Testicular germ cell tumors are the most common cancers in young men. In most cases, patients may present a painless testicular swelling. However, in 10% the presentation is variable and related to site of metastasis and complications. Clinically apparent gastrointestinal involvement was seen in 5% of cases and dominates by gastrointestinal bleeding. We report a case of testicular choriocarcinoma involving the small intestine revealed by melena and complicated by acute intussusception. Testicular cancers are the most common malignant neoplasm in men aged 15-35, but only constitute 1% of cancers in males . In mostPatient information: a 33-year-old, with no medical history besides 5-pack-year history of tobacco use, has been admitted to our emergency department with melena of 3 weeks duration. He denied hematemesis, abdominal pain, changes in bowel habits or vomiting.Clinical findings: on physical exam, the patient was normotensive, afebrile and has normal heart rate. He had significant pallor. The abdominal exam was benign and the rectal exam showed melena. Left testicular swelling was noted, which had become hard on palpation with negative transillumination test.Diagnostic assessment: laboratory studies showed anemia with Hb of 8.7g/dL. Esophagogastroduodenoscopy was done urgently and showed a gastritis. No active bleeding was seen. A scrotal ultrasound was performed, revealing a left testis measuring 6x5.2x6 cm with a heterogeneous echo texture and multiple nodular lesions suspicious for neoplasm. The patient's β-human chorionic gonadotrophin level was elevated at 805588IU/mL. Lactate dehydrogenase level was also elevated at 699 U/L, and serum α-fetoprotein level was normal at 2.8 ng/ml. The following day, the patient developed serious abdominal pain with bilious vomiting. An urgent computerized tomography was done and showed a small bowel intussusception due to an umbilicated lesion measuring 4x3cm, with multiple liver, lung and left kidney nodules.Therapeutic intervention: the patient underwent left orchiectomy with intestinal resection, removing the umbilicated lesion and biopsy of the liver nodule. Histologic studies of the left testis, intestinal and hepatic specimens removed revealed choriocarcinoma.Follow-up and outcomes: the multidisciplinary team decision was an aggressive chemotherapy, but unfortunately, the patient died few days after.Testicular cancers, though rare 1%), represent the most common neoplasm among young men. It is more common in white males than black males %, repres. Most teGastrointestinal metastases were found in 27% of testicular cancer cases in a postmortem study . In a neet al. [But clinically apparent gastrointestinal involvement was seen in < 5% of cases, and presents as abdominal pain 46%), melena (44%), hematemesis (24%), vomiting or abdominal mass . Clinica%, melenaet al. .In patients with testicular cancer, especially those with disseminated choriocarcinoma, gastrointestinal involvementshould be considered if symptoms of gastrointestinal bleeding develop . The patAlthough there have been reports in the literature of germ cell tumors metastasizing to the gastrointestinal tract, they have generally been in the setting of known primary testicular cancer or metastatic disease. The specification of our case is the diagnostic of testicular choriocarcinoma, which wach until then ignored, a small intestine metastasis revealed by melena and complicated by acute intussusception.Testicular germ cell tumors are a malignancy of the young. Young men presenting with evidence of gastrointestinal bleed with suggestions of underlying malignancy may not offer information on testicular swelling, even if present. A review of systems that includes scrotal/testicular swelling should be conducted and a genital examination done if appropriate. An early recognition of germ cell malignancy localized in the upper GI tract and adequate multimodality treatment can have a profound effect on the patient management. However, these patients belong to a poor prognosis group with an overall unfavorable outcome, even with today´s standard treatment.


Müllerian duct aplasia-renal agenesis-cervicothoracic somite dysplasia (MURCS) association is a rare syndrome. This unique condition consists of Müllerian duct aplasia, cervicothoracic somite dysplasia, and renal aplasia, and skeletal abnormalities manifesting in childhood. We report the case of a 14-year-old girl who presented to the orthopedic clinic with spinal deformity and Sprengel’s shoulder complicated by a background of MURCS association. The treatment modalities of scoliosis include posterior spinal fusion and the vertical expandable prosthetic titanium rib. On the other hand, Sprengel’s deformity is surgically managed by Woodward’s procedure. The management plan for our patient involved correcting scoliosis by the posterior spinal fusion procedure and performing Woodward’s procedure to correct Sprengel’s deformity simultaneously.Simultaneous scoliosis correction with posterior spinal instrumented fusion and Sprengel's deformity correction with modified Woodward’s procedure is a promising surgical technique that can lead to favorable outcomes. Müllerian duct aplasia-renal agenesis-cervicothoracic somite dysplasia (MURCS) association is a variant of the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome; it is a very rare condition causing renal agenesis, Müllerian duct agenesis, and cervical somite abnormalities. MURCS is known to be an inherited autosomal dominant condition that only affects females. It was first described in 1979 by Duncan et al. -4. It caA 14-year-old girl presented to the orthopedic clinic with spinal deformity. The girl was in her pre-menarche period and was under medical evaluation for primary amenorrhea. She had normal secondary sexual characteristics with Tanner stage 3. The patient’s family history and past medical and surgical history were all unremarkable except for a hernia repair performed at two years of age. The patient also complained of occasional back pain without any neurological deficits. On physical examination, she was found to have right upper thoracic scoliosis and her left shoulder was elevated. She had a large rib hump on the right side with waist asymmetry. Left shoulder abduction was limited to 100⁰ as compared to normal abduction on the right side. A plain radiograph and a CT scan were performed, which showed elevated left scapula with a small omovertebral bar connected to the C5 vertebral body Figures .There was upper thoracic scoliosis of 56⁰ with partial fusion of C7 and T1 vertebral bodies. MRI scan of the spine was unremarkable for any intraspinal anomalies. Pelvic MRI showed agenesis of the uterus, cervix, and upper part of the vagina, along with left renal agenesis. The problem list included congenital scoliosis with 56⁰ upper thoracic curve, with left shoulder Sprengel’s deformity (Cavendish type 3) and left shoulder limited abduction. Posterior spinal instrumented fusion using bone graft combined with modified Woodward’s procedure was planned. During the operation, the patient was placed in a prone position under general anesthesia. The patient was draped in a manner so that the left shoulder girdle could be manipulated. Intraoperative neuromonitoring was employed to monitor SSEPs and MEPs for all the extremities. A midline incision was given from the upper cervical to upper lumbar vertebrae. We undermined the skin and subcutaneous tissues to the medial border of the left scapula. Following that, we subperiosteally dissected and retracted the muscles on both sides of spinous processes to the costotransverse process in the thoracic spine. On the left side, the rhomboids and trapezius muscles were freed from the chest wall muscles. An omovertebral bone was located attached from the cervical spine to the medial border of the scapula. Through extraperiosteal dissection, the omovertebral bone along with the fibrous tissue was excised. Levator scapulae muscle, which was found contracted, was also excised. Pedicle screws were inserted from T1 to T12 vertebrae through the freehand technique under fluoroscopy guidance. Soft tissue release including interspinous ligaments and spinous processes were resected in the thoracic spine. We used two cobalt chromium (CoCr) rigid rods and the translation technique to correct scoliosis. A moderate amount of correction was achieved. We attached a crosslink between the two rods. Afterward, we shifted our focus back to the scapula and released it further from the musculature. With the help of towel clips, the scapula was pulled downwards and rotated until the spinous processes of the two scapulae were on the same level. We then used fiber wire suture and passed it through the medial border of the scapula and tied it around the CoCr rod on the same side at around 45⁰ angle. To further strengthen our correction, we used Ethibond nonabsorbable sutures with the same technique as described for the fiber wire suture. Satisfactory descent of the scapula was achieved and no changes were recorded in SSEPs and MEPs with regard to the brachial plexus. We routinely use allograft bone chips for fusion; thus, in this case, we used the same after decortication. We used a cell saver throughout the procedure. The closure was done in layers using absorbable vicryl for fascia and subcutaneous tissue and monocryl absorbable for the skin.Postoperative X-ray imaging showed good correction. The patient was actively moving all her extremities. A Velpeau bandage was applied and maintained for two weeks. Following that, a supervised shoulder rehabilitation program was started with active shoulder exercises. The patient was asked to continue the recommended exercises at home. After two years of follow-up, an X-ray was performed and showed successful correction of scoliosis and scapula and a clinically good shoulder abduction of 130⁰ (Figure MRKH syndrome, a rare disorder characterized by the absence of the uterus, is associated with a normal karyotype of 46,XX. MRKH is a syndromic umbrella with various other subtypes. MURCS association, the type 2 variant of MRKH, is a rare developmental disorder characterized by uterine aplasia, renal agenesis, vertebral anomalies, and short stature. The incidence of MRKH syndrome is unique and rare and as per the data in the medical literature, it has an occurrence rate of one out of 4,000-5,000 female newborns [In this report, our main objective is to shed light on and emphasize the importance of further investigations with regard to the spinal deformities that can occur in patients suffering from MURCS association. We also wanted to highlight the procedure performed; in the standard Woodward’s procedure, the paraspinal musculature such as the trapezius and the rhomboids muscles are sutured to the spinous process more caudally in order to put the scapula in a downward position -13. AhmaThrough this report, we wanted to highlight the significance of conducting crucial investigations in patients suffering from MRKH syndrome and its variants. A multidisciplinary team approach is required to ensure successful treatment outcomes in the management of similar cases. Further study projects focusing on this topic should examine the handling of similar presentations with the proposed technique, i.e., concurrent scoliosis correction with posterior spinal instrumented fusion and Sprengel's deformity correction with modified Woodward’s procedure. Comparing and contrasting the future outcomes and documenting them for study baseline will contribute immensely to the literature on this topic.


