Synchronous multicentric osteosarcoma (SMOS) is a rare disease characterized by simultaneous multicentricity of intraosseous osteosarcoma without visceral involvement. SMOS, including a skull lesion, which occurs relatively rarely, and reconstruction using a frozen autograft after the excision of a lesion of SMOS has been infrequently reported previously.We report an 18-year-old girl with SMOS, with lesions located in the left distal femur, right proximal humerus, and left occipital bone. Her major complaint was pain and swelling around the left knee joint. Asymptomatic lesions of the humerus and skull bone were detected on a systemic bone scan. No visceral organ metastasis was observed. A biopsy of the distal femoral lesion revealed osteosarcoma. Based on the histological findings, multiple bone lesions, and absence of visceral lesion, the clinical diagnosis of SMOS was made. After five courses of neoadjuvant chemotherapy with a regimen of doxorubicin and cisplatin, reconstruction using a tumor prosthesis following wide excision of the left distal femur was performed, and total necrosis was histologically observed in the retracted specimen. Following three cycles of adjuvant chemotherapy, tumor excision and reconstruction with a frozen autograft treated with liquid nitrogen was conducted for both lesions of the humerus and skull, rather than tumor prosthesis or synthetics, in order to retain a normal shoulder function, and to obtain a good cosmetic and functional outcome after treatment of the skull lesion. Further adjuvant chemotherapy could not be administered after the completion of the surgical treatment for all lesions because the adverse events due to chemotherapy were observed. At over 5 years after the diagnosis, she remains clinically disease-free.An early correct diagnosis, the proper management of chemotherapy, and surgical treatment for all lesions are essential for achieving a good clinical outcome, even in SMOS including a skull lesion. By performing reconstruction using a frozen autograft for a proximal humeral lesion and a skull lesion after confirming the good histological efficacy of neoadjuvant chemotherapy for the primary lesion, the excellent function of the shoulder joint and a good cosmetic outcome at the site of the skull lesion was acquired without complications or recurrence. Synchronous multicentric osteosarcoma (SMOS) is characterized by simultaneous multicentricity of intraosseous lesion without visceral involvement, such as lung metastasis . SMOS isOsteosarcoma at the skull region is also rare, and acounting for only 6 to 8% of osteosarcomas , 9. The Chemotherapy is very important for supporting the surgical outcome of tumor patients. In a few previous reports, long survivors of SMOS also had necessarily received chemotherapy, and more than 90% necrosis of the tumor cells in the specimen excised from the patients had been observed histologically , 7, 8. AWe herein report an 18-year-old girl with multicentric synchronous osteosarcoma, including a skull lesion, and describe the clinical findings and treatment outcome for chemotherapy, two-stage tumor excision for all lesions. Our study was approved by the ethics committee of Kanazawa University Hospital  number 2019–61(3094)) in compliance with the guidelines of the 1975 Declaration of Helsinki. Written informed consent was provided by the patient to obtain her case details and any accompanying images published.An 18-year-old woman was referred to our department with a major complaint of a pain and swelling around the left distal femur. The symptom had been increasing for the past 6 months. She consulted a local doctor because her symptoms had not improved over time. Neither trauma nor injury was reported. Her previous history was also unremarkable, and no family history was found. A physical examination revealed swelling around her left distal femur and tenderness upon palpation. Neither ballottement of the left knee joint nor an evident soft tissue mass were observed. Laboratory tests revealed a threefold higher alkali-phosphatase level than the upper limit, but no other abnormal data, including the lactate dehydrogenase level and inflammation reaction, was found. A bone sclerotic lesion with periosteal reaction on the distal femur was found on X-ray Fig. a, b. Com2, and that of cisplatin was 120 mg/m2. The chemotherapy was performed every three weeks. After the completion of neoadjuvant chemotherapy, the uptake of all lesions on the bone scan diminished  and vincristine (2 mg/body) was performed for the second course of adjuvant chemotherapy. The improvement of cardiac function was confirmed, and the doxorubicin (60 mg/m2) and cisplatin  were given again for the third course of adjuvant chemotherapy. A total of eight courses of chemotherapy were completed, including three courses of adjuvant chemotherapy. The total dose of doxorubicin and cisplatin was 420 mg/m2 and 816 mg/m2, respectively. The humeral lesion had almost completely disappeared radiologically, and the occipital lesion was only slightly visible on images. Both the alkali-phosphatase level and the lactate dehydrogenase level remained normal in laboratory tests.Since physical recovery from the primary surgery and wound healing were observed, adjuvant chemotherapy was resumed at seventeen days postoperatively for the residual lesions of the humerus and occipital bone. The regimen for an adjuvant chemotherapy was the same as a neoadjuvant chemotherapy. A mildly decreased cardiac function was observed on echocardiogram after the completion of the first course of adjuvant chemotherapy, and chemotherapy with another regimen of high-dose methotrexate (10 g/mTumor excision of both the humeral lesion and the occipital lesion, and reconstruction using a frozen autograft, rather than a tumor prosthesis or synthetics, was planned at 6 months after the diagnosis, because a histological analysis demonstrated that chemotherapy showed good efficacy in the treatment of the primary lesion. For the humeral lesion, the tumor location was identified using a fluoroscopy, based on preoperative MRI findings. For the skull lesion, the tumor location was identified with the assistance of a navigation system. At first, tumor excision for the occipital lesion was performed with a margin of at least 2 cm Fig. a. The frFurther chemotherapy was not administered after the second surgery because the adverse events due to chemotherapy, such as a myelosuppression and a mildly-decreased cardiac function, were observed. She was discharged from the hospital after the recovery from the surgery was confirmed. She was prudently observed under active surveillance, and underwent close follow-up examinations in an outpatient clinic every 3 or 4 months after discharge.At 68 months’ follow-up after the detection of SMOS, a disease-free condition with neither local recurrence nor metastasis was obtained, and bone union for the humerus and skull lesion had also been achieved on images (Fig. Multicentric osteosarcoma accounts for only approximately 1% of all osteosarcomas, and is divided into two types: synchronous and metachronous type , 3. DomeOur treatment strategy for SMOS is basically the same as that for osteosarcoma Fig. . To idenWhen the surgical margins for all lesions are histologically clear, the primary treatment is considered to be over, or additional adjuvant chemotherapy may be considered if the patients can afford to undergo these treatments, with careful observation for adverse events. After completion of the primary treatment, the postoperative state will be prudently observed at follow-up in an outpatient clinic, with examinations every three or four months until at least five years at least after surgery.Osteosarcoma commonly presents with lung metastases, and a standard examination includes chest CT. Additional examinations are not regularly performed except for when a patient presents symptoms, such as pain or swelling. Patients with skull osteosarcoma often present with headache, motor impairment, or cranial nerve palsies, depending on the tumor site –12. HoweChemotherapy is very important for supporting the surgical outcome of tumor patients. In a few previous reports, long survivors of SMOS had necessarily received chemotherapy, and more than 90% necrosis of the tumor cells in the specimen excised from the patients had been observed histologically due to the efficacy of chemotherapy, which was assessed according to the Rosen and Huvos classification , 7, 8. OThe histological confirmation of the efficacy of neoadjuvant chemotherapy in the whole section of the distal femoral lesion, especially the bone lesion, was necessary for determining whether the same regimen chemotherapy for the other two lesions should be continued or not. When a frozen autograft is used for reconstruction after wide excision, the efficacy of chemotherapy on excised soft tissue lesion can be evaluated histologically; however, the efficacy is not evaluated in bone lesion. Frozen autograft is available for almost all bone tumors and has been reported to be associated with many advantages, including preservation of the bone stock, retention of the joint function in cases in which the epiphysis is preserved, and the fact that the graft can be a perfect fit for the excised bone defect. However, the indications need to be well considered in each case. In cases involving multiple bone lesions, such as the present case, the selection of an appropriate treatment strategy is essential, and we referred to the results of a histological assessment of the effects of neoadjuvant chemotherapy on the primary bone lesion when considering treatment for residual lesions. In addition, the epiphysis could not be preserved in the present case because the lesion extended to the epiphysis. Thus, a tumor prosthesis was selected for reconstruction after wide excision of the distal femoral primary lesion.Hemicortical excision with a clear margin and reconstruction using a frozen autograft treated with liquid nitrogen is reportedly a reliable technique for retaining a good joint function through minimally resection of the tumor and preservation of as much of the normal tissue around the resected tumor as possible –25. ThisComplete excision with a wide margin was associated with an improved survival, and local recurrence after surgery of the skull tumor is the major cause of treatment failure and decreases the survival rate. However, the anatomy of the head is complicated, and complete resection of the skull lesion is often difficult to achieve –12. SyntIn conclusion, SMOS including a skull lesion is rare; nevertheless, the early, correct diagnosis, and proper strategy of chemotherapy and surgery for all lesions, are essential for ensuring a good clinical outcome. Reconstruction using a frozen autograft treated with liquid nitrogen was found to be feasible for bone lesions, including a skull lesion, even in a case of multicentric osteosarcoma, when the histological efficacy of neoadjuvant chemotherapy for the primary lesion was good. Our patient achieved an excellent right shoulder function, and a good cosmetic and functional outcome without any complications by reconstruction by following reconstruction using a frozen autograft. In addition, clinically disease-free survival of over five years after the diagnosis can be obtained, although further follow-up with regular close examinations will be required, as the survival associated with this disease is commonly poor.


