched gland ducts along with columnar epithelial cells with poor nuclear dysplasia arranged in papillary growth patterns. Therefore, the tumor was diagnosed as a benign pulmonary lesion , and the operation was completed without deploying any additional procedures.A 20-year-old woman with no smoking history presented a round-shaped shadow in the right middle lung field on a chest X-ray during her medical checkup on employment Fig. a, while Macroscopically, the mass was a solitary, white-colored, well-defined, and solid component measuring 2.9 × 2.5 cm in diameter Fig. d. These At 1 month after the initial operation, the patient underwent completion right upper lobectomy and systematic lymph node dissection. Anterolateral thoracotomy was performed via the fifth intercostal space, same with the incision in the initial operation; further, the lower lobe and chest wall surrounding the wound were widely attached, and both the major and minor fissures were firmly adhered. Although peeling off the adhesions was difficult, the remaining upper lobe was successfully removed without any complications such as vessel injury, lung damage, and massive bleeding. According to the pathological findings, no residual tumor or lymph node metastasis was present, and the final pathological stage was pT1cN0M0 stage 1A3 . The postoperative course was uneventful, and the patient was discharged on postoperative day 6. She did not wish to receive any adjuvant therapy. At 1-year after the second operation, the patient was well without any evidence of recurrence.In the present report, we observed two important clinical issues. First, WDFA showed a high accumulation of FDG on PET. Second, the intraoperative diagnosis of WDFA appeared difficult using histological examination with frozen section analysis.Force et al. reported the first case of WDFA with FDG-PET findings . Their cIn addition, WDFA showed well-defined oval or lobulated solid lesions on contrast-enhanced CT, which are often homogenously enhanced without calcifications. Yamakawa et al. reported that intratumoral enhancing vasculature was noted in the early phase of dynamic CT, whereas a persistent and plateau enhancement was noted in the delayed phase . HoweverFurthermore, to the best of our knowledge, no case of WDFA has been diagnosed using intraoperative frozen section analysis, whereas some cases have been diagnosed via aspiration cytology preoperatively. Geisinger et al. reported four cases of WDFA diagnosed using aspiration cytology with immunochemical staining; however, these authors concluded that the cytological diagnosis of WDFA may be challenging . FinallyMomozane et al. summarized 31 cases of WDFA resected in Japan, and they asserted the difficulty of establishing a definitive diagnosis preoperatively . Among tWe found that WDFA is associated with a high accumulation of FDG on PET scan. Moreover, WDFA may be difficult to diagnose using only small biopsy specimens and using frozen section analysis intraoperatively. Thoracic surgeons and pathologists alike should consider WDFA as one of the differential diagnoses when relatively young women demonstrate a well-defined solid lung lesion with a high accumulation of FDG. If there is strong possibility of WDFA, the necessity of anatomical resection should be considered.


A 64-year-old male presents with shoulder pain, arm pain, and a chronic cough. CT imaging of the thorax shows a large 8.0 x 6.7 cm mass with central necrosis in the left upper lung lobe with invasion into the chest wall with partial destruction of the second and third ribs, and left axillary adenopathy. Bilateral adrenal nodules are identified via CT imaging and subsequently biopsied. Histologically, the mass reveals sheets of atypical epithelioid cells with round nuclei and abundant eosinophilic cytoplasm. Immunostaining is positive for CD31, CD34, FLI-1, AE1/AE3, and CK7, diagnostic of primary epithelioid angiosarcoma. The patient developed symptoms of confusion, dizziness, and ataxia. An MRI showed metastatic brain lesions. One month later, the patient had worsening symptoms. Repeat imaging demonstrates enlargement of the bilateral adrenal masses, a new lesion posterior to the left kidney, and doubling of the size of the brain lesions. This case illustrates the metastatic potential and pattern of the spread of an aggressive primary pleural angiosarcoma that is not described elsewhere in current literature. It also highlights the importance of timely intervention based on the rapid metastatic progression of this neoplasm.  Angiosarcomas represent only 1% of all soft tissue malignancies . Tumor aThe pathogenesis of primary pleural angiosarcoma is unclear. Conditions currently linked to the development of pleural epithelioid angiosarcomas include a history of chronic tuberculous pyothorax, prior radiotherapy, and asbestos exposure. The common initial clinical presentation is characterized by effusion, pleural thickening, and chest pain. Less common presentations can include bloody effusion, hemoptysis, or solitary pleural mass . FrequenWe present a case of a 64-year-old male who presented with shoulder pain and a chronic cough. Extensive workup and immunohistochemistry revealed the diagnosis of a primary epithelioid angiosarcoma. The patient had extensive metastasis to the brain and adrenal glands. Due to the aggressive nature of the primary neoplasm, few reports of the metastatic pattern are reported. A 64-year-old male with a past