Venous aneurysms are rare diseases, and according to their locations, history will change. They will be diagnosed based on the clinical history and imaging modalities. The exact incidence of external jugular vein aneurysm remains controversial. In the neck, venous aneurysm has been reported most commonly in the internal jugular vein. Frequently the venous aneurysm has a fusiform shape, and the saccular type is extremely rare.trans-fixation of the external jugular vein was done without any complications.Here we present a case of the external jugular vein aneurysm which was misdiagnosed as a branchial cyst presented with gradual swelling in the left supraclavicular region. The patient was diagnosed intraoperatively, and by histopathological examination. The patient successfully underwent surgery of Proximal and distal control of the external jugular vein without resection of the clavicle were performed, and Idiopathic, spontaneous venous aneurysm of the external jugular vein thrombosis is extremely rare clinical findings. Computerized tomography was the gold standard test for the diagnosis of venous thrombosis, but nowadays neck ultrasound is the diagnostic test of choice. However, the mass was like a branchial cyst by ultrasound.External jugular vein aneurysm is rare, when it was a saccular type and thrombosed without any causes it will be extremely rare. When idiopathic thrombosis of external jugular vein aneurysm was confirmed by imaging modalities, then it was symptomatic, enlarged, ruptured or disfigured, the surgical excision will be mandatory without anticoagulant drugs preoperatively or postoperatively. •More than 100 years ago venous aneurysm have been reported for the first time, and remains rare after one century.•Computerized tomography was the gold standard test for the diagnosis of venous thrombosis, but nowadays neck ultrasound is the diagnostic test of choice. However, the mass was like a branchial cyst by ultrasound.•When idiopathic thrombosis of external jugular vein aneurysm was confirmed by imaging modalities and investigations then it was symptomatic, enlarged, ruptured or disfigured, the surgical excision will be mandatory without any anticoagulant drugs preoperatively or postoperatively.•In this paper a case of the external jugular vein aneurysm which was misdiagnosed as a branchial cyst with review of the literature is discussed. They will be diagnosed based on the clinical history and imaging modalities ,2. In th22.1On August 27, 2020, a 28-year-old woman, was admitted to the chest clinic in Rania Medical City (RMC) private hospital, she presented with gradual swelling in the left supraclavicular region, at the beginning the mass was painless, but within 1 month the pain started with no past medical and surgical history.2.2Subsequently, physical examination revealed a hard, painful, tender, non-pulsative mass at the left supraclavicular region , on the 2.3trans-fixation of the external jugular vein was done without any complications. The cyst was excised, after opening the cyst intraoperatively it was clotted. Histopathological examination was made, and diagnosed as thrombosed external jugular vein aneurysm. On September 12, 2020, the stiches have been removed.On September 3, 2020, after explaining the procedure to patient the cardiothoracic and vascular surgeon with his team decided to surgery to remove a branchial cyst. On September 3, 2020, the patient underwent surgery by the first author, with local anesthesia in the supine position, with tilting of the neck toward right side and some extension. After good disinfection, and covering of the patient, through a transverse incision, the cyst was looks like venous aneurysm, black, uncompressible, and connected to the external jugular vein proximally. The cyst was extended toward the chest under clavicle. Due to an inflammatory reaction, there was adhesion around the cyst had been removed. Proximal and distal control of the external jugular vein without resection of the clavicle was performed. Ligate and 2.4After two days remained at critical care unit, and the patient was discharged to home for outpatient follow-up. Additionally, after 2 months, the patient did not have any additional local or general events during the follow-up period, and there was no recurrent swelling.3The literature confirmed the rarity of this incidence. Venous aneurysms are either acquired or congenital . AcquireClinical features of venous aneurysms are soft, non-tender or compressible swelling on the course of the vein . Our patComputerized tomography was the gold standard test for the diagnosis of venous thrombosis, but nowadays neck ultrasound is the diagnostic test of choice ,14,35. HComplications of the neck veins are rare like thrombophlebitis, embolism or thrombosis, but still are threatening the life of patients  because 4External jugular vein aneurysm is rare, and if it was a saccular type, and thrombosed without any cause it will be extremely rare. When idiopathic thrombosis of the external jugular vein aneurysm was confirmed by imaging modalities and investigations then it was symptomatic, enlarged, ruptured or disfigured, surgical excision will be mandatory without any anticoagulant drugs preoperatively or postoperatively.Ethical approval has been given by the ethics committee of our faculty.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Rawand A. Essa: Conception and design, execution, analysis and interpretation of data, involved in drafting the article, revised it critically for important intellectual content, read and approved the final version of the manuscript. Sirwan K. Ahmed: Conception and design, execution, analysis and interpretation of data, involved in drafting the article, revised it critically for important intellectual content, read and approved the final version of the manuscript. Shero A. Rasul: involved in drafting the article, revised it critically for important intellectual content, read and approved the final version of the manuscript. Dunya H. Bapir: involved in drafting the article, revised it critically for important intellectual content, read and approved the final version of the manuscript. Chawan P. Abubakr: involved in drafting the article, revised it critically for important intellectual content, read and approved the final version of the manuscript. Shiwan Q. Hamad: involved in revised it critically for important intellectual content, read and approved the final version of the manuscript.We declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We understand that the Corresponding Author is the sole contact for the Editorial process. He is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs.Not applicable.Dr. Rawand A. Essa, and Registered Nurse Sirwan K. Ahmed: Accept full responsibility for the work and conduct of the study, had access to the data, and controlled the decision to publish.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.No competing interests were disclosed.


Angiosarcomas represent highly-aggressive malignant lesions of the endothelial cells of blood vessels, affecting mostly the elderly population, and usually located in the scalp or face. As cutaneous angiosarcomas often metastasize to the lung, they can manifest in various forms. We report a case of a 77-year-old male who presented after a posttraumatic blunt scalp lump that was initially diagnosed as infected subgaleal hematoma. This was later found to be an angiosarcoma. Further workup revealed that the tumor was invading the dura, with a rare pattern of mixed concomitant cystic and solid lung metastasis with ground-glass infiltrates. The patient underwent soft tissue reconstruction with split-thickness skin graft for the scalp lesion and palliative chemotherapy. We are discussing the common manifestations of scalp angiosarcomas and their potential pulmonary metastatic patterns. Also, a review of the differential diagnoses that may mimic cutaneous scalp angiosarcoma will be demonstrated. Angiosarcomas represent a highly-aggressive vascular malignancy affecting the endothelial cells of blood vessels. While angiosarcomas can occur anywhere in the body, they most commonly occur in the face or scalp of elderly population. However, angiosarcomas are rare and represent less than 1% of all head and neck malignancies, and less than 2% of soft tissue sarcomas A 77-year-old diabetic male presented to the emergency department 1 month after mild blunt head trauma. A soft tissue lump on the left vertex was palpable following the incident. He had associated intermittent mild headache, with no other significant symptoms and with unremarkable neurologic examination. The lump persisted for the next month following the event and on examination, it was soft, erythematous, mildly tender, with slight necrotic changes in the overlying skin. The laboratory findings were unremarkable. Computed tomography (CT) of the head showed no skull fractures or intracranial hemorrhage. A soft tissue scalp thickening and hematoma were appreciated at the left frontoparietal region . InnumerThe patient was admitted to the hospital, and was planned to undergo debridement. However, the lesion was suspicious intraoperatively as the cutaneous surface of the lesion was variegated, nodular, firm, and ill-defined. Therefore, excisional biopsy for the lesion was done, and confirmation of 5-mm negative margins was obtained. Split-thickness skin graft harvested from the lateral thigh was applied to cover the excised area in the scalp.Histopathological examination of the specimen revealed an infiltrating neoplasm composed of anastomosing vascular channels lined by atypical endothelial cells, displaying frequent mitosis . The lesFurther work-up for metastatic evaluation included head MRI, and CT scan of the neck, chest, abdomen, and pelvis. Head MRI showed that the lesion was infiltrating the left frontal and parietal bones, passing through the calvarium and infiltrating the dura with evidence of dural enhancement .Fig. 3MRNeck CT revealed subcentimetric lymph nodes that appeared suspicious for malignancy due to their rounded shape, and loss of fatty hilum. Interestingly, chest CT revealed multiple pulmonary thin-walled cysts, a cavitary lesion with peripheral calcifications and/or rim enhancement, scattered regions of ground glass opacities, and a solid pulmonary nodule with stippled calcifications and enhancing rims .Fig. 4AnMeanwhile, the surgery site was not healing properly, with residual nodular lesions and tendency to bleed after light touch which required blood transfusions. Palliative chemotherapy of paclitaxel was started. The patient expired in 3 months’ after initial presentation.Angiosarcomas represent a highly-aggressive vascular malignancy that originate from the endothelial cells of vascular or lymphatic structures. While they can occur anywhere in the body, they most commonly affect the face or scalp of elderly patients. Angiosarcomas are rare and represent less than 1% of all head and neck malignancies, and less than 2% of soft tissue sarcomas When scalp angiosarcoma is suspected clinically, head CT scan is recommended as the best initial imaging modality to characterize bone alterations that might be related to the lesion. MRI is an essential modality for evaluating the lesion extension for both the skin and intracranial spaces Cutaneous angiosarcomas rapidly penetrate through the skin, early metastasize mainly hematogenously and commonly recur after treatment. The lung is the most common location for angiosarcoma metastases. Liver, bone and lymph nodes are other common sites et al. reported that the mean age for patients was 73 years, and the primary location of most cutaneous angiosarcoma lesions was in the head and neck In a large series of 434 cutaneous angiosarcomas cases with over 34 years of surveillance, Albores-Saavedra In another series, very poor prognosis was reported for angiosarcoma tumors that metastasize, with a 4-month survival for cases with lung metastases Different treatment modalities were reported in the literature. Thus, effective treatment of angiosarcoma is not clearly established Angiosarcoma is a rare aggressive tumor with early metastases. The cutaneous form is the most common, and most cases occur in the head and neck, and typically after 60 years of age. Scalp angiosarcoma can have different dermatologic manifestation that include enlarging painful lump, or a non–resolving bruise. Metastases to cervical lymph nodes and the lungs are common. We are reporting an atypical clinical presentation with a rare pattern of mixed concomitant cystic and solid lung metastasis with ground-glass infiltrates. While multimodality imaging is vital for proper staging and management, it is important for clinicians and radiologists to be oriented about the potential radiological findings and correlate them with suspicious clinical findings and risk factors to achieve early diagnosis of these challenging malignancies.All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.This article does not contain any studies with animals performed by any of the authors.Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethics approval: An approval from Hamad Medical Corporation, Medical Research Council (MRC) was obtained prior to submission of this manuscript.Funding statement: This article did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