Spinal cord tumors are sporadic and account for around 2%-4% of central nervous system neoplasms. Ependymoma is one of the most common spinal cord neoplasms and can present with different neurological signs and symptoms. They commonly present with neck or back pain and associated neurological involvement, with sensory symptoms usually antedating the motor symptoms. We now present a rare case of spinal ependymoma in a 26-year-old female who presented with isolated neck pain and the absence of other neurological symptoms. Attention to peculiar characteristics like isolated neck pain might be an essential key to early diagnosis and better prognosis. Spinal cord tumors are exceptionally rare, accounting for around 2%-4% of central nervous system neoplasms . EpendymA previously healthy, 26-year-old female presented with an initial symptom of isolated neck pain. She denied any trauma, associated headache, nausea, vomiting, blurry vision, numbness, tingling, muscle weakness, or radiating pain. She did not notice any fever, fatigue, joint pain, changes in weight, or appetite. She did not recall any recent travel, sick contacts, or risk factors for human immunodeficiency virus (HIV).On physical examination, the patient was afebrile, and her vital signs were within normal limits. On palpation of the neck, isolated neck tenderness was observed without any erythema, warmth, or swelling. Her active and passive range of motion was preserved. There was no nuchal rigidity, and Kernig and Brudzinki's signs were negative. Hoffman and Spurling's signs were negative as well. Her further neurological exam revealed 5/5 motor strength in all muscle groups in bilateral upper and lower extremities, and a sensory exam revealed intact sensation to light touch, pain, and temperature in all dermatomes. Vibration and proprioception were intact, and 2+ reflexes were noted in all muscle groups. Her chest, cardiovascular, abdominal, and extremities examination were unremarkable.Initial laboratory examination, including complete blood count (CBC) with differential, inflammatory markers, and renal and liver function, were within normal limits. The X-ray of the cervical spine was done and was unremarkable. Given the benign neurological findings, a trial of muscle relaxants and anti-inflammatory medications was given. Due to the non-resolution of her symptoms for three weeks, MRI of the cervical spine was performed to rule out any cervical pathology, which revealed a heterogeneous intramedullary lesion at the mid-body of C2 to the upper body of C4 vertebral levels, raising suspicion for an intramedullary neoplastic lesion. Screening of the entire central nervous system (CNS) was otherwise unremarkable Figure .To establish a specific diagnosis, the patient underwent a posterior cervical laminectomy. Gross total resection was not achieved due to a drop in sensory potentials during intraoperative neurological monitoring. Histopathological examination of the resected tissue showed glial neoplasm with hyalinized perivascular pseudorosettes with mild pleomorphism. No pseudopalisading necrosis or glomeruloid vascular proliferation was seen. These findings were consistent with World Health Organization (WHO) Grade 2 ependymoma.The patient had no significant motor neurological impairment after surgery. However, a significant sensory and proprioceptive loss was observed due to a posterior spinal approach. She remains progression-free at two years with magnetic resonance imaging (MRI) showing a stable residual tumor Figure .Neck pain is one of the leading causes of disability. With an annual prevalence rate of around 30%, it causes a significant burden to healthcare systems in the United States . Most caIntramedullary spinal cord tumors can exist with a diversity of symptoms. Neck or back pain is often the earliest symptom . In patiIt is essential to recognize and address such early symptoms judiciously, as further imaging can help not only in establishing a diagnosis but also in providing valuable details regarding tumor characteristics such as tumor size, presence or absence of cystic changes, and compression of vital structures. Such information regarding tumor characteristics is crucial as, along with presurgical functional status, it remains a significant predictor of postoperative prognosis -11.Our patient underwent immediate surgery, which confirmed the diagnosis of WHO Grade 2 ependymoma. Due to the decrease in sensory potentials on intraoperative neuromonitoring, gross-total resection was not achieved. No significant motor neurological impairment was noticed after surgery. She sustained an expected decrease in sensory perception and proprioception in the setting of the posterior spinal surgical approach with marked improvement at one year from surgery . Her resCervical intramedullary ependymoma is a rare, slow-growing spinal cord tumor that can present with different, non-specific neurological symptoms. Neck pain, with usually benign differential diagnosis, can be an early presenting symptom for more grave illnesses such as ependymoma. It is necessary to identify peculiar symptoms like isolated neck pain, as it can be key to early diagnosis and better prognosis, as presurgical functional status is a significant predictor of postoperative prognosis.