medical history of hypertension and 30 pack-year history of smoking presented to the emergency department with complaints of shoulder and arm pain with a chronic cough. The patient’s workup includes an initial chest x-ray, and subsequent CT thorax showing a large 8.0 x 6.7 cm mass in the left upper lung with central necrosis and direct invasion of the left chest wall with partial destruction of the second and third ribs with left axillary adenopathy Figure . The masHistology of the adrenal lesion revealed clusters of atypical epithelioid/polygonal cells with vesicular nuclei, prominent nucleoli, and eosinophilic cytoplasm. Immunohistochemically, tumor cells stained positive for vascular markers CD31, CD34, and FLI-1, and with keratins including CK7 and AE1/AE3  and epithelial markers (cytokeratins), factor VIII, and vimentin. Additional epithelial markers used for vascular tumors include CK7 and CK14. Epithelioid angiosarcomas are positive for CK8 and CK18 in roughly half the reported cases. Epithelioid variant of angiosarcoma co-expresses cytokeratin . New immImaging studies can rarely distinguish the primary lesion from a metastatic lesion ,7. Our pMetastatic patterns of primary pleural angiosarcomas are not well documented. Pulmonary metastasis from cutaneous and cardiac angiosarcomas occurs in 60%-80% of cases ,4,9. AddOur case shows a unique pattern of metastasis and progression of an epithelioid angiosarcoma initially diagnosed from a biopsy of an adrenal mass. Histology and immunohistochemistry were diagnostic in this case. Correlation with clinical and radiologic findings supports the pleura of the lung as the primary site of this epithelioid angiosarcoma. Additionally, we report that over the course of one month metastatic lesions in the brain were significantly increased. This extensive pattern of metastasis has not been previously documented in literature.


Calcific tendinitis is a common pathology in the shoulder but is uncommon in the peroneus longus tendon, which is considered when patient presents with a palpable tenderness without signs of inflammation. Differential diagnosis is important, as the condition is often overlooked. Conservative treatment has proven successful, though surgery might be an alternative. Calcific tendinitis is a common pathology in the shoulder but is uncommon in the peroneus longus tendon, which is considered when patient presents with a palpable tenderness without signs of inflammation. Differential diagnosis is important, as the condition is often overlooked. Conservative treatment has proven successful, though surgery might be an alternative. The current study reports a case of a 58‐year‐old woman with an uncomfortable swelling and local tenderness in the lateral part of the right lower extremity. After diagnostic MRI, a surgical excision was performed. Pain resolved after surgery.Calcific tendinitis is a disorder characterized by deposits of hydroxyapatite  in any tendon of the body. A common localization of calcific tendinitis is in the tendons of the rotator cuff, especially in the supraspinatus and infraspinatus tendons. In the lower extremity, calcifications are rare and are usually found in the patellar and Achilles tendons or in the greater trochanter.A comprehensive literature review was performed by searching the PubMed‐National Center for Biotechnology Information database using the keywords ‘calcific, tendinitis AND peroneus’. The search yielded 5 publications, 1 of which was on ossification, while another was on hip pain. One case report of calcific tendinitis was found in the Elsevier bibliotheca. In total, 4 case reports on calcific tendinitis of the peroneus tendon were found and included in our literature review . ESWT may be considered if no improvement is observed with other nonoperative techniques. It appears that the effect of calcium disintegration or alterations in the deposit's consistency is derived from direct energy transfer. Observed trends show a better dissolution rate with high‐energy waves for single solid deposits.Surgical treatment is considered after 6 months if symptoms progress or fail to improve with conservative management or earlier if activities of daily living are significantly impacted. In cases of calcific tendinitis of the shoulder, arthroscopic surgery is preferred.Our case is important because in our case report, calcific tendinitis was found in the proximal part of the peroneus longus tendon, whereas the four other case reports described the involvement of the distal part of the tendon. A possible etiology could have been micro‐tears due to horse riding because of permanent dorsal flexion of the foot in the stapes.In our case, due to the calcific depositions in the peroneus tendon, open surgery was performed. Surgery was chosen as the management of choice in our case, as the symptoms impaired the daily life of the patient. Our case report is the only one with surgery as a treatment, but this option was more acceptable for the patient.Calcifications of the peroneus longus tendon are very rare, but this diagnosis should be considered when a patient presents with a hard‐palpable swelling. Surgery is a good option for treating calcific tendinitis with no risk of recurrence.None declared.AT and STM: conceived of this case report. AT and SA: wrote the first draft of the manuscript. AM: revised the final manuscript. All the authors have read and approved the manuscript.Informed patient consent was obtained.