Buschke–Löwenstein tumor is a giant condyloma acuminata infection that is characterized by degeneration, invasion, and recurrence. It is associated with human papilloma virus infection. It develops around the genital and perineal area, sometimes causing a large budding ulcerated lesion. Although human immunodeficiency virus infection is frequent in Africa, there are few descriptions of Buschke–Löwenstein tumor diagnosis and its management. Screening for other sexually transmitted infections must be systematic among these patients.3) and hepatitis B infections. Real-time polymerase chain reaction revealed human papilloma virus-16 and other high-risk human papilloma virus deoxyribonucleic acid. The diagnosis of Buschke–Löwenstein tumor was made on mass biopsy, and the patient underwent multidisciplinary intervention . Medium-term evolution was, however, fatal due to opportunistic infection.We report herein the case of a 21-year-old African origin male patient who developed a perineal swelling. Physical examination showed evidence of a huge exophytic tumor made up of budding pinkish vegetations, with serrated crests, a ‘’butterfly wing’’ structure, and a cauliflower-like appearance crowned with centrifugal circinate lesions. Multiple condylomatous lesions of the anal margin were also present. The patient tested positive for human immunodeficiency virus (cluster of differentiation 4 count of 119 cells/mmBuschke–Löwenstein tumor is a rare tumor associated with human immunodeficiency virus infection. It is more frequent in male human immunodeficiency virus-positive patients. There is a need to screen for other sexually transmitted infections. In most cases, the treatment is surgical, in association with local therapies. However, recurrences are common. Buschke–Löwenstein tumor (BLT) is a giant condyloma acuminata characterized by its degenerative and invasive potential as well as its recurrent nature after treatment , 2. It iA 21-year-old single unemployed male patient from African origin presented to our health facility with an asymptomatic margin swelling noticed over the last 6 months. His past medical history was significant for T10 intercostal herpes zoster complicated with postherpetic neuralgia. He frequently practiced unsafe intercourse, and his partner had no anogenital lesions. He denied any anal or homosexual intercourse.Physical examination of the perianal region revealed huge exophytic budding vegetation with batwing disposition, with sharp edges, giving an aspect of a cauliflower crowned with centrifugal circinate lesions, surrounding the anal verge like a sheet Fig. . The gla3. Treponema pallidum hemagglutination assay (TPHA)/Venereal disease research laboratory (VDRL), hepatitis D, and chlamydia serologies were negative. Given the lack of financial means, some investigations such as abdominopelvic computed tomography (CT) scan were not performed.A complete blood count showed moderate (8.2 g/dL) hypochromic and microcytic anemia (Mean corpuscular volume (MCV) 58 fL, Mean corpuscular hemoglobin concentration (MCHC) 19 pg) with lymphopenia. He tested positive for hepatitis B  and HIV-1 with CD4 count of 119 cells/mmHistological analysis of a sample obtained from the perianal mass under light microscopy after coloration with hematoxylin and eosin staining showed skin with hyperkeratosis, orthokeratosis and parakeratosis, hyperacanthosis, florid papillomatosis with fusion of papillae. Numerous koïlocytes, characterizing viral infection, were identified inside the acanthosis Fig. . The basWe report the case of a young patient with clinical histological and virologic characteristics of a giant condyloma. The patient was found in the age range with the highest risk of occurrence of HPV infection associated with these tumors. Unprotected sexual intercourse was reported by the patient. The striking finding was the triple coinfection of HBV, HPV, and HIV with severe immunodepression that could justify the extensive nature of lesions with high potential for degeneration and a preexisting low-grade dysplasia. The presence of HR HPV-16 and other HR HPV is consistent with literature that classifies it as the most prevalent in the world and as a high risk. Histopathology of the biopsy sample was consistent with a condylomatous tumor, the presence of significant diffused koïlocytosis all over the epidermis presenting several mitoses and dystrophic cells.Probably known over the years but well characterized at the start of the twentieth century, BLT is a rare giant condylomatous lesion of the anogenital region. It is more frequent in male immunocompromised patients , 8. AssoThe peak of occurrence differs by geographic area, being 20–25 years in the USA and Asia and 40–45 years in the Middle East region , 13, 15.A sample biopsy enables us to have histologic confirmation and to look for degeneration foci. BLT is a well-defined tumor. It is characterized under optical microscopy by significant epithelial hyperplasia, sometimes a pseudoepithelioma with an intact basement membrane, hyperacanthosis, hyperpapillomatosis, and koïlocytosis, which are consistent with HPV infection. However, their presence is not constant .3, as in our patient. Persistence, worsening, and recurrence of lesions are frequent in coinfected lesions. It appears that the coinfected population usually has multiple infections by several phenotypes and mostly with high-risk oncogenic viruses HPV 16 and 18 [Coinfection between HPV and other sexually transmissible infections is frequent and can have a bidirectional impact on the course of the disease, justifying systematic screening. Hence, HPV and HIV coinfection favors progression to dysplasia and cancer by modifying local and tissue immunity . HPV infTreatment of anal BLT is primarily surgical. It consists of total excision. However, it is associated with two main problems: recurrence and wound healing delay, often necessitating a temporal loop colostomy , 19, 20.Buschke–Löwenstein tumor or giant condyloma acuminata is a rare tumor associated with HPV infection whose transmission is mainly via the sexual route. It is frequent in males and prompts the search for states of immunosuppression as well as other sexually transmitted infections. The particularity of our patient was a triple coinfection HIV–HPV–HBV and the multidisciplinary management. Although wide surgical excision of the tumor seems to be the optimal therapeutic strategy, local treatment and management of risk factors should also be associated. Early recognition and treatment will provide a good outcome.


In this article, we present a 31-year-old female who presented with intermittent headache and oligomenorrhea of over 10 years’ duration. Imaging revealed a large suprasellar mass with sellar extension. The patient underwent an endoscopic endonasal trans-sphenoidal surgery to resection of the mass. Clinical, radiological, and operative findings from this patient were initially considered to be Rathke’s cleft cyst (RCC). However, postoperative histological examinations revealed a mature cystic teratoma. No radiotherapy was performed after surgery. At the most recent follow-up, approximately 1 year later, the patient is doing well with no headache and no recurrence of the teratoma. The 2016 WHO Classification of Tumors of the Central Nervous System, teratomas can be classified into three types: mature, immature, and teratomas with malignant transformation (–Teratomas are a type of germ cell tumor (GCT) differentiating from three germ layers. Central nervous system teratomas are very rare, accounting for 0.2%–0.9% of all intracranial tumors . Accordiormation , 4. Matuormation , and theormation , 8. Suprrmation –4. We hA 31-year-old female was admitted to our hospital complaining of oligomenorrhea and increasing headaches. She reported an 11-year history of intermittent headache , which used to be precipitated by fatigue and were alleviated by rest or non-steroidal anti-inflammatory drugs (NSAIDs). When the headaches increased in frequency and intensity and were accompanied by mild nausea, culminating in a headache lasting for 1 week with no relief from NSAIDs, the patient sought medical attention. She denied vision loss, visual field defects, polyuria, lactation, central obesity, or acromegaly during the course. The general physical examination was completely normal, and the neurologic examination showed no focal signs. A brain magnetic resonance imaging (MRI) scan with contrast was performed, demonstrating a 19 mm × 24 mm × 23 mm irregular suprasellar lesion with slight intrasellar extension. The lesion signal characteristics were isointense on T1-weighted imaging and hyperintense on T2-weighted imaging. No obvious gadolinium enhancement was noted Table 1.Endoscopic trans-sphenoidal surgery was performed. In the procedure, the cyst was observed to be predominantly suprasellar in location. It contained ivory-whitish viscous material and was resected. Hematoxylin–eosin staining is as follows: on a background of abundant myxoid stroma, we can see the following components: fibrous cyst walls lined with simple cuboidal and short columnar epithelium  of the sellar region in terms of clinical manifestations and neuroimaging.The 2016 WHO Classification of Tumors of the Central Nervous System  . MRI sigIn the present case, RCC was suspected prior to the histological examinations of the tumor because the gender, age, clinical presentations, and neuroimaging characteristics aligned with a diagnosis of RCC.Suprasellar MCTs are relatively rare. MCTs occur more frequently during the first or second decade of life. Rarely, reported cases have occurred on the third or fourth decade of life . OverallThe published case reports and series written in English that focus on suprasellar MCTs are limited. Therefore, we performed a comprehensive literature review of related articles and identified eight patients with a diagnosis of MCT, summarizing the data of clinical manifestations Table 2,The most prominent symptoms at diagnosis are neurological defects (six of eight patients), particularly visual disturbance (five of eight). Headache (three of eight) and diabetes insipidus (three of eight) were also commonly seen. One patient reported amenorrhea. Regarding MRI appearance, signal intensities on T1WI and T2WI vary from case to case. In some cases, inclusions like teeth, fat, and calcification can be detected , 15. VarNeuroimaging characteristics of teratomas are not of high specificity, which make it difficult to distinguish mature teratomas from other intracranial neoplasms located in the suprasellar region that include other GCTs , craniopharyngioma, and RCC. Therefore, our case highlights the importance of obtaining a histological diagnosis to differentiate teratomas from other lesions.Histologically, MCTs are commonly multicystic, contain sebaceous fluid, and are identified by the presence of differentiated ectodermal , mesodermal , and/or endodermal elements (mucinous and ciliated epithelium). All three layers may not be seen in every case of teratoma. The differential diagnosis includes dermoid cysts, epidermoid cysts, colloid cysts, immature teratomas, and teratomas with malignant transformation.For this case, our preoperative diagnosis was Rathke’s cleft cyst, and given the absence of hair, skin, or teeth, the intraoperative findings seemed to confirm our primary diagnosis. However, MCTs were confirmed by the histological examination of the specimen when cyst walls lined with simple cuboidal and columnar epithelium, a mass of mucous acinous cells , and cartilage were identified. Our case highlights the importance of obtaining a histological diagnosis to differentiate MCTs from other lesions. It would also be important to exclude the presence of additional germ cell components, which would require additional treatment postresection.The typical treatment for mature teratomas is neurosurgical excision because of their benign behavior , which wMCTs in the sellar region are extremely rare, and their imaging usually lacks specificity. Therefore, it is important to obtain a thorough histological diagnosis. MCTs are benign, and complete surgical excision is the first-line treatment. In selected cases, radiation therapy was conducted in some cases but is not recommended as routine treatment. Whether to perform radiotherapy depends on the physician as there is a lack of evidence on this aspect. Close follow-up is indispensable for patients with MCTs.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the participant for the publication of any potentially identifiable images or data included in this article. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.SJ drafted the manuscript. SJ and ZW analyzed the data. YY made the pathological diagnosis and drafted the article of pathological findings. All authors contributed to the article and approved the submitted version.This work was supported by the National Key Research and Development Program of China (2018YFA0108600), the Natural Science Foundation of Beijing Municipality (7182134), the CAMS Initiative for Innovative Medicine (2016-I2M-1-017), Beijing Nova Program (Z181100006218003), and the National Natural Science Foundation of China (82170799).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Dens invagination is a developmental anomaly that requires specific treatment approaches. The invagination is enamel-lined in the crown of the tooth truly negligible,and usually there is no extension on the level of the external amelocemental junction. A well ending surgical root canal treatment of an invaginated tooth with a retrograde filling is presentedin this case report. Periapical radiographic examination, after 3 months and 6 years of follow-up, showed periapical healing with osseous formation . Dens invaginatus (DI) is a growing anomaly, which eventuates in an enamel-lined cavity intruding into the crown or root prior to the mineralization phase  .The mosThe frequency of DI is reported to be 0.04-10%  .Its preThe most popular taxonomy was suggested by Oehlers   , which Type I: a negligible form of enamel-lined, which does not enlarge over the amelocemental junction but arises within the limits of the crown  .Type II: an enamel-lined form attacking the root, which stands restricted as a blind sac. In this form, it is possible to be linked to the dental pulp.Type III: this form is the one, which penetrates into the root perforating at the apical area showing a ‘second foramen’ in the apical or in the periodontal area.It does not have an instant link with pulp. The invagination might be completely lined by enamel, but frequently cementum is found lining the invagination  .Teeth wA 25-year-old female patient with a history of swelling in the upper left anterior palatal region (teeth #9 to #11) referred to Endodontics Clinic affiliated to Shiraz University of Medical Sciences.Medical history was unremarkable . The radA clinical diagnosis of DI (Oehlers’ Type I), necrotic pulp, and chronic apical abscess was established. The treatment plan was root canal therapy,incision, and drainage, follow-up, and apical surgery if necessary. The complexity of the tooth anatomy and prognosis was explained to the patient and a written consent form was obtained before each phase of the treatment.In total, 2% lidocaine with 1:80000 epinephrine  was injected into the buccal vestibule and clamp and rubber dam was applied.Access cavity preparation was done with high-speed turbine and diamond fissure bur .The working length was measured with radiography .Root canal was shaped with the ProTaper rotary file  and irrigated by Sodium hypo chlorite (5.25%).Due to active discharge; calcium hydroxide  paste was used for two times and the access cavity was sealed with Cavit between appointments (every 2 weeks). The root canal was obturated by lateral condensation technique with gutta-percha conesand AH-26 sealer after 4 weeks  . Due to persistent swelling after the second month of follow-up and no change in cervical discharge, apical surgery was regarded as the treatment plan. Surgical procedure was performed under surgical microscope. Treatment was initiated using 2% lidocaine with 1:80000 epinephrine .A full-thickness mucoperiosteal triangular flap was raised following an intrasulcular incision and distal relieving incision. The lesion had perforated the cortical bone.The margins were smoothed using a round bur in a slow speed hand piece with physiological saline irrigation.Granulation tissue was removed and sent to oral pathology laboratory .The root end resection (3mm) was performed with high-speed fissure bur. Cavity preparation was done, using ultrasonic device and retrograde ProRoot- MTA was inserted. The flap was repositioned and sutured. Clinical examination showed healthy clinical appearance andfunction after the third month. The radiographs showed partially healing of the radicular cyst, and the 6-year follow-up revealed complete healing.DI must be recognized and diagnosed and treated at the soonest time in order not to produce radicular and periapical pathosis.Usually a patient cannot recognize an anomaly such as DI, until clinical signs appear, i.e., an acute dentoalveolar abscess or sinus tract  .In thisInterappointment medicament was considered to compensate the shortcomings of canal preparation. Calcium hydroxide was used for its antimicrobial action and for controlling the exudation of the canal.Then, the canal was obturated with lateral condensation of gutta-percha cones and AH-26 sealer after 4 weeks.A complex procedure is required to treat invaginated teeth. A complicated root canal formation is presented in invaginated teeth, which cannot be instrumented completely.Therefore, they need to be opted for a combination of orthograde and surgical treatment  , 12.DueMany hypotheses were suggested about the expansion of an invaginated tooth. Following to the deterioration of the dental lamina, a new theory claims that it can be led to fusion, germination, or agenesia.This is also supported by the fact that invagination is most common in maxillary lateral incisors and premolars, the most popular sites of agenesia, and that it occurs in supernumerary teeth - 14. An The three-month radiograph follow-up showed partial healing of the radicular cyst and the six-year follow-up revealed complete healing.


Chondromyxoid fibroma (CMF) of the calcaneus is extremely rare. We report a case of CMF of the calcaneus in a 34-year-old female. She had foot pain for one year and had increased pain for the last two months. The patient complained of limping due to the pain she felt. CMF of the calcaneus was treated with curettage and bone grafting. The patient was allowed to mobilize the very next day of surgery with weight bearing as much as she could tolerate. No recurrence was encountered during the 18-month follow-up of the patient. The patient could perform activities in her daily life painlessly. Carefully performed curettage and bone grafting is an effective treatment method in the treatment of CMF of the calcaneus. CMF in the calcaneus may not be as rare as it is thought, and should be considered in the differential diagnosis. Chondromyxoid fibroma (CMF) is a very rare benign primary bone tumor . CMFs arAlthough pathologic examination of CMF is difficult, CMF is distinguished from other bone tumors in histopathological examination with a plentiful combination of both myxoid and chondroid intercellular material with loculated areas of spindle-shaped or stellate cells and varying numbers of multinucleated giant cells of different sizes ,7. The pThere are quite a few studies in the literature reporting CMF of the calcaneus ,6,8-11. A 34-year-old female had pain in the left foot that had been going on for one year and had been exacerbated for the last two months. She complained of limping because of the pain she felt. There was no history of trauma. She did not have any disease and previous history of surgery. On examination of the patient, there was severe tenderness with palpation at the lateral of left foot calcaneocuboid joint level. Ankle and subtalar joint range of motion was in normal limits. In her neurological examination, there was no pathological finding.In the left foot X-ray images, it was observed that there was a sclerotic mass around the calcaneocuboid joint adjacent to the calcaneus Figure .A computerized tomography (CT) was performed on the left foot of the patient. The CT images showed a 13 x 6mm lesion with sclerotic rim in the calcaneus in the area adjacent to the calcaneocuboid joint Figure .T2 weighted magnetic resonance imaging (MRI) of the lesion showed a high-intensity signal Figure .In the differential diagnosis of the patient, fibrous dysplasia, osteochondroma, osteoblastoma, giant cell tumor, aneurysmal bone cyst, unicameral bone cyst, nonossifying fibroma, intraosseous lipoma or ganglion, chondroblastoma, and CMF were considered. A bone biopsy was planned. A needle biopsy was performed and CMF was diagnosed as a result of examination of the samples Figure . SurgeryUnder spinal anesthesia, a skin incision was made immediately proximal to the calcaneocuboid joint in the lateral of the left foot. Then bone tissue was approached. In the localization to come over the mass in the calcaneus, a 2x1 cm bone window was opened by osteotome. The mass was excised through this bone window, curettage was done in the region of the mass. The calcaneocuboid joint is preserved. The defect formed after curettage was filled with a spongiose bone graft. The bone removed as a window was replaced.The patient was allowed to mobilize by weight bearing as much as she could tolerate the next day after surgery. The day after surgery, ankle and subtalar joint range of motion exercises were started. During the 18-month follow-up period, the patient had no symptoms and CMF recurrence. An X-ray image of the foot taken at the 18th month follow-up postoperatively is shown in Figure CMF is a very rare benign aggressive cartilaginous tumor of less than 0.5% of all bone tumors ,12. MoreAlthough the most common symptom in patients with CMF is chronic pain, the symptoms may not be seen in patients ,13. CMF Morphologically CMF has various differential diagnoses, however, one of the closest differential diagnoses is low-grade chondrosarcoma. It is of paramount importance to distinguish these tumors as treatment and prognosis differ .The treatment of CMF is very challenging due to recurrence. There are cases in the literature treated with simple curettage, curettage and bone grafting, en bloc resection and even amputation ,15. TherCarefully performed curettage and bone grafting is an effective treatment method that reduces the patient's pain, increases the function and the quality of life in the treatment of CMF of the calcaneus. CMF in the calcaneus may not be as rare as it is thought, and should be considered in the differential diagnosis.


Acute subdural hemorrhage (SDH) is a rare complication that can occur after a spontaneous intracranial aneurysmal rupture. It is commonly associated with a subarachnoid and/or an intracerebral hemorrhage but rarely occurs as an SDH alone. A 52-year-old female presented to our institution with a severe headache and third cranial nerve palsy. A computed tomography (CT) scan revealed acute left SDH, without a subarachnoid hemorrhage (SAH), and a computed tomography angiogram (CTA) and cerebral angiography demonstrated the presence of a left supraclinoid aneurysm pointing towards the cavernous sinus. Endovascular occlusion of the aneurysm was performed using a flow diverter. A follow-up CT scan revealed a resolved SDH. In similar situations, vascular imaging, such as CTA and cerebral angiography, is required to assess the cerebral vasculature. This case report describes a patient presenting with the sudden onset of a severe headache associated with a cranial nerve palsy and a brain CT scan showing an acute SDH in the absence of trauma or an anticoagulation history. The treating physician should be highly vigilant of the possibility of a ruptured intracranial aneurysm as the underlying SDH etiology. Acute subdural hemorrhage (SDH) is a well-known complication following head trauma and may cause a sudden loss of consciousness and neurological deficits in a previously healthy individual. A ruptured aneurysm of the internal carotid artery (ICA)-posterior communicating artery (Pcom) is the most common site for an associated uncommon spontaneous acute SDH . IntracrA 52-year-old female on hypertensive medications presented to the Emergency Department (ED) with a headache for three days mainly involving the left side of the head and left eye. The patient was suspected of presenting with migrainous symptoms and was managed with pain relief treatment and metoclopramide. After three days, the patient returned to the ED with a severe headache, double vision and nausea, and vomiting. She had no history of loss of consciousness, seizure, or trauma and had not been treated with an anticoagulant. On neurological examination, she was awake and alert with a Glasgow Coma Scale (GCS) score of 15/15 and was without a motor deficit, except for left third cranial nerve palsy; therefore, we consulted an Ophthalmology team. A brain computed tomography (CT) was performed and showed a large left acute subdural hematoma  was performed later and confirmed the subdural hematoma and absence of subarachnoid bleeding. A CT angiogram (CTA) showed a left supraclinoid ICA multilobular aneurysm measuring 8 × 6 × 8.5 mm in the anteroposterior, transverse, and craniocaudal dimensions Figure , pointinThe best therapeutic management was determined to be endovascular management with embolization using a flow diverter Figure . The patSlow progressive deployment of a flow diverter  started from the distal LICA to the cavernous segment of LICA, which resulted in a significant flow reduction in the aneurysmal sac with contrast stagnation in the delayed phase. No complications occurred during or immediately after the procedure. The patient was discharged after five days of aspirin and ticagrelor. A follow-up brain CTA showed SDH regression and clinical improvement Figure .The presence of a subdural hematoma without a subarachnoid hemorrhage due to an intracranial aneurysm is an extremely rare occurrence ,4. In thA high index of suspicion is necessary to diagnose a ruptured ICA aneurysm in a patient with a nontraumatic SDH, especially in the absence of an SAH. Vascular imaging should be performed including a CTA, MRA, or cerebral angiogram to evaluate the entire cerebral vasculature. Furthermore, in the presence of an ICA aneurysm, endovascular management can be performed. Moreover, reporting a similar case or performing a cohort study is important to have a better understanding of the condition and to increase the index of suspicion of healthcare practitioners.


Ruptured abdominal aortic aneurysms (RAAA) evolving aortocaval fistula (AF) can have catastrophic hemodynamic effects. Surgical repair is imperative, but the optimal technical approach is still under debate. Our objective is to present 3 cases treated with endovascular repair (EVAR) at a University Hospital. Case #1, a 71-year-old man presenting a 7.1cm RAAA with AF, repaired with a monoiliac stent graft and femoral-femoral bypass; Case #2, a 76-year-old man presenting a 9.9cm RAAA with AF, repaired with a bifurcated stent graft; Case #3, a 67-year-old man with previous history of EVAR, presenting a type 3 endoleak with late rupture related to AF, repaired with a tubular stent graft. All cases unfolded with delayed recovery and significant complication rates, although AF symptoms had resolved by hospital discharge. EVAR techniques for AF may require secondary interventions but are feasible, despite the lack of consensus, considering the rarity of this RAAA presentation. The patients’ characteristics, according to the Society of Vascular Surgery reporting standards guidelines, clinical presentations, and imaging findings are shown in We used the OsiriX MD Imaging Software®  for preoperative EVAR planning in all cases. All surgical procedures were performed through an open bilateral common femoral access with general anesthesia and the patient in a supine position. All procedures were headed by an experienced vascular surgeon assisted by 2 vascular surgery residents and 1 vascular surgery fellow. Post-operatively, patients were instructed to take antiplatelet medication and statins  after hospital discharge. Detailed surgical procedures and patients’ outcomes are presented in Syme is credited with being the first to describe an aortocaval fistula in 1831.The clinical presentation of an AAA with AF usually involves a pulsatile abdominal mass, abdominal pain, and an abdominal machinery-like bruit.-Considering these severe clinical outcomes, surgical repair is imperative. However, the optimal technical approach is still under debate. Open repair has been the recommended therapy for years, but is associated with significant morbidity, mortality, costs, and delayed recovery.In 2016, Orion et. al. published a literature review of 40 articles with a total of 67 treated patients (26 in the endovascular - EVAR group and 41 in the open repair - OR group).The endovascular approach has proved to be a valuable technique in management of this challenging and life-threatening condition, with mortality rates in the literature that range from 16% to 66%, especially in patients with poor cardiac status who wouldn’t be suitable for OR.All three patients survived the emergency treatment, were discharged hospital, and had resolution of symptoms, although one patient needed vascular reintervention to a treat femoral graft infection and one patient to ensure optimal AF sealing. The choice between open or endovascular repair was made based upon clinical and hemodynamic status, anatomical characteristics, and prompt availability of devices for endovascular treatment. Nevertheless, we believe it is important that the surgeon is familiar with both techniques to provide optimal acute care.Hopefully, this case series can contribute to understanding of the disease and its clinical outcomes, presenting a selection of different surgical strategies used, and stimulate further discussion and research.This study was approved by the Institutional Ethics Committee (Decision number 2.886.117).


Solid pseudopapillary neoplasm of pancreas (SPN) is a rare entity. It is almost exclusively seen in females within the second and third decades of life with only small minority affecting children. Due to the paucity of the number of cases seen, the natural history of the disease is not fully understood. SPN tumors of the pancreas are usually found incidentally and usually have an excellent prognosis. We herein present a case of a 33-year-old lady diagnosed with SPN, who presented with abdominal fullness, two weeks post cesarean section. Solitary pseudopapillary neoplasm (SPN) makes up 2% of the all the exocrine pancreatic tumor and is very rare ,2. The SA 33-year-old female with no comorbid condition, who was two weeks post uncomplicated cesarean section, presented with abdominal fullness associated with progressive abdominal distension. She denied abdominal pain, vomiting, or early satiety. She did not report any history of fever, jaundice, weightloss, change in micturition, or bowel habit. On admission, her blood pressure was 106/88 mmHg, pulse rate was 88 beats/min, and respiratory rate was 18 breath/min. On examination, she was afebrile, anicteric, and not cyanosed with no palpable lymphadenopathy. She had a moderate distended abdomen that moved with respiration and a healing Pfannenstiel scar. On palpation, the abdomen was soft and nontender with positive shifting dullness, no palpable mass was felt, and bowel sounds were normal. Abdominal ultrasound on admission revealed moderate to severe ascites. Diagnostic paracentesis revealed features suggestive of chronic inflammation with elevated protein level and no evidence of malignant cells. Abdominal CT scan revealed a heterogeneous mass at the epigastric area, which was partly solid and partly cystic in nature with multiple foci of calcifications measuring approximately 8.1 cm in diameter abutting both the tail of the pancreas and the stomach as shown in Figure Upper gastrointestinal endoscopy was normal. Laboratory work-up did not reveal any features of pancreatic insufficiency, liver injury, or cholestasis. Tumor markers, carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9), were all within normal range. The patient underwent elective surgery. Intra-operatively, a well-defined, encapsulated, oval firm mass measuring approximately 9 cm by 10 cm was found attached firmly to the pancreatic parenchyma at the junction between the body and the tail Figure . A complCystic neoplasms account for a small percentage of all pancreatic tumors, of which solid pseudopapillary tumors 1%-2%) are a subgroup. Their origin is not clearly understood . They ar%-2% are Due to their indolent nature, they tend to produce vague nonspecific symptoms. As these lesions enlarge, they may then cause symptoms from mass effect, such as abdominal pain, vomiting, and early satiety due to gastric outlet obstruction. However, a significant percentage of these tumors is incidental finding on abdominal imaging done for other reasons ,8.The preoperative diagnosis is based primarily on radiological assessment that includes abdominal CT and magnetic resonance imaging (MRI) or sometimes even an abdominal ultrasound, which mostly contributes to an incidental finding of these neoplasms as a hypoechoic mass with mixed echogenicity ,2,4. TheHistological confirmation is not necessary, although in unresectable cases, fine needle biopsy may be performed with 62%-70% preoperative accuracy ,11. HoweComplete surgical resection is the standard of care and the most effective therapy for pseudopapillary neoplasms -5,13, wiMinimally invasive techniques have been gaining ground and popularity with some small series reporting successful laparoscopic resection with similar surgical outcome, overall short hospital stay, less analgesia requirements, and overall patient satisfaction as compared to open method . CommonlSolid pseudopapillary neoplasms of the pancreas are characterized by excellent long-term prognosis following complete surgical resection. Therefore, early diagnosis and treatment can help prevent potential local infiltration to adjacent structures and metastasis in distant organs.


Delayed presentation of intraperitoneal rupture of the urinary bladder in a child after blunt trauma is a rare occurrence. On ultrasonography, diagnosis of bladder injuries has been sparsely reported in the literature. We report a case of intraperitoneal bladder rupture in a four-year-old child and describe the role of ultrasonography in providing a prompt and accurate diagnosis of the entity as mortality increases if surgical repair is delayed. On high-resolution ultrasonography, rent was noted in the urinary bladder dome with fluid collection in the paracolic gutters and between loops of the small bowel. Peritoneocentesis demonstrated urine and the child was taken up for laparoscopic repair of the bladder tear, which was visualized at the bladder dome. Cystogram performed at one week was unremarkable and the post-operative period was uneventful with no complaints at a one-month follow-up. Around 60% to 85% of all bladder injuries result from blunt trauma to the abdomen but the incidence of intraperitoneal urinary bladder rupture is relatively uncommon and exceedingly rare in children . Delay iA four-year-old boy presented with complaints of inability to pass urine for 48 hours and insidious onset progressive abdominal distension that developed secondary to trauma to the abdomen while playing. Clinical examination revealed suprapubic tenderness. On day three following the incident of trauma, the child was referred for ultrasonography of the abdomen and pelvis that demonstrated a circumscribed fluid collection measuring 8.0 × 10.0 × 12.0 cm with scattered internal echoes and hyperechoic contents in the dependent portion of the suprapubic region. High-resolution ultrasonography of the pelvis was performed, which demonstrated hypoechoic rent at the dome of the urinary bladder (Figure Intraperitoneal rupture of the urinary bladder occurs typically as a result of a direct blow to the already distended bladder and constitutes 15% of major bladder injuries . On ultrThe standard imaging technique for the diagnosis of bladder injury is retrograde cystography with a reported accuracy of 85%-100% , but shoWe present a case of a four-year-old child with blunt trauma to the abdomen and describe the ultrasonography appearances of intraperitoneal urinary bladder rupture with delayed presentation and stresses on the fact that the entity needs to be included in the differential diagnosis of abdomino-pelvic fluid collection, especially in children given the history of trauma. Furthermore, urinary retention should be reviewed with caution in the trauma setting even in the absence of pelvic fractures. This case also highlights the role of ultrasonography in providing an accurate diagnosis of urinary bladder rupture in resource-starved settings. Delayed diagnosis of bladder rupture may be associated with metabolic derangements. Delay in the presentation and treatment may substantially increase mortality. Therefore, early and accurate diagnosis of intraperitoneal bladder rupture with imaging techniques such as high-resolution ultrasonography is imperative for a good prognosis.


We discuss the case of a 36-year-old male patient who presented with gait impairment. On examination, he had clinical findings of cervical myelopathy. The patient was evaluated with an MRI of the brain and spine, which revealed multiple spinal tumors, some causing significant canal stenosis. The spinal tumors involved the cervical, thoracic, and lumbar regions. There were both intramedullary and extramedullary tumors with an extraspinal extension. The patient's MRI brain also revealed bilateral vestibular schwannomas. His family history was negative. He subsequently underwent surgery for multiple spinal lesions followed by debulking of the right-sided vestibular schwannoma. The radiological findings of both intramedullary and extramedullary spinal tumors affecting the spinal cord and extensively involving the cervical, thoracic, and lumbar regions, and the requirement of spinal and cranial surgery concurrently make this a challenging neurosurgical case. Neurofibromatosis is a genetic disorder of the nervous system that causes tumors to form in the brain, spinal cord, and nerves . The conA 36-year-old male patient presented with progressive weakness of the lower limbs for two months. Additionally, tingling, numbness, and stiffness were present. He had previously consulted his local doctor when he had reached a stage where he had been unable to walk, and he had been advised to undergo an MRI of the spine. The patient was a known diabetic and hypertensive. The MRI of the spine had revealed multiple spinal tumors Figures , 2, 3. TOn further questioning, he stated that he did have a degree of hearing loss on the right side, which he had noticed for the past six months, and a mild headache, which was more recent in origin. He did not have any family history suggestive of NF2. On examination, he was oriented to person, place, and time. His speech was also normal. Cranial nerve examination revealed that the functions of the cranial nerves 1-6 were not affected. However, there was cranial nerve 7 (CN VII) involvement in the form of right facial asymmetry  and loss of taste sensation on the anterior two-thirds of the tongue. For cranial nerve 8 (CN VIII) examination, the Rinne test was performed. Air conduction was greater than bone conduction on both sides and the Weber test lateralized to the left ear. This signified sensorineural hearing loss on both sides with greater severity on the right side. The functions of the other cranial nerves were within normal limits. Regarding motor functions, the nutritional status of all four limbs was normal. Both the upper limbs had a normal tone. Clasp-knife spasticity was present in both the lower limbs. The power of the proximal and distal left upper limbs was normal (grade 5). The power of the proximal right upper limb was grade 5 while that of the distal right upper limb was grade 3. For the lower limbs, the power was grade 2 for the proximal and distal parts of both sides. Cerebellar signs - dysmetria and dysdiadochokinesia - were present on the right side. As for deep tendon reflexes (DTRs), the biceps jerk on both sides was within normal limits. On the right side, triceps jerk and brachioradialis jerks were lost. However, on the left side, they were within normal limits. DTRs in the lower limb, such as the knee and the ankle jerks, were brisk. Plantar was upgoing on both sides. Also, the patient did not have any sensory loss along the affected dermatomes. However, posterior column sensations including vibration and proprioception were affected in the lower limb. The gait could not be tested due to the low power of muscles in the lower limb.The patient's MRI spine without contrast revealed multiple spinal tumors in the cervical, thoracic, and lumbar areas Figures -3. Of noExcision of the cervical and dorsal tumors was done in the same setting via a C6-7 and T11-12 laminectomy respectively. Postoperatively, the patient had significant improvement in his lower limb power (grade 4) and gait.Biopsy of both the tumors suggested schwannoma. Almost a month later, the patient underwent a right retromastoid craniectomy with debulking of the right vestibular schwannoma. A near-total excision was performed, leaving the residual tumor around the internal meatus with anatomical preservation of CN VII Figure . PostopeNF2 is inherited as an autosomal-dominant condition . Of noteAt the time of his presentation, our patient was symptomatic for both cranial and spinal lesions. Although the presentation of this patient was symptomatic and slowly progressive, patients can be asymptomatic on presentation in some cases . PatientSpinal tumors occur in 89% of cases of NF2. However, multiplicity is found in about 56% of these [We described the case of a patient who presented with concurrent tumors in the brain  and the spinal cord. The spinal tumors were found in the cervical, thoracic, and lumbar regions. It is unique to have such a large area of involvement. Also, both intramedullary and extramedullary  spinal tumors were noted in this patient. The requirement of spinal and cranial surgery almost concurrently makes this case challenging and interesting.


Ischemic bowel injuries are generally caused by arteriosclerosis, thromboembolism, or vasculitis. Ischemic enteritis is less common than ischemic colitis because of the rich collateral arteries of the small intestine. In the present case, smooth muscle degeneration of the mesenteric to the submucosal veins caused ischemic enteritis and small bowel obstruction.An 85-year-old woman with recurrent enteritis eventually developed small bowel obstruction. We performed laparoscopic partial resection of the small intestine. The pathological findings revealed smooth muscle degeneration of the mesenteric veins that caused ischemic enteritis. Venous changes were detected not only in the injured region, but also in a part of the normal region of the resected specimen. She continued to experience some minor symptoms postoperatively; however, these symptoms subsided in a short period with medicine discontinuation.This report shows the possibility that a disease causes ischemic enteritis with unique venous pathological changes and may recur postoperatively. Intestinal ischemia typically develops because of arterial thromboembolism. Other common causes of ischemic bowel disorders are venous thrombosis or vasculitis –3. IscheAn 85-year-old woman was referred to our hospital because of nausea, vomiting, and right lower abdominal pain. She had been admitted to our hospital 2 months previously because of infection enteritis. After her hospital discharge, she had experienced diarrhea and constipation repeatedly. Her medical history included appendicitis, collagenous colitis, myocardial infarction, hypertension, and asthma. Her regular medications included aspirin, several depressors, and stomach medication; she was not taking any herbal medication. On examination, her body temperature was 38.5 °C, and she had shaking chill and tenderness in the right abdomen. Her blood workup showed a white blood cell count of 20,480/μL; the levels of all other blood parameters, including C-reactive protein, were normal. An abdominal computed tomography (CT) revealed thickened wall and stricture of the ileum near the terminal ileum, with dilation and fluid accumulation in the small bowel Fig. . No decrIntestinal ischemia is mainly caused by arteriosclerosis and arterial thromboembolism. –3. IscheIn general, arteriosclerosis and thromboembolism are the main causes of intestinal ischemia. Venous occlusion is an uncommon cause of intestinal ischemia and is mainly caused by venous thrombosis or vasculitis associated with conditions, such as systemic lupus erythematosus, and Behçet disease –3. In thFurthermore, the pathological changes in the veins were detected not only in the part of the ischemic lesion, but also in the normal part of the small bowel. Although mild venous changes were detected in parts without stenosis, we think that severe anomalous venous drainage did not occur, and the mucosa was not severely damaged. The continuity of the venous changes between the stenotic and the normal parts was uncertain. In a previous report, surgical resection was mostly required for ischemic enteritis with stenosis, and postoperative recurrence ratio of ischemic enteritis is uncertain , 11, 12.The differential diagnosis for small bowel stricture includes inflammatory bowel disorders, malignant tumor, tuberculosis, nonsteroidal anti-inflammatory drug-associated enteritis, trauma, antiphospholipid antibody syndrome, and abdominal adhesions related to previous surgery , 7, 13. Etiology for this presented disease is unclear. In many cases of elderly patients, small bowel stenosis is caused by neoplastic lesion such as carcinomas and lymphomas. Ischemic enteritis, rheumatoid vasculitis, and diaphragm disease have been reported as the rare causes of small bowel stenosis , 14–16. Generally, intestinal stenosis or obstruction cases with severe symptoms undergo surgical intervention. With regard to ischemic enteritis, two types have been described on the basis of the cause: occlusive and nonocclusive , 17. In With respect to future follow-ups, detection of small bowel disorders is challenging. Previous reports have shown that the recent development of double-balloon endoscopy or capsule endoscopy has enabled the observation and detection of small bowel lesions , 7, 18. We present the case of a patient with ischemic enteritis caused by rare mesenteric venous changes. This disease could lead to ischemic enteritis without arteriosclerosis, thromboembolism or vasculitis. In addition, the uncommon pathological changes were also detected in the intact part of small bowel; therefore, ischemic enteritis and small bowel stenosis may recur after surgery because of this pathological abnormality.


Rectal tonsils are localized hyperplastic lymphoid tissues in the rectum, and the initial endoscopic findings are consistent with those for neoplastic lesions. However, rectal tonsils are benign entities, and the diagnosis should be made cautiously. A 70‐year‐old man presented with pain on defecation with rectal bleeding. Colonoscopy revealed a 3‐cm protruding mass in the rectum with mucosal erosion, but no malignant features were observed on forceps biopsy. Endoscopic ultrasonography (EUS) showed that the lesion was a hypoechoic mass without blood flow. Fine needle aspiration under EUS revealed no malignant components, although the size of the lesion had shrunk, and symptoms, such as blood‐stained stool, tenesmus, and discomfort during defecation, had resolved. A second forceps biopsy showed intermediate‐sized lymphocytes without lymphoepithelial lesions. Based on immunostaining, the lesion was diagnosed as a rectal tonsil.Rectal tonsils occur due to localized proliferation of reactive lymphoid follicles in the submucosa or muscularis mucosa. However, endoscopic diagnosis is difficult since less invasive treatment is performed for neoplastic lesions of the rectum to preserve the function of the anal sphincter. Diagnosis and treatment of small lesions might be possible by endoscopic resection; however, for relatively large lesions, formulating a diagnosis based only on biopsy specimens becomes even more difficult. Therefore, repeated biopsies might be helpful for the diagnosis of rectal tonsils and for excluding other neoplasms. Rectal tonsils (RTs) are localized hyperplastic lymphoid tissues in the rectum, and the initial endoscopic diagnosis is consistent with that for neoplastic lesions.A 70‐year‐old man presented with pain during defecation with rectal bleeding. He had a history of myocardial infarction and was on oral clopidogrel. Rectal examination revealed a hard palpable mass that bled easily in the lower rectum. Colonoscopy revealed a large protruding reddish mass in the lower rectum, with mucosal erosion Figure . SMTs suFour months after the initial colonoscopy, scar tissue had formed over the lesion Figure , and 14 RTs, also known as benign lymphoid polyps, are localized lymphoid hyperplasia or benign lymphomas. They are caused by excessive diffuse and localized proliferation of lymphoid follicles in the rectal mucosa. The proliferation of lymphoid follicles is especially common in the terminal ileum but rarely occurs in the rectum. Therefore, it might be discovered incidentally; however, if the lesion is large, it might cause discomfort during defecation or hematochezia.On endoscopy, the morphological form usually appears as a polypoid or serrated lesion with or without erosion; however, there are no specific features unique to RT. Hence, a diagnosis based on visual inspection is difficult, especially when differentiating between other types of SMTs such as malignant lymphoma, myogenic tumors, and neuroendocrine tumors.Similar to ordinary endoscopy, EUS is reported to be a feasible modality for diagnosing rectal lesions and is superior to CT or MRI, especially for small lesions7. Differentiating between rectal tonsils, neuroendocrine neoplasms, and malignant lymphoma is difficult because all these lesions appear hypo to isoechoic on imaging and often originate from the second layer. Hence, procedures such as endoscopic resection are useful for both diagnosing and treating small lesions.However, in general, less invasive treatment is preferred for neoplastic lesions of the rectum to preserve the function of the anal sphincter. Moreover, since RT is benign, it is important to be familiar with this disease to avoid misdiagnosis and overtreatment.In this case, the patient was symptomatic, and surgical resection was initially considered. Fortunately, surgery could be circumvented due to the spontaneous shrinkage of the lesion and because it was diagnosed as RT due to repeated diagnostic endoscopies and biopsy. In retrospect, we should have performed a deeper biopsy, such as mucosal incision‐assisted biopsy, because a good biopsy specimen might have helped a definitive diagnosis at the first analysis.However, from a clinical standpoint, our case is very valuable because it showed that even a large RT could regress spontaneously. Further, the natural course was followed until scar tissue developed over the lesion without excision. In retrospect, it can be deduced that repeated biopsies are useful for the diagnosis of RTs and for excluding other neoplasms. However, the natural course of RT remains unclear, and long‐term follow‐up is required.In conclusion, RTs are rarely seen in the daily clinical practice of colonoscopy.Clinicians should bear in mind that RTs are benign and self‐limiting entities, and the diagnosis should be made cautiously to avoid unnecessary surgery.The authors declare no conflicts of interest.None.


Primary cardiac neoplasms are rare, with 3/4 cases being benign. Most malignant neoplasms are sarcomas. Clinically, they present as pseudovalvular obstruction or remote embolism and rarely as a paraneoplastic syndrome. Median survival depends on complete resection rather than histologic type. We describe the case of a 65-year-old woman who presented to the hospital with a three-month history of asthenia, anorexia, weight loss, and progressive worsening of exertional dyspnea. Transthoracic echocardiogram showed a bulky mass in the auricles with significant transvalvular obstruction of the mitral valve. The CT scan showed a voluminous mass in the interauricular septum with the invasion of both atria and restriction of flow in both pulmonary veins. A transvenous biopsy was performed and histology revealed a primary intimal sarcoma. The patient was not eligible for surgery and was proposed for palliative chemotherapy, but she succumbed to her illness in less than two weeks. This report describes this rare and rapidly fatal disease and reviews the literature. Cardiac tumors may be primary or secondary, the latter being 100 to 1000 times more common than the former . Primary2 saturation was normal on room air, and had pretibial edema of both limbs. Abdominal and neurologic examinations were normal. Laboratory examination showed anemia , thrombocytopenia , elevated liver parameters  and elevation of N-terminal part of natriuretic peptide type B . The other tests were normal. An electrocardiogram showed sinus rhythm and a normal rate of 70 beats per minute. The patient was admitted with new-onset heart failure for evaluation and investigation.A 65-year-old woman with dyslipidemia and a history of obesity presented to the emergency department. For the past three months, she had complained of worsening asthenia, anorexia, weight loss, and dyspnea on exertion. She had been to the emergency department several times and was receiving beta-blockers and anticoagulants because she was suffering from new-onset atrial fibrillation (AF). On physical examination, she had a normal body temperature, a heartbeats in the normal range, and a normal blood pressure in the supine position. The other cardiovascular findings were unremarkable; she had crackles in the pulmonary base on auscultation, peripheral blood ODuring hospitalization, the patient re-entered AF and required rate control with beta-blockers. Despite adjustment of diuretics, acute hypoxemic respiratory failure was observed. To better characterize cardiac morphology and functionality, an echocardiogram was performed, which showed a mass with voluminous dimensions greater than 62 × 53 mm at the level of the left atrium, resulting in significant obstruction, with a mean gradient between the left atrium and left ventricle (LA/LV) of 18 mmHg, and which appeared to have infiltrated the atrial septum and extended to the right atrium without causing obstruction but with indirect evidence of right ventricular overload . Expression of CD34, cytokeratin (antigen E1/antigen E3), and desmin were negative, supporting a diagnosis of intimal sarcoma , systemic embolism (early metastasis in right-sided origin), or, less commonly, constitutional symptoms as a paraneoplastic syndrome. These tumors are diagnosed by transthoracic echocardiogram or CT examination .Prognosis is as for other histologic types and depends mainly on complete surgical resection. These tumors are extremely destructive and the median survival time is little more than one year . DefinitIn conclusion, early detection and treatment are of paramount importance because of their prognostic and beneficial therapeutic effects. Other, more common diseases present with these findings, so health care providers must be extremely suspicious, as symptoms may be nonspecific, and non-contrast CT scan may be non-diagnostic leading to delayed diagnosis. The final diagnosis was possible upon an abrupt clinical deterioration during hospitalization by executing a CT scan with contrast. Thus, reporting such cases is of utmost importance to raise clinical awareness of such aggressive, rapidly fatal tumors.


Ectopic adrenal gland in the ovary is very rare case, and even more rarer in older women. We reported a case of ectopic adrenal tissue as an incidental finding in left ovary from a 68-year-old woman. She presented with bearing down sensation due to uterine prolapse for 5 years. Upon physical examination, uterine prolapse grade III, cystocele, and rectocele were observed. Ultrasonography findings showed 0.69 cm intramural myoma, and no specific findings were found in the bilateral adnexae. She underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and anterior-posterior repair. The final pathologic diagnosis of the case was ectopic adrenal gland tissue in the left ovary and uterine leiomyoma. No eventful reactions were observed during hospitalization and after discharge. Although ectopic adrenal gland rarely occurs in elderly women and in the pelvic ovaries, it has a risk of neoplastic transformation and accompanying germ cell tumor and sex cord tumor. Hence, if the ectopic adrenal gland tissue is suspected during surgery, the tissue should be removed. Additionally, by closely examining the contralateral ovary, determining whether other lesions are suspected is necessary. If the other lesions including germ cell tumor or sex cord tumor are suspected, a biopsy of the contralateral ovarian tissue should be performed. Thus, gynecologists must have knowledge about ectopic adrenal gland tissues. Ectopic adrenal gland tissue is induced by small fragments of the adrenal cortex originating from the ectoderm during the course of invasion into the central vein during adrenal gland development, and was first reported by Morgani in 1740 . This tiPatient information: a 68-year-old multiparous  woman presented with a bearing down sensation due to uterine prolapse grade III that lasted for 5 years. At the time the patient was first diagnosed with uterine prolapse, she had a follow-up observation at a local hospital after a pessary was inserted, but she visited this hospital for surgical treatment. Past medical history of hypertension was reported. She was taking medications due to hypertension, and her blood pressure was well controlled.Clinical findings: as a result of physical examination, there was no palpable mass in the lower abdomen area, and there was no tenderness at all. As a result of gynecology examination, there were no specific findings other than grade III uterine prolapse.Diagnostic assessment: a transvaginal sonographic evaluation revealed a 0.69 cm intramural-type uterine myoma, and no other lesions were observed on both adnexa.Therapeutic intervention: the symptoms of the patient´s uterine prolapse were causing discomfort in her daily life. As she was post-menopausal, her ovaries were no longer producing female hormones. For these reasons, the patient agreed to a prophylactic bilateral salpingo-oophorectomy during hysterectomy. Although no ovarian lesions were present, neither of the ovaries were functional and there was a risk that lesions such as ovarian malignant masses may develop later. Therefore, the patient underwent laparoscopic hysterectomy with prophylactic bilateral salpingo-oophorectomy as well as anterior and posterior repairs. The surgically removed uterus, bilateral ovaries, and fallopian tubes were sent to the pathology department for histological analysis.On section, the cut surface showed intramural leiomyoma and both adnexa were unremarkable, grossly. Microscopic examination revealed 0.3x0.2x0.2 cm sized ectopic adrenal tissue in the left ovary. The tissue consisted of pale cells with spongy-appearing cytoplasm and polygonal cells with acidophilic granular cytoplasm, which is reminiscent of zona fasciculata and zona reticularis of the adrenal cortex . The ectFollow-up and outcome of interventions: the patient presented with no complications six months after surgery.Informed consent: the patient consented to the publication of a case report containing her clinical data; because her case was rare, and she wanted to be helpful in the treatment of such a case in the future.Although no ovarian lesions were found by our on the preoperative ultrasound, we chose to perform a prophylactic bilateral salpingo-oophorectomy during the patient´s hysterectomy based on consideration of the cost-benefit balance. The risk of ovarian cancer increases with age, such that the prevalence rises from 20 per 100,000 among women aged 50 years to 40 per 100,000 women aged 70 years [Ectopic adrenal gland tissue is located in a site other than the normal location of the adrenal gland. The development of adrenal glands occurred during the fourth and fifth weeks of gestation and comprises an adrenal cortex originating from the mesoderm and an adrenal medulla originating from the ectoderm , 6. Duriet al. [et al. [Ectopic adrenal gland tissue can also be observed in other mammals, but in most humans, it is found in childhood with a 50% occurrence, and the average age of onset is approximately 5.8 years. Because it becomes atrophied with age, the incidence rate drops sharply with a probability of 1% in adults, and it is particularly rare to be observed in adult women . Accordiet al. . Because [et al. .An ectopic adrenal gland is a very rare in elderly women, and is often diagnosed incidentally following surgical treatment and histological examination. However, surgical removal of the tissue is necessary because of metabolic and neoplastic complications. Furthermore, carefully checking whether there are any suspicious findings of a malignant ovarian tumor in the contralateral ovary is needed, and a biopsy should be performed if necessary.