Cardiac myxoma is a benign neoplasm composed of stellate to plump, cytologically bland mesenchymal cells set in a myxoid stroma. Although benign, as they can lead to severe complications, they are often removed surgically. A 39-year-old female presented with a chief complaint of generalized fatigue. Patient had a history of a large 7cm x 2.5cm left atrial myxoma resected at the age of 32 years after she presented with symptoms of dyspnea on exertion. The dyspnea was due to prolapse of the mass through the mitral valve during diastole, leading to functional severe mitral stenosis. The mass was resected with clear margins confirmed on biopsy. On physical examination, heart rate was regular with no murmurs. No signs of congestive heart failure were noted. A 2D echo revealed a mobile structure in the left atrium along with mild mitral regurgitation. Cardiac MRI showed a 21mm x 9mm well defined, pedunculated, mobile mass in the left atrium arising from inter-atrial septum. The mass was hyperintense on T2 weighted images with patchy delayed hyper-enhancement consistent with recurrence of a myxoma. The patient underwent a repeat median sternotomy with the removal of left atrial mass and repair of atrial septum with hemashield patch. The mass was sent for pathological evaluation confirming the diagnosis of recurrent myxoma. On genetic testing, patient tested negative for mutations in PRKAR1A gene (mutated in up to 60%-80% cases with Carney complex), MEN1, RET and sarcoma (TP53) genes. Cardiac myxomas are rare primary benign tumors of the heart with a small recurrence rate. Follow-up studies have rarely reported recurrences after complete resection. However, in our case not only did the patient have the sporadic form of myxoma with recurrence, but it also occurred within three years of the previous resection despite complete removal with clear margins. Cardiac myxomas are the most common primary benign tumors of the heart. The World Health Organization (WHO) defines a cardiac myxoma as a neoplasm composed of stellate to plump, cytologically bland mesenchymal cells set in a myxoid stroma. They usually arise in the atrial chambers with a greater predisposition for left atrial chamber than the right. Although these tumors are benign, they can lead to complications such as mitral valve obstruction or systemic embolism. As a result, they are often removed surgically.Sporadic cases have a very low recurrence rate of 1%-3 %, whereas patients with familial forms and complex forms have higher recurrence ranging from 12%-22% [A 39-year-old woman presented with a chief complaint of generalized fatigue. She denied any fevers, weight loss, chest pain, and shortness of breath, orthopnea, edema, syncope or light-headedness. She had a history of left atrial myoma that was resected three years ago. The myxoma was diagnosed after she presented with acute hypoxic respiratory failure secondary to acute pulmonary edema. She was found to have a 7.0 cm x 2.5 cm left atrial myxoma connected to the interatrial septum on echocardiogram as seen in Figure There was severe functional mitral valve stenosis due to the prolapse of the left atrial mass through the mitral valve during diastole as seen in Figure The biopsy was consistent with a myxoma with clear margins. Patient’s past medical history was also significant for Ewing’s sarcoma, pelvic sarcoma and parathyroid adenomas. There was no family history for myxomas or other endocrinological tumors.On examination, patient had normal heart rate with regular rhythm. No murmurs were appreciated. No signs of congestive heart failure were noted. An echocardiogram revealed a mobile structure in the left atrium attached to the inter-atrial septum. Further evaluation by cardiac MRI showed a 2.1 cm x 0.9 cm well defined, pedunculated, mobile mass in the left atrium arising from inter-atrial septum. The mass was hyperintense on T2-weighted imaging. The mass demonstrated patchy delayed gadolinium enhancement on postcontrast images. Based on location and MRI characteristics the most likely diagnosis was the recurrence of myxoma Figures , 4The patient had a repeat median sternotomy with removal of left atrial mass and repair of atrial septum with hemashield patch. The mass was sent for pathological evaluation, which showed soft tissue with myxoid changes along with chronic inflammation and hemosiderin, confirming the diagnosis of recurrent myoma Figures , 6. No oOn follow-up, the patient was asymptomatic and in sinus rhythm. Given her history of recurrent myxomas and multiple endocrinological tumors, she was referred for genetic testing, which was negative for PRKAR1A gene, which is mutated in up to 60%-80% cases with Carney complex. She also tested negative for germline susceptibility to endocrine disorders including MEN1, RET and sarcoma (TP53) genes. As no clear cut guidelines are available regarding follow-up in such cases, the plan was to obtain at least an annual transthoracic echocardiogram to evaluate for recurrence of the tumor.Cardiac myxomas are benign tumors of the heart that most commonly arise from the left atrial chamber. Although the recurrence rates are extremely low in the general population, the rate is significantly higher in patients with familial forms and complex syndromes.One such complex syndrome is Carney complex, a rare familial syndrome associated with recurrent atrial myxomas along with endocrine and non -endocrine tumors, abnormal skin pigmentation and schwannomas . Althoug1. Incomplete resection leading to a regrowth.2. Familial predisposition for recurrence.3. Implantation of embolic fragments of the original tumor in the myocardium spontaneously or due to a previous surgery.4. Recurrence occurring from a pretumor focus present in another part of the myocardium. 5. Malignant transformation of myxoma.Atrial myxoma can present with a wide variety of presentations depending on location, mobility and tumor size. The symptoms also vary depending from being asymptomatic to constitutional symptoms including anemia, fever, cough, weight loss and headache, to embolization and hemodynamic consequences. The constitutional symptoms are linked to inflammatory markers produced by the body as well as the tumor itself including IL-6 ,6. The mAtrial myxomas are usually diagnosed on transthoracic echocardiography (TTE), which provides information regarding structure, location and hemodynamics in case of myxomas. TTE may be followed by trans-esophageal echocardiography and cardiac MRI in cases where the TTE evaluation is limited by poor diagnostic windows and poor characterization of the mass.The treatment of choice for myxomas remains surgical excision since the report of the first resection by Swedish cardiac surgeon Clarence Crafoord and his team in 1954 . AlthougEven though myxomas seldom recur after complete removal as described earlier, most recurrences are seen in the first 10 years.Our patient presented with atrial myxoma for the first time at the age of 36 years. The mean age reported is between 42-66 years. Younger cases are usually seen in familial forms. However, in our case not only did the patient have sporadic form of myxoma with recurrence, but it also occurred within three years of previous event despite complete surgical resection.Atrial myxomas are the most common tumors arising in the heart. Although benign, they can lead to a wide variety of symptoms including embolization and heart failure. As a result, they are usually removed by surgical resection. Although rare, recurrences can be seen in familial cases.


Gallstone ileus is a dramatic complication of gallstone disease, uncommon but not exceptional in a busy emergency department. It represents a cause of mechanical intestinal obstruction, which predominantly occurs in elderly and frail patients; this contributes to the high morbidity and mortality rates associated with this condition. The modern radiologist is frequently asked to determine the cause of bowel obstruction and should be aware of the most pictorial features of this unusual disease. Broadly speaking, abdominal radiography and ultrasonography alone are limited in detecting the cause of bowel obstruction, but the sensitivity for the preoperative diagnosis of gallstone ileus may be improved by combining the findings obtained by both techniques. Computed tomography is the modality of choice for the diagnosis of this disease: it may accurately describe the number, size, and location of migrated gallstones and the exact site of bowel obstruction, providing a detailed preoperative planning. Magnetic resonance imaging may be used in selected cases for an exquisite anatomic definition of the fistulous communication. Firstly described in 1654 by Erasmus Bartholin, Danish physician and mathematician, gallstone ileus (GI) is an infrequent but dramatic complication of cholelithiasis; it constitutes an uncommon cause of mechanical bowel obstruction, but not exceptional in a busy emergency department. Despite medical advances over the last 350 years, it still represents a diagnostic and therapeutic dilemma, with a high mortality rate since it predominantly occurs in elderly, debilitated, and multimorbid patients. It follows that a prompt diagnosis is mandatory to avoid complications and allow an accurate preoperative planning. In the last two decades, some advances in the radiologic diagnosis of this condition by sonography, abdominal radiography, computed tomography, and sporadically magnetic resonance have been reported, offering new insights into this unusual entity.GI represents a cause of mechanical intestinal obstruction resulting from gallstone migration and subsequent impaction into the bowel lumen. It is unusual among the causes of mechanical bowel obstruction accounting for 0.4–5% of cases , with a GI usually occurs in debilitated patients with multiple comorbidities who had suffered from past episodes of calculous cholecystitis; elderly women are more frequently affected, with a female-to-male ratio of 6 : 1  up to 16The most common underlying cause of GI is represented by the presence of a biliary-enteric fistula (BEF). Cholecystoduodenal fistulas are the most frequent due to the proximity of the gallbladder to the duodenum, seen in 32.5–96.5% of cases ; cholecyGI onset is generally