Ovotesticular disorder or true hermaphroditism is defined as the presence of both ovarian and testicular tissues in the same individual irrespective of the patient’s karyotype. Ovotesticular disorder represents 5% of disorders of sex development. Cases of true hermaphroditism must be treated like men or women based on their age, external genitalia and the orientation of the patient. Here we report a case of true hermaphroditism which was diagnosed with seminoma on histopathological examination. The patient underwent orchiectomy, followed by two cycles of chemotherapy. Ovotesticular disorder or true hermaphroditism is defined as the presence of both ovarian and testicular tissues in the same individual irrespective of the patient’s karyotype. It is an extremely rare condition with a prevalence rate of less than 1/20,000 . The risA 20-year-old young man presented with severe lower abdominal pain since four days. He complained of dull aching pain in the left iliac region for the last month, which was intensified for the last four days. The pain was not associated with fever, burning micturition or vomiting. The pain was relieved on taking antispasmodics and on taking rest. The patient did not complain of any specific discomfort in his past medical history was also unremarkable. There was no blood relationship between his parents, and his elder brother was a healthy normal male with two children. On examination, patient was phenotypically a normal male with well developed external male genitalia. He had a normal male distribution of hair. The external phallus was normal in size, and urethral orifice was present in normal position with no hypospadias. On palpation, the right testes were present in the right scrotal sac and were normal in size. However, the left scrotum was empty. There was no lymphadenopathy. Patient described of having erections but had no experience of sexual activity. In the left iliac region, tenderness was elicited, but no mass was palpable.Following admission, investigations revealed normal levels of total Testosterone (482.82ng/dl) and Estradiol (16pg/ml) for a male. Luteinizing hormone (16.32mIU/ml) and follicle-stimulating hormone (28.74mIU/L) were elevated. All these findings are consistent with primary testicular failure. Serum Prolactin and Dehydroepiandrosterone levels as well as the thyroid function tests, were normal. The cytogenetic analysis of the karyotype showed genotype 46XY.Abdominopelvic ultrasonography showed a well-circumscribed, ovoid, heterogeneously hypoechoic lesion of 2.2×2.6×1.3 cm size in the left iliac region. It also showed the presence of a small uterus adjacent to the bladder wall. MRI showed multinodular, sharply defined, 2.1×2.6×1.2cm homogeneous tumour of low signal intensity on T2-weighted images and areas of signal intensity heterogeneity related to haemorrhage or necrosis. MRI findings suggested seminomatous changes of the left testis.Patient and his relatives were correctly counselled about the condition. Efforts were made to counsel the patient psychologically. After proper surgical workup, an exploratory laparotomy was planned. There were a small, well-developed uterus, fallopian tubes and bilateral ovaries Figure . As the The left testis was present near the left deep inguinal ring. It was rubbery in consistency and the surface looked normal. There was no enlargement of the local lymph nodes. The left testis was removed in toto because of the high chances of malignancy suggested by MRI. A biopsy was taken from the right testicle by making a small incision over the scrotal skin in order to rule out any dysgenesis or ovotesticular tissue. Right testicular biopsy showed normal histology with seminiferous tubules without any dysgenesis or ovarian tissue. The histology of the ovarian sections showed ovarian parenchymal tissue with primary and secondary follicles, a corpus luteum, and several corpora albicantia. Histopathological examination revealed seminoma of the left testis Figure .Patient was discharged on 7th postoperative day. The patient was referred to the oncologist for further management. Two cycles of chemotherapy were planned and the patient was counselled for sperm banking before chemotherapy. He could not go for sperm banking due to financial constraints. Postoperatively two cycles of chemotherapy with carboplatin were given. Patient is in regular follow up with the oncologist and is having no complaints at this time.True hermaphroditism diagnosis is made based on the histological presence of both testicular and ovarian tissue in the same individual. Almost 90% of subjects will present at birth with ambiguous genitalia like microphallus, hypospadias, urogenital sinus, a fusion of penoscrotal labia, or cryptorchidism . OvotestThe karyotype of patients can be 46XX (60%), 46 XY(7%), other mosaic karyotypes like 46XX/46XY, 46XY/45X(33%) . Two-thiRadiological examination plays a vital role in the assessment of DSD cases. For diagnosis, sex hormone testing, ultrasound, computed tomography and magnetic resonance imaging can be done. Ultrasound remains the modality of choice in the evaluation of patients with ambiguous genitalia as there is no exposure to radiation or contrast. In some cases, endoscopy or diagnostic laparoscopy is needed in addition to radiological imaging . HoweverTrue hermaphroditism is rarely associated with gonadal tumours. Some cases of malignancies like dysgerminoma and gonadoblastoma have been reported in true hermaphroditism subjects . As the Cases of true hermaphroditism must be treated like men or women based on their age, external genitalia and the orientation of the patient. Surgical treatment followed by hormonal support is the mainstay of treatment. In cases where the gonads are associated with malignant changes, it should be removed with postoperative chemotherapy or radiotherapy given according to the type and stage of the disease. To prevent malignancy, corrective surgery is recommended for undescended testes in children before the age of two years.While most of the Ovotesticular disorder cases present with the ambiguous genitalia during infancy, some cases may also come into light during adulthood as seen in our case. A multidisciplinary team should do the management of a patient with Ovotesticular disorder. DSD management may include medical treatment, surgical correction of ambiguous genitalia and removal of dysgenic gonads or Mullerian components, and psychological counselling.


Urachal remnant anomalies are uncommon in adults and can be confused with a variety of clinical conditions when symptomatic or infected. Vesicourachal diverticulum is the rarest type, accounting for approximately 3% to 5% of congenital urachal anomalies. We report the case of a 42-year-old female patient, who presented to the emergency department with lower abdominal pain and a palpable abdominal mass. An infected vesicourachal diverticulum was diagnosed after imaging studies and was initially treated with intravenous antibiotic therapy and drainage of the urachal diverticulum to the urinary bladder through a JJ stent. Finally, the patient underwent open surgical excision of the urachal remnant. The postoperative course was uneventful, and the histopathological examination confirmed the diagnosis of vesicourachal diverticulum. We recommend drainage of an infected vesicourachal diverticulum through the bladder by JJ stent placement inside its lumen during cystoscopy, as an alternative to percutaneous drainage reported in the literature. Urachal remnant anomalies are rare in adulthood, with a reported incidence of 1 : 5000 in adults, and a higher prevalence in men than women with a ratio 2 : 1 . It is g9/L with 77.2% neutrophil predominance and a high C-reactive protein of 93.4 mg/L. Urine analysis was normal and urine culture showed no bacterial growth. Abdominal ultrasonography (US) revealed a cystic lesion extending from the umbilicus to the bladder dome, measuring 7.8 × 3.5 cm, and free fluid in the pouch of Douglas. Computed Tomography (CT) revealed a cystic lesion with peripheral enhancement arising from the bladder dome and extending to the umbilical region, leading to a suspected diagnosis of an infected urachal diverticulum , between the transverse fascia anteriorly and the parietal peritoneum posteriorly. It varies from 3 to 10 cm in length, and it commonly has an approximate diameter of 8 to 10 mm .The urachus involutes before birth and remains as a connective tissue band, the median umbilical ligament. Incomplete obliteration of the urachus results in four types of congenital anomalies such as patent urachus 50%) in which a communication between the bladder and the umbilicus exist, umbilical-urachal sinus 15%) in which the urachus opens into the umbilicus and drainage from the umbilicus can be present, vesicourachal diverticulum 3-5%) in which the urachus has a wide patent opening into the bladder, and urachal cyst (30%) in which the urachus encompasses a cyst-like lesion within its length [-5% in wh0% in whi5% in whiUrachal remnants may remain asymptomatic, but when complicated by infection they may be confused with other abdominal or pelvic diseases at clinical examination or with malignant tumors at imaging, due to nonspecific symptoms , 3. VesiThe urachus is located in a clinically silent area, so the clinical signs in case of infection or neoplasm may be nonspecific, delayed, or absent . PatientΙn most of the cases, percutaneous needle biopsy or fluid aspiration may be necessary for the diagnosis and therapeutic planning [Abdominal US, CT scan, MRI, cystography, sinography, and cystoscopy can help with the differential diagnosis and they can show the relationship of the infected urachal anomaly with the surrounding tissue and adjacent organs . Imagingplanning . Howeverplanning , 4. Uracplanning  and are planning , 3.The initial management of infected urachal anomalies should include broad–spectrum antibiotic therapy, combined with percutaneous or surgical drainage. Total surgical excision should be performed after the infection has cleared . This twThe recommended surgical approach for all the types of urachal anomalies is complete excision of the urachal remnant, in order to avoid the 30% risk of infection recurrence and the potential of malignant transformation later in life . AnomaliVesicourachal diverticulum is the most uncommon type of urachal remnant anomalies. Although rarely detected and even more rarely presenting with symptoms of infection, it should be considered in the differential diagnosis of cases with abdominal pain. Because of nonspecific symptoms at presentation, imaging studies like ultrasound, computed tomography, and cystoscopy are essential for final diagnosis. The initial management of infected urachal diverticula should include antibiotic therapy combined with adequate drainage. We would like to add drainage through the bladder by JJ stent placement inside the diverticulum as an alternative to percutaneous drainage reported in the literature. The total excision of the urachal remnant, including resection of a cuff of normal bladder, consists of the final treatment, in order to prevent infection recurrence or future malignancy.


Ovarian ependymoma is a rare malignancy. Because of the extreme rarity, certain features of the neoplasm, including its clinical behaviour and optimal therapy, are incompletely characterized.A 32-year-old pregnant woman at term presented with a left ovarian neoplasm that occurred in the early stage of pregnancy. She underwent left adnexectomy during the caesarean section, and the neoplasm was histologically and immunohistochemically identified to be ovarian ependymoma. Immunohistochemical staining with oestrogen receptors and progesterone receptors showed strong positive staining. According to reports in the literature, the pathological type of ovarian ependymoma in our patient was the extra-axial type. Interestingly, the foetus was also found to have bilateral ependymal cysts during pregnancy. The patient received no further surgical treatment or adjuvant therapy. She and her 14-month-old baby both have no evidence of disease at present. The follow-up of both mother and child is still continuing.The case presented here illustrates high levels of oestrogen during pregnancy may stimulate viable malignant ependymal cells to proliferate. Hence, young women with extra-axial-type ependymomas may not be suitable for fertility preservation. Moreover, hormone-based therapies can be a potentially effective treatment for women with extra-axial ependymomas. Ovarian ependymoma is an extremely rare gynaecologic malignancy that poses numerous diagnostic and treatment challenges. Because of the extreme rarity, certain features of the neoplasm, including the clinical behaviour, molecular profile, and optimal therapy, are incompletely characterized. Herein, we present a case of primary ependymoma of the ovary that appeared after pregnancy and grew gradually during pregnancy as well as a summary of primary ovarian ependymomas based on a review of all such cases published in the English literature.A 32-year-old woman  at term presented at our institution with a mass on her left ovary and previous caesarean section requiring a caesarean section. Her general medical and gynaecologic histories were unremarkable. In 2015, she had a caesarean section because of a foetal diaphragmatic hernia. Prior to this pregnancy, both gynaecological examination and transvaginal ultrasonography were negative. Transvaginal ultrasonography revealed an anechoic cyst in the left adnexal region at 45 days pregnant, with a size of approximately 2.6*2.4 cm. Subsequently, several pelvic ultrasound examinations were performed during the pregnancy, revealing that the cyst was enlarged and gradually became a cystic solid mass; colour doppler flow imaging suggested the color flow absence in the mass. In addition, ultrasound examination also showed that there was no echo area at the anterior corner of the foetal side of the ventricle at 28 weeks and 5 days of gestation. Then, foetal magnetic resonance imaging(MRI) was performed for further evaluation. A cystic solid soft tissue mass was demonstrated in the left adnexal region measuring 6.14*5.83 cm therapy was reported by Fang et al. in 2015, in which a 30-yr-old female with a large pelvic ependymoma who was treated with presurgical GnRH analogue therapy and fertility-sparing surgical resection remained disease-free after over 30 months without post-surgical treatment . SimilarThe case illustrates high levels of oestrogen during pregnancy may stimulate viable malignant ependymal cells to proliferate. Young women with extra-axial-type ependymomas may not be suitable for fertility preservation. Hormone-based therapies can be considered as a treatment option for patients with extra-axial ependymomas.


During operative exploration of the neck for parathyroid surgery, the surgeon should always consider possible ectopic locations of the glands and have a reasonable surgical strategy for locating these ectopic glands. During operative exploration of the neck for parathyroid surgery, the surgeon should always consider possible ectopic locations of the glands and have a reasonable surgical strategy for locating these ectopic glands. This 35‐year‐old patient had previous left adrenalectomy for nonfunctioning adrenal adenoma, excision of his right inferior parathyroid gland for parathyroid adenoma 6 years ago and open enucleation of pancreatic head and uncinate process neuroendocrine tumors (insulinomas) 2 years ago. He now presents with recurrent hypercalcaemia secondary to primary hyperparathyroidism and operative exploration of his left neck reveals the following image.What clinical syndrome does he fulfill, and what are the lesions presented in the given image?This patient tested positive for a mutation in his multiple endocrine neoplasia type 1 (MEN1) gene.In the case of possible missing or ectopic parathyroid glands, we recommend a logical approach to dissection of these glands intra‐operatively starting from the most likely and accessible areas to least so. For superior glands, the posterior surface of the upper pole of the ipsilateral thyroid gland should be carefully inspected, following which a search can be undertaken along the tracheo‐oesophageal groove, para‐oesophageal space, posterior retro‐oesophageal space, and piriform sinus. In the case of inferior glands, the search should follow the thyro‐thymic tract to the thymus (anterior mediastinum) wherein a cervical thymectomy may be performed , subsequently the carotid sheath may be dissected (carefully preserving the vagus nerve), failing which an ipsilateral thyroid lobectomy may be performed if suspicion for an intrathyroidal gland exists.None declared.BP, RN, GT: contributed equally to the preparation, editing, and revision of this manuscript.Patient consent was sought for the production of this article, and no Ethics Committee approval was required for this publication.


Oroantral fistula (OAF) often develops after extraction of posterior maxillary teeth and requires surgical closure. If it persists, OAF may result in maxillary sinusitis. This paper reports a case of an oroantral fistula, associated with chronic maxillary sinusitis. A 46-year-old female patient presented with a history of traumatic tooth extraction, which led to OAF formation. Three unsuccessful attempts were made to close it elsewhere. With one operation, we performed Caldwell-Luc surgery and closed OAF with a collagen membrane and plug and a buccal flap. The patient was assessed at 1-, 3-, 6-, and 12-month and 8-year follow-up visits, with no signs of maxillary sinusitis or OAF recurrence being found with the efficient amount of bone and opportunity for further dental rehabilitation like sinus lifting and dental implantation. We believe that this approach may be a viable option in similar cases. Oroantral fistula (OAF) is a relatively frequent complication after extraction of posterior maxillary teeth . TherefoImmediate postextraction oroantral communications must be closed within 48 hours following surgery. If primary closure has not been achieved within these time limits, the internal surface becomes epithelised and a chronic OAF develops. In such cases, spontaneous closure is impossible . The estIn the present case report, we describe a surgical protocol for the treatment of OAF associated with chronic maxillary sinusitis.A 46-year-old female patient was referred to the Oral and Maxillofacial Surgery Clinic  with oroantral fistula, associated with left-sided chronic maxillary sinusitis. The patient reported that tooth 2.6 had been extracted elsewhere three years before and afterwards, she noticed leakage of liquids through the nose while drinking. The patient visited a dental surgeon where she was diagnosed with oroantral fistula (OAF). However, an attempt to close it failed and thereafter so did two other attempts. The patient also complained of recurrent episodes of facial pain and pressure.On examination, OAF and scar tissue at the postextraction site were observed in the projection of absent tooth 2.6. Besides that, tooth 2.5 was found to be extensively damaged so it could not be restored. The surgical plan included extraction of tooth 2.5, maxillary sinusotomy, and OAF closure with a collagen membrane in one operation. The patient signed the informed consent form for operation and the use of results of treatment for scientific and educational purposes. The patient underwent full preoperative examination , with no relevant clinical data being found. It was provided orthopantomography for additional investigation and evaluation of the condition of the maxillary sinus.Surgical treatment included Caldwell-Luc sinusotomy and sinuplasty with the local tissues with our changes: for covering the bone window and oroantral connection and plugging the fistula, we used different forms of bovine collagen  with the 3D orientation of fibrils that can increase the osteoconduction features of material.Local anaesthesia was obtained with 4% articaine hydrochloride with 1 : 100,000 epinephrine. A 5 cm semilunar incision encompassing OAF was made, and a full-thickness buccal flap was elevated. The oral mucosa adjacent to OAF was excised. Tooth 2.5 was extracted. A round window in the lateral wall of the maxillary sinus was prepared with a cylindrical diamond bur. Special care was taken to leave at least 15 mm of bone between the OAF and the window. The normal mucous membrane was left intact, whereas the diseased sinus membrane was debrided with curettes . The intThe balloon was then inflated with 10 ml of sterile saline . The flaThe patient was prescribed with ceftriaxone 1 g IM twice daily for 7 days, loratadine 10 mg once daily for 7 days, ibuprofen 600 mg thrice daily for 4 days, and oxymetazoline 0.05% nasal spray twice daily for 7 days.The Foley catheter and the sutures were removed 1 and 7 days after surgery, respectively. No early postoperative complications occurred.The patient was assessed at 1-, 3-, 6-, and 12-month and 8-year follow-up visits. No signs of chronic maxillary sinusitis or OAF were found during clinical examination and orthopantomography. A significant increase in volume and density of bone at the surgical site is shown in a series of consecutive radiographs .Two alternatives for further rehabilitation  were offered to the patient. As the patient refused another surgical intervention, prosthodontic treatment was approved and provided at the fifth month after surgery. Both quality of life and working ability of the patient improved dramatically after completing the treatment.As a rule, OAF cannot be closed when sinus infection is present, so complete sinus debridement is mandatory before OAF closure. In this case, the patient required surgical treatment of maxillary sinusitis because the sinus membrane was irreversibly diseased and the patient reported of frequent acute exacerbations of maxillary sinusitis (up to 5 times a year), which occurred regardless of any previous attempts to treat this condition. To prevent reinfection, we decided to perform both sinus debridement and OAF closure in one operation.To date, surgical techniques tend to be less invasive and radical. This is also true for maxillary sinus surgery, where the traditional Caldwell-Luc approach has been almost completely replaced by functional endoscopic sinus surgery. However, the latter requires high professional skills and special armamentarium, which is not always available. On the other hand, the Caldwell-Luc surgery is a simple, less expensive, and time-tested method, which yields good results . NeverthSeveral options for OAF closure are available, all of them having their advantages and disadvantages. The buccal advancement flap technique is the easiest way for closing both immediate and chronic OAFs. Despite some drawbacks, the vestibular depth reduction, and rather limited blood supply being among them, it yields good clinical outcomes . To overTo make dental implantation possible, bone grafting may be performed when residual bone volume is insufficient or a large bony defect is present. Different types of grafting materials  have been used for this procedure . The bonIn some cases of OAF, simultaneous sinus floor elevation can make the surgical procedure easier as the area of the defect in the Schneiderian membrane decreases. This approach also facilitates further implant surgery. But it is contraindicated if any signs of sinus infection are present . In our Third molar autotransplantation has also been considered a promising treatment for OAF, which has many advantages, some of them being immediate restoring of a missed tooth, low cost, and possibility of orthodontic treatment. However, there is very scarce data of clinical performance in immediate postextraction oroantral communication closure and no data for chronic OAF closure . So, we The use of bovine collagen membrane and plug for covering of area of oroantral fistula and bone window during the operation of sanitation of the maxillary sinus helped to get good postoperative results such as the absence of recurrence of inflammatory process (maxillary sinusitis) due to removing the connection with oral cavity, stopping the circulation of microorganisms, and persistent contamination of maxillary sinus, also, with the stimulation of regeneration of bone because of the element of osteoconduction in collagen material and creating the conditions for further dental rehabilitation.