preceded by many episodes of silent or symptomatic biliary disease: recurrent and chronic inflammation of the gallbladder and surrounding tissues leads to adhesion formation, pressure necrosis, and wall erosion, with subsequent cholecystoenteric fistulation and gallstone migration.The gallstone must be greater than 2–2.5 cm to cause bowel obstruction in the absence of a digestive pathology which can determine stenosis. Indeed, many smaller calculi may pass spontaneously through a normal gastrointestinal tract and may be excreted uneventfully in the stool . The usuFrom a clinical point of view, a large part of the patients will have a well-known history of prior acute cholecystitis or biliary symptoms. Most of the BEF are clinically silent. GI takes an insidious course: the presentation is typically nonspecific, with usually intermittent obstructive symptoms as the stone progresses aborally through the bowel, including nausea, vomiting, vague abdominal pain, and distension . This inBouveret's syndrome is a rare variant, seen in 1–3% of cases of GI : a gallsManagement of GI is controversial because of patient age and multiple comorbidities. Whilst open surgery has been the cornerstone of treatment, other approaches have been more recently employed, including endoscopy, laparoscopic surgery, and lithotripsy , althougAmong the surgical options, enterotomy with stone extraction alone appears to be more suitable: it is less invasive, with a low rate of complications . In addiHere, we provide a comprehensive description of imaging findings in gallstone ileus, detailing possible pitfalls and pathognomonic relevance of the most pictorial features.Plain abdominal radiography (XR) is routinely performed in emergency settings as a first-line imaging approach for investigating bowel obstruction; for decades, it had maintained the gold standard role in the diagnosis of GI.The classic and pathognomonic imaging finding in GI consists in the association of air in the biliary tree (pneumobilia), ectopic radio-opaque stone, and small bowel obstruction (SBO), named after the radiology pioneer Leo Rigler as “Rigler's triad.” Originally described for abdominal XR, the modern radiologist is more likely to encounter its CT counterpart  Figure . HoweverAt abdominal XR, the outstanding feature of SBO is distended small bowel ansae proximal to the site of obstruction with decompressed distal bowel; upright or left lateral decubitus films demonstrate multiple air-fluid levels. In proximal occlusions, as in the case of Bouveret's syndrome, the stomach may be dilated as well. Paucity of small-bowel gas, or “the gasless abdomen,” is another possible radiological presentation, due to fluid-filled dilated intestinal loops rather than endoluminal gas; this finding is more commonly seen in the supine radiograph, whereas the upright acquisition may demonstrate the “string of beads” sign, produced by small air bubbles entrapped in the intestinal folds between valvulae conniventes. The absence of small-bowel gas in the setting of SBO usually indicates a high-grade occlusion .A wide range of sensitivity is reported in the literature for the diagnosis of GI on abdominal films. In a series of 27 patients with surgically confirmed GI , Rigler'In another series , the autOf course, the radiologist evaluating an abdominal XR should always be aware of any change in gallstone position when compared to previous imaging studies, suggesting, in the absence of previous surgery, stone migration to anomalous sites.The presence of an air collection in the gallbladder is another finding suggestive for GI, firstly reported by Balthazar and colleagues  who idenHowever, it should be borne in mind that pneumobilia may result from prior surgical or endoscopic biliary manipulation, and therefore, the clinical picture should be taken into consideration when evaluating this radiographic sign in order to avoid misdiagnosis .In 64 reported cases of Bouveret's syndrome , the mosAbdominal XRs are limited in detecting the cause of bowel mechanical obstruction, since most gallstones are not sufficiently opaque to be depicted. Abdominal ultrasonography (US), on the other hand, is the imaging method of choice for diagnosing gallstone disease , due to We do not routinely perform abdominal US in an adult patient suspected of having SBO, but in many institutions, the increased use of ultrasounds in the initial assessment of patients with abdominal pain has made point-of-care US relevant also to the diagnosis and characterisation of SBO .A varying association of GI sonographic imaging findings has been described in the literature, including pneumobilia or air in the gallbladder fossa, detection of aberrantly located gallstone, bowel loop distension and wall swelling, and peritoneal fluid .Pneumobilia is excellently detected at US, with greater sensitivity than XR : reflectIn a series of 23 patients , the autWith a sensitivity of 90–93%, specificity of 100%, and accuracy of 99% , computeThe most common signs associated with GI were previously defined by Yu et al.  and inclWhen a bowel obstruction is suspected, the standard protocol for CT scanning provides the use of intravenous (IV) contrast material with a portal venous phase acquisition . IV contEven nonenhanced CT acquisition may be valuable in case of patients with a known history of contrast allergy or with renal impairment, leading in some cases to a better detection of ectopic rim-calcified gallstones which would be missed as part of bowel wall or alimentary content , or to bMoreover, even if sometimes the detection of gallstones may be difficult depending on their composition, CT scan with multiplanar reformatted images can exactly locate the migration site of the ectopic stones , establiThe correct evaluation of gallstone size is relevant too, since also those smaller than 2 cm may be dangerous as they may become larger by accretion while descending the intestinal canal and thus produce reflex spasm or volvulus .Nonetheless, the accurate definition of the size of the gallstone lodged in the bowel lumen could sometimes be challenging, due to various components of the gallstone itself with different densities. In their work, Gan and colleagues  defined Even if abdominal XR may demonstrate diagnostic features of GI, namely, Rigler's triad, CT is more accurate in detecting such pathognomonic association of findings , 9 Figu.The use of hyperattenuating oral contrast agent is finalized to better visualize the anatomy of the bowel. In the case of GI, it may help to detect the fistulous path extending between the gallbladder and the gastrointestinal tract, visualized as contrast accumulation within the gallbladder , 23 Fig.However, many institutions have omitted the routine administration of high-attenuation oral contrast media in SBO investigation for several reasons: patients are frequently nauseated and may vomit, with a risk of aspiration; the bowel just proximal to the transition point could be rarely opacified in case of a high-grade obstruction; and the low-attenuation content (fluid and gas) within the bowel lumen usually provides excellent contrast with the wall, which may be obscured on the contrary by high-attenuation oral contrast material . FurtherWith respect to Bouveret's syndrome, reviewing 40 CT studies of this rare GI variant, Cappell and Davis  found thPossible mimicker of gallstone ileus on CT imaging is represented by a small group of other nonstrangulating cause of bowel obstruction; among them is worth mentioning that primary enterolith of the upper GI tract, highly attenuating bezoars or other foreign body, may closely resemble the CT appearance of a migrated stone. Primary enterolithiasis is an uncommon cause of small bowel obstruction. It is generally accepted that the production of enteroliths is favoured by states of intestinal dysmotility, especially in cases of duodenal or jejunal diverticulosis. Mostly composed of choleic acid and other bile metabolism products, these stones tend to have similar CT features of gallstone, being usually calcified and round-shaped . AbsenceMagnetic resonance cholangiopancreatography (MRCP) represents the imaging modality of choice in investigating biliary tree pathologies since it provides fine anatomical details, allowing the detection of small calculi and clarifying the differential diagnosis with other biliary conditions. Despite its high sensitivity, MRCP is not routinely performed in acutely ill patients most of all because of longer time of acquisition and insufficient panoramicity. This technique has a sensitivity of 97.7% for gallstone detection, higher than abdominal XR (40–70%), CT scan (90–93%), and even than US (95%), especially in cases of isoattenuating and radiolucent stones that can be missed at abdominal XR and CT, or even in cases of very small ones (<3 mm) , 26.MRCP application in GI diagnosis and characterisation is almost anecdotal in the literature. This technique may arguably be useful in selected cases of GI with the potential to further improve diagnostic yield for noncalcified calculi due to the excellent discrimination of fluid from gallstones, the latter appearing on T2 weighted images as signal voids in the context of the high-signal fluid. Moreover, if sufficient fluid is present in a collapsed cholecystoenteric fistulous tract, it may be delineated on MR images  concludeFurthermore, MRCP together with CT may play a potential role in the management of chronic stones inside the gallbladder, helping in estimating the tendency to fistulation towards the bowel : gallstoAbdominal XR and US are first-level imaging modalities widely performed in the emergency setting to investigate patients with acute abdomen but are quite insensitive in the diagnosis of GI. Nowadays, CT is the imaging modality of choice for this disease, as well as in identifying alternative causes for patient symptoms: it provides a detailed description of the multiplicity, precise size, and location of the migrated gallstones, thus guiding the surgeon towards an accurate preoperative planning to prevent complications like recurrence due to unseen additional calculi remaining in the proximal bowel. In selected cases, MRI might be used as a potential adjunct in precisely defining the fistula anatomy.


Background: Dysphagia is a condition that can have many underlying causes, often different between adults and children and its early diagnosis is crucial especially during childhood and adolescence, given the importance of proper nutritional intake to ensure adequate growth and development. Case report: We described the case of a 17-year-old girl reporting dysphagia for solids for approximately one month. No symptoms were previously referred. Oesophagogastroduodenoscopy was performed, detecting an image of ab extrinseco compression at the level of the mid-cervical oesophagus. An upper gastrointestinal tract radiography confirmed an oesophageal impression above the arch of the aorta suggestive of vascular abnormality. Computed tomography angiography and three-dimensional reconstruction techniques showed the presence of a lusoria artery that originated from the medial margin of the descending aorta and crossed the trachea and oesophagus posteriorly to the distal third. The lusoria artery was transected via a left thoracotomy and re-implanted into the right common carotid artery with complete symptom resolution. Conclusions: Dysphagia lusoria is an impairment of swallowing due to compression from an aberrant right subclavian artery. The diagnosis is always difficult, as the symptoms are often nonspecific. It is imperative to accurately identify and properly manage dysphagia in pediatric age and this is only possible with an anamnestic, clinical and instrumental process that takes into account an adequate differential diagnosis. Dysphagia is defined as any disruption to the swallow sequence that results in the compromise of the safety, efficacy or adequacy of nutritional intake . The resThe assessment of a child or adolescent presenting symptoms related to a swallow dysfunction primarily consists of an effective medical history and objective examination and continues with a series of investigations including the clinical feeding evaluation, the video fluoroscopic swallow study, upper gastrointestinal radiological series and endoscopic evaluations . In terms of treatment, the pediatric patient with dysphagia benefits from a specialized multidisciplinary approach that includes pediatricians, neurologists, otolaryngologists, pulmonologists, gastroenterologists, dietitians, occupational therapists and speech-language pathologists . A surgiHelicobacter pylori infection was also reported.A 17-year-old girl was admitted to the Pediatric Clinic of our Children’s Hospital for the appearance of sudden dysphagia for solids for about a month. No symptoms were previously referred. In previous medical history, only allergy to dust mites and sideropenic anemia in supplementary therapy with iron was reported. Thyroid ultrasound as well as screening for celiac disease and thyroid function were performed with normal results. Positivity for Upon arrival, the girl was in good general condition. In the physical examination, normal chest and abdominal objectivity was found. Due to the difficulty in eating, she was on a diet of blended and homogenized foods. The haematochemical tests confirmed sideropenic anemia , probably due to a menorrhagia reported in the previous three months.H. pylori on biopsies was negative.According to the symptomatology, an oesophagogastroduodenoscopy was performed, detecting an image from ab extrinsic compression at the level of the middle-cervical oesophagus, apparently pulsating A. At theBased on the findings of the endoscopic examination, an upper gastrointestinal tract radiography was initially performed, confirming an oesophageal impression above the arch of the aorta B. SubseqFollowing a multidisciplinary evaluation, in view of the worsening symptomatology, the patient was transferred to cardiac surgery to assess the possibility of a surgical approach. After a surgical evaluation, a reimplantation of the right carotid subclavian artery was first performed. Imaging tests  performed in the following days showed an oesophageal compression of the arterial stump. A second operation was then performed with a subclavian lusoria artery stump section. The surgery was well tolerated. In the immediate post-operative period, a rapidly resolved Claude Bernard Horner syndrome of the right eye was reported. The patient resumed gradual feeding and was discharged after a month in good general condition. After two further months, she was currently asymptomatic and reported no dysphagia.Although digestive disorders are the most common causes of dysphagia, there are other less frequent diseases that must be excluded from the diagnostic process. This group includes disorders caused by vascular compression of the oesophagus on the mediastinum.Dysphagia lusoria is defined as a swallowing disorder secondary to the extrinsic compression of the oesophagus by vascular structures. Abnormalities of any mediastinal vessel can potentially cause this pathology, but the most common one described in the literature is represented by an aberrant right subclavian artery (ARSA). This is related to the fact that it is the most common congenital alteration of the aortic arch . The most frequent point of origin of lusoria artery is the so-called “Kommerell’s diverticulum”, an aortic diverticulum. Normally, during the embryonic development a double aortic system develops which requires the subsequent obliteration of different components to ensure normal vascular anatomy. If for some reason this process is incomplete or inadequate, it will produce one of the alterations of the large vessels. Among the many classification systems, the most common one divides them into five main groups : (1) a dARSA has an estimated prevalence of 0.4%–2% in the general population and in most cases is asymptomatic. Children may present with recurrent lung infections or stridor while adults more often present with dysphagia lusoria . The lusWith regard to treatment, in moderate cases, lifestyle changes and education on eating behavior can substantially improve the clinical condition of the patient. The surgical approach does not yet have clear indications and its use remains controversial: it depends on the anatomical relief, urgency and experience of the surgeon himself . There aThe diagnosis of dysphagia lusoria is complex because the symptoms are often non-specific; at the same time the oesophagogastroduodenoscopy is negative in 50% of cases . AlthougIt is imperative to accurately identify and properly manage dysphagia in pediatric age, even more readily than in adults because children and adolescents are subject to a rapid development of the body and even minor swallowing alterations could interrupt growth and cause long-term sequelae. This is only possible with an anamnestic, clinical and instrumental process that takes into account an adequate differential diagnosis.


Giant multilocular prostatic cystadenoma (GMPC) is a rare type of prostatic epithelial neoplasm. Thus, the imaging features of this condition are not well known. We report the imaging and clinical manifestations of a case of GMPC.The case reported here relates to a 71-year-old man who complained of urination frequency and excessive urination at night. He underwent computed tomography (CT) and magnetic resonance imaging (MRI) examination before surgery, both tests revealed a mass body in the prostate.Ultrasound-guided fine needle aspiration was performed and a diagnosis of GMPC was made by histological examination.The patient received radical pelvic tumor resection successfully.Two months after surgery, the follow-up CT and magnetic MRI re-examination found no signs of recurrence.GMPC is a rare prostatic neoplasm with atypical clinical symptoms. MRI provides valuable information about GMPC. In case of a giant multilocular prostatic mass with well-defined boundary and abundant vascularity, benign feature on diffusion-weighted imaging, GMPC should be considered. Since then, less than 40 cases have been reported. Imaging examination especially by magnetic resonance imaging (MRI) can reveal not only the components of the tumor but also the condition of adjacent organs. This provides valuable information for accurate diagnosis and differential diagnosis of GMPC. We herein report the imaging, clinical, and histologic findings of a case of GMPC and provide a review of literature on this condition.Giant multilocular prostatic cystadenoma (GMPC) is a rare benign tumor arising from the prostate gland. The tumor commonly presents as a locular cyst-solid mass in the pelvic. It was first reported by Watanabe et al22.1This study was approved by the investigational review board of affiliated hospital of Chinese medicine. Informed written consent was obtained from the patient for publication of this case report and accompanying images.2.2A 71-year-old man presented with a 3-month history of urination frequency and excessive urination at night. He reported no history of hematuria, fever, or pain. Digital rectal examination showed an enlarged prostate with disappeared central sulcus, no obvious nodules were seen, the boundary of the prostate was unclear. Laboratory tests revealed many abnormal findings. Serum total prostate-specific antigen (TPSA) was 47 ng/mL ; free prostate-specific antigen (FPSA) was 3.96 ng/mL (0–2.5 ng/mL); creatinine was 120. 2 μmol/L (44–110 μmol/L). A urine test showed positive urine protein.2.3A large multilocular cystic-solid mass was observed in the pelvic cavity with a partially ill-defined border in nonenhanced computed tomography (CT) image Fig. . The tumThe tumor manifested heterogeneous signal intensity (SI) on T1-weighted imaging (T1WI) and T2-weighted imaging (T2WI). Most areas of the tumor were isointense with surrounding muscles on T1WI with patchy high SI areas Fig. . The str2.4Fine needle biopsy was performed under ultrasound guidance, which found no obvious evidence of malignancy. The patient underwent radical pelvic tumor resection. A cystic-solid mass was identified in the right pelvic floor, and prostate and seminal vesicle adhered to each other. Examination of the specimen revealed a 12 cm × 9 cm × 6.5 cm gray-red mass. The surface was covered with an incomplete capsule. The cut surface appeared gray-white, and various sized cysts were filled with brown or milky liquid. Some areas were honeycomb-shaped. Histologically, adenoid and cystic structures in a fibrous stroma were seen in the tumor. Immunohistochemical examination showed that epithelial cells of the neoplasm were positive for prostate-specific antigen (PSA), NKX3.1 and prostate acid phosphatase (PSAP); basal cells were positive for P63 and high molecular weight cytokeratin; stromal cells were positive for CD34, smooth muscle antibody, Desmin, estrogen receptor, and prolactin receptor. Collectively, these led to the diagnosis of multilocular prostate cystadenoma.TPSA and FPSA were normal  after 2 months of surgery. CT and MRI re-examination found no signs of recurrence.3–15 In this condition, the tumor always originates from the prostate and extends to the space between the rectum and bladder, sometimes it may attach to the prostate with pedicle or even be completely separated from it. The tumor boundary is usually clear without invasion to the adjacent tissues and organs. This disease may appear at any age, but it is more commonly seen in 35 to 65 years old. It often manifests as lower abdominal masses or progressive dysuria, sometimes present with frequent urination. Radical excision is recommended for this condition. Patients will have an excellent prognosis and recurrence is rare if the tumor is totally removed.GMPC is a rare benign neoplasm of prostatic origin. It is characterized by significantly enlarged prostatic cystadenoma, most of them are larger than 10 cm in size (about 68% in the literature). Occasionally, constipation caused by mechanical compression of the rectum can be seen. These manifestations are suggestive of a lower urinary tract disease but not specific, similar to the features of prostate hyperplasia. Elevated serum PSA is commonly seen in most patients. It may be caused by the rupture of some prostate glands in the enlarged cyst, leading to the release of PSA into the blood. Histologically, GMPC is typically composed of hyperplastic prostate glands and multiple cysts. The cysts are lined with stratified columnar and cuboidal cells. This case is consistent with previous reports.,7,9 No atypical cell proliferation or mitosis was recognized. Immunohistochemical analysis showed the tumor cells were positive for PSA and PSAP staining, indicating a prostatic origin.Most of the clinical symptoms arise from localized effects of the mass, including palpable abdomen mass, oliguria, intermittent urination, and acute urinary retention. GMPC is often characterized with multilocular masses in the pelvis. The septa in the cyst are often irregularly thickened. The tumor is mostly located between the rectum and bladder, whereas larger masses may extend beyond the pelvic cavity. The cysts display varied densities because of hemorrhage or mucin components. The relationship of tumor with adjacent organs may be revealed by contrast-enhanced CT scan. However, CT alone is not effective in making an accurate diagnosis. Due to its excellent soft tissue resolution, MRI may provide more information,7,10 on the broader and compositions of the tumor. The surrounding tissue invaded or compressed by the tumor can be seen clearly in multiple MR sequences. Hemorrhage and mucin in cysts are easily seen in T1-weighted and T2-weighted images. Furthermore, the DWI reflects the cellularity and risk degree of the tumor. In our case, slightly higher SI on DWI and ADC maps suggested the benign nature of this tumor. Dynamic contrast-enhanced MRI (DCE-MRI) can also reflect the blood supply and boundary of tumors clearer than CT. Solid part of the tumor showed persistent enhancement on DCE-MRI, indicating the state of fibrous tissue of the tumor. Local invasion and lymph node involvement were not observed.Preoperative imaging examination provides valuable tumor information. Due to the large size of GMPC, it is difficult to determine the origin of this retroperitoneal tumor by ultrasound. However, CT or MRI might reveal components of the tumor and its relationship with adjacent organs, which is crucial for the optimal determination of surgical procedure. They are often smaller than GMPC, with a diameter of less than 10 cm. They are easily recognized by their unilocular shape and nonenhancement of the cyst wall. The prostatic abscess is caused by prostate infection, the clinical symptoms of such cysts are always noticeable. On DWI, the SI indicates diffusion restriction in the abscess, which is different from appearance of GMPC. MRI can also be used to discriminate malignancies such as sarcoma and cystadenocarcinoma. These malignancies may present multiple cystic mass but more solid component than GMPC, markedly high SI on DWI and low SI on ADC are important for differential diagnosis. When fat, teeth, bones, or hair are present in a mass, the diagnosis of teratoma is easy because there may be fat, teeth, bones, or hair components in the mass, which is easily identified by imaging.Differential diagnosis includes various cystic lesions arising from retroperitoneal space and pelvic cavity, such as prostatic cyst, prostatic abscess, prostate sarcoma, prostate cystadenocarcinoma, müllerian duct cysts, and cystic teratoma, and lymphangioma. Prostatic cyst and müllerian duct cysts are commonly asymptomatic and are often occasionally found during routine physical examination.Although the final diagnosis of GMPC is made by histopathologic examination, imaging modalities especially MRI may also provide valuable information. In case of a giant multilocular prostatic mass with well-defined boundary and abundant vascularity, a benign feature on DWI, a differential diagnosis of GMPC should be considered.Data curation: Jingya Chen. Zhengjun Li, Jian Zhang.Investigation: Hu Chen, Huiming WU. Yajing Wang.Methodology: Wei Zhang, Zhongqiu Wang.


Staphylococcus aureus is a causative pathogen of infective endocarditis, and it rarely causes pancarditis in healthy children. The clinical decision for surgical intervention of left-sided heart vegetation is challenging despite the availability of management guidelines.Infective endocarditis is more prevalent among children with congenital heart diseases as compared to healthy children. Community-acquired methicillin-resistant Staphylococcus aureus infection, with left-sided vegetation, mitral valve regurgitation, pancarditis, brain abscess, and stroke. She underwent an emergency vegetectomy and mitral valve repair. Three weeks after the first surgery, she developed left ventricular pseudoaneurysm that required life-saving surgical intervention. The child gradually recovered and was discharged home with acceptable cardiac function and mild neurological deficit.We report a case of a previously healthy 12-year-old girl who presented with aggressive endocarditis secondary to community-acquired methicillin-resistant Pancarditis, especially with an aggressive progression resulting in intracardiac pseudoaneurysm, is rarely reported in healthy children. The definition of the optimal timing of surgical intervention in pediatric infective endocarditis management is lacking and the clinical decision-making process remains challenging. The development of left ventricular pseudoaneurysm is serious and also needs an immediate intervention, given the high risk of its rupture and subsequent devastating outcomes.Staphylococcus aureus is an etiology for aggressive infective pancarditis in a healthy child, leading to an intracardiac pseudoaneurysm. Emergency surgical interventions should be considered in children with left-sided vegetation to prevent devastating consequences.Community-acquired methicillin-resistant  Reports suggest that the incidence of community-acquired methicillin-resistant S. aureus (CA-MRSA) is increasing among healthy children [Pediatric infective endocarditis (IE) is a life-threatening infection that usually affects children with pre-existing cardiac conditions. Its incidence in children with a normal heart structure is 8–35.4% ,2. The mCardiac complications associated with IE and pancarditis can be intra-cardiac  or extra-cardiac  ,3,6. DesWe report about a 12-year-old girl presenting with complicated CA-MRSA-pancarditis to a tertiary government hospital. Despite controlling the infection, she developed few complications that necessitated an emergent lifesaving surgery (within 24 h) to achieve acceptable cardiac and neurological recovery. The work herein has been reported in line with the SCARE criteria.21 [2A 12-year-old girl, with no predisposing medical conditions, initially presented to a local health care service with a three-day history of fever, headache, vomiting, and altered mental status. As meningoencephalitis was suspected, she was first treated with intravenous ceftriaxone and acyclovir for seven days then along with vancomycin for three days. While the fever initially subsided for two days, her condition subsequently deteriorated with more lethargy, headache, high-grade fever, vomiting, diarrhea, abdominal pain, and dark yellow urine. Brain computed tomography (CT) scan revealed multiple scattered small brain abscesses. Thus, she was transferred to our hospital, a tertiary governmental hospital, by ambulance for further management. Other medical and surgical histories were unremarkable, and the family members had a fair psychosocial status with no cardiac diseases.2) of 39.5 °C, 105/70 mm Hg, 130–150 beats/min, 30 breaths/min, and 95–100%, respectively. Physical examination revealed an ill-appearing, hypoactive child with pallor and small erythematous macules on the palms and soles that were consistent with the Janeway lesions. She had mild respiratory distress and cold extremities associated with muffled heart sounds on chest auscultation. She also had generalized abdominal tenderness and hepatomegaly. Neurological examination was initially unremarkable except for lethargy.Her vital signs at presentation included a body temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation at room air  and gentamicin (5 mg/kg/day). She was stable, but had signs of mild heart failure. Chest radiography revealed significant cardiomegaly with bilateral pleural effusion, while trans-thoracic echocardiography (TTE) revealed two vegetations in the left ventricle (LV): one was attached to the anterior mitral valve (MV) leaflet with significant MV regurgitation and the other was an elongated mass attached to the MV chordae, without any other vegetation in the aortic valve or the right side of the heart . Serial Follow up TTE were performed in the next three weeks which revealed a progressive localized dilatation in the LV at the posterior MV attachment site, consistent with an LV pseudoaneurysm . In late3S. aureus-infected children in Riyadh (Saudi Arabia) is 23.2% [The incidence of MRSA among is 23.2% , which iis 23.2% . CA-MRSAis 23.2% ,5,15. Ouis 23.2% ,9,16. InVarious specific indications for surgical intervention are described in different IE management guidelines without clear timing in all of the guidelines ,7,17. Th4We recommend immediate surgical intervention in children with pancarditis that involves left-sided vegetation, once indicated, and a close follow-up using serial echocardiography to detect complications early. Early surgical intervention of LV pseudoaneurysm is strongly favored, given the risk of a devastating outcome if lifted without intervention.No conflict of interest.No founding or grants provided for this case report publication.Not applicable.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Nada Aljassim: First author and corresponding author. Responsible for initiation of reporting, writing editing the manuscript and literature review.Nabil Almashraki: Patient course and data collection, literature review.Mohamed Tageldein: cardiac surgeon contributed in operation details and patients course, literature & manuscript review.Omer Tamimi: pediatric cardiologist shared patient’ s echo images,literature & manuscript review.Mohamed S. Kabbani: literature & manuscript review.Jihad Zahraa: literature & manuscript review.Mohammed Alshehri: review of infectious disease literature & manuscript review.Not applicable.I am fully responsible for the work and have access to the data, and controlled the decision to publish.Dr. Nada AljassimCorresponding authorNot commissioned, externally peer-reviewed.


Dedifferentiated liposarcomas (DDLPS) are rare, high-grade malignancies that usually originate in the retroperitoneum. Frequently, they present as asymptomatic masses, abdominal distention, abdominal pain, and weight loss. They tend to grow significantly and are usually large in size at the time of diagnosis. Surgical resection is the mainstay of treatment; however, local recurrence is common. When unresectable, they can invade local structures and produce a significant mass effect on the adjacent organs. Here we present the first case of malignant gastric outlet obstruction (MGOO) and acute pancreatitis from a retroperitoneal DDLPS. Soft tissue sarcomas are rare and heterogeneous group of connective tissue tumors. They originate from mesenchymal tissue and subdivide into more than a dozen subtypes; the most frequent subtypes are leiomyosarcoma and liposarcoma . LiposarRetroperitoneal liposarcomas are challenging to treat. Surgery continues to be the only potentially curative approach, but success rates are limited. Locoregional recurrence of retroperitoneal sarcomas is the major, problematic aspect of the disease’s management. Large tumor size at diagnosis is associated with an increased risk of recurrence and death ,2. We reA 43-year-old male with a known history of retroperitoneal DDLPS presented to the emergency department complaining of upper abdominal pain with band-like radiation to the back. Associated, he had multiple episodes of vomiting for one day. On physical exam, he was found to have diffuse abdominal tenderness and distention. The patient had undergone exploratory laparoscopy for tumor resection, and right radical nephrectomy for stage IV retroperitoneal dedifferentiated liposarcoma one year before the presentation. The resected mass was 20 cm in size. The surgical and pathologic margins of the resected specimen were negative at that time. The microscopic findings revealed a spindle mass with fibrous stroma consistent with a Grade 3 dedifferentiated liposarcoma Figure . After sOn admission, a CT scan of the abdomen revealed enlargement of the previously noted masses. The tumor was reported to be 17 cm in size (identified by yellow arrows), extending into the duodenal lumen, causing a duodenal obstruction Figure . The CT Subsequent esophagogastroduodenoscopy demonstrated a large polypoid mass in the second portion of the duodenum, completely obstructing the duodenal lumen Figure . A 22 mmRetroperitoneal sarcomas are rare tumors with an overall incidence of 0.3-0.4 per 100,000 population . At the Malignant gastric outlet obstruction (MGOO) is commonly seen in patients with pancreatobiliary and gastric cancers ,7 but isOther reported complications of retroperitoneal liposarcoma include lumbar or pelvic nerve plexus compression, non-malignant serous ascites, and very rarely, paraneoplastic syndromes  . Management of DDLPS is typically radical surgical resection with pre-operative chemoradiation for local control . RelativA retroperitoneal DDLPS presenting with MGOO and acute pancreatitis is rare, and to the best of our knowledge, has never been reported in the literature. Retroperitoneal DDLPS are highly invasive tumors with high recurrence rates. Thus, close follow-ups with imaging such as CT scans should be considered for monitoring of recurrent disease even after complete surgical excision.


Gossypiboma denotes a mass of cotton retained in the body following surgery. Migration of gossypiboma from initial site is a rare entity and could pose some diagnostic difficulties. Migration of gauze sponge has been reported to occur in several organs of the body. There have been few reported cases but the true incidence may be much higher due to under reporting for fear of litigation.We present an unusual case of a 58-year-old grand multiparous woman who had gauze retention for 5 years following a hysterectomy and presented with acute urinary symptoms. The gauze sponge transmigrated from the peritoneal cavity to the bladder and was partially extruded through the external urethral meatus. She had laparotomy for the removal of gauze sponge with good outcome.Retained foreign body especially surgical sponges (gossypiboma) infrequently occurs and can be a source of great concern to the surgeon and patient. Foreign bodies inside the body cavities and organs can present with several non-specific clinical features that can make diagnosis difficult. Migration of surgical sponge  into the urinary bladder is uncommon when compared to other abdominal and pelvic viscus. A gossypiboma in the peritoneal cavity creates a fistulous tract through the thick wall of the urinary bladder from long period of chronic inflammation as seen in the index case where the previous surgery was performed 5 years prior to onset of symptoms. Due to the non-specific presentations of gossypiboma, especially those in the bladder, several investigative modalities need to be employed to help make a prompt diagnosis. Most long-standing cases would require laparotomy due to the dense adhesions that occur around the site of the gossypiboma. Lack of appropriate diagnosis leaves the patient with recurrence of distressful symptoms and the consequent morbidities.Transmigration of a gauze sponge over 5 years from the peritoneal cavity into the urinary bladder and through the external urethral meatus following a hysterectomy is a rare occurrence and can present diagnostic difficulties. High index of suspicion, prompt diagnosis and management will help reduce the high morbidity that is associated with the condition as in the case reported. The term was derived from Gossypium (cotton in Latin) and bom . Migration of this gossypiboma from initial site is a rare entity and diagnosis could be difficult. Migration of the gauze sponge has been reported to occur in the duodenum, ileum, stomach, urinary bladder and lungs . The incWe present the case of a 58-year-old grand multiparous woman who had laparotomy with removal of gauze that has transmigrated from the peritoneal cavity to the bladder and partially extruded through the external urethral meatus. The SCARE criteria were strictly followed to produce this case report .2A case of 58-year-old grand multiparous, 3-years postmenopausal woman, who presented with a one-month history of moderate to severe lower abdominal pain of sudden onset, continuous, crushing in character, worse with urge to defecate and micturate, relieved by intake of analgesic and not related to position. However, there was no abdominal mass or swelling, no change in bowel habit and there was no preceding trauma. There was associated urinary frequency, urgency, urge incontinence, dysuria and occasional passage of purulent fluid and blood in urine but no fever. There was no history of bleeding per vaginam, post coital bleeding and vaginal discharge; no chronic cough, bone pain but weight loss. She had total abdominal hysterectomy 5 years prior to the onset of symptoms in a private hospital due to suspected endometrial hyperplasia. However, there was no evidence of histological analysis of the tissue removed.On examination, her vital signs were stable, there was no palpable abdominal mass. Examination of the urogenital system revealed a gauze partially extruded from the urethral meatus with purulent discharge as shown in Diagnosis of cystitis secondary to foreign body in the bladder complicated by fistulous formation was made. CT urography result revealed presence of foreign body in the bladder with pelvic abscess collection. Other investigations showed normal laboratory findings. She subsequently had exploratory laparotomy for gossypiboma by a joint team of gynaecologist, urologist and general surgeons. Intraoperative findings revealed: presence of gauze shown in She remained stable throughout the post-operative days and was discharged on the 13th day post operatively. She has been seen in the Gynaecology clinic on two occasions after surgery and still remained stable.3Retained foreign body especially surgical sponges (gossypiboma) infrequently occurs and can be a source of great concern to the surgeon and patient. These foreign bodies can present with several non-specific clinical features that can make diagnosis difficult ,5,6,8. MType 1: externally introduced by self for sexual gratification or as a result of psychiatric illnessType 2: (Iatrogenic): Foreign body left at the time of major bladder surgeryType 3 (Migratory): The foreign body usually migrates from areas/structures surrounding the bladder, commonly the uterus, rectum and vaginaOur patient had vesical migration of a gauze left in the peritoneal cavity after abdominal hysterectomy 5 years prior to onset of symptoms.Four stages of gossypiboma migration has been proposed following experimental animal studies . These aFor a gossypiboma in the peritoneal cavity to create a fistulous tract through the thick wall of the urinary bladder, there would be a long period of chronic inflammation ,13 as seDue to the non-specific presentations of gossypiboma, especially those in the bladder, several investigative modalities need to be employed to help make a prompt diagnosis. These diagnostic modalities may involve ultrasonography, cystoscopy, CT scan, X-Ray and laparoscopy . ProtrusGossypiboma in the urinary bladder although rare but can be prevented through appropriate documentation and recounting of all surgical sponges and instruments used during the surgery prior to closure of surgical sites/ cavities in the body.4Transmigration of a gauze sponge over 5 years from the peritoneal cavity into the urinary bladder and through the external urethral meatus following a hysterectomy is a rare occurrence. This condition can be associated with diagnostic difficulties. High index of suspicion, prompt diagnosis and management will help reduce the high morbidity that is associated with the condition as in the case presented.This is no conflict of interest to declare.There was no external funding received during the conduct of the research. The report was fully funded by the researchers.Ethical approval was obtained from Ethic and Research Committee of the Enugu State University of Science and Technology Teaching Hospital, Parklane. Enugu with reference number: ESUTHP/C-MAC/RN034Nol.1/224 and dated 16th December, 2019.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 contributions made by the authors are as summarised below:N/A.Enebe Joseph Tochukwu.Not commissioned, externally peer-reviewed.


Pigmented villonodular synovitis is a rare disease which may involve any joints. It has localized and diffuse forms, and the latter is more aggressive with a higher recurrence rate. Different treatments are applied to each form of the disease, but there is no standard surgical procedure or any consensus on whether adjuvant therapy should be used. Many factors may lead to recurrence of the disease; however, there is no reliable way to predict the recurrence.A 21-year-old female patient presented with a one-year history of progressive pain of the right knee.Pigmented villonodular synovitis.We performed an anterior approach arthroscopic synovectomy and a posterior approach open synovectomy in the popliteal fossa, but the patient declined to take radiotherapy as a post-surgical adjuvant therapy. Then, she received a repeat arthroscopic synovectomy 20 months later because of the recurrent lesions, and a radiotherapy was performed 6 weeks after the second surgery.There were no abnormal signs in the right knee on magnetic resonance imaging scanning 6 months after the second surgery. The range of motion of her right knee was normal.Pigmented villonodular synovitis is a rare disease which may involve any joints. Surgical resection plus adjuvant therapy is recommended for patients with risk factors of recurrence. However, Mrinal et al still attribute it to the locally aggressive connective tissue tumors, a family of lesions that usually involve the joint synovia, bursae, tendon sheath, and fibrous tissue adjacent to the tendon. PVNS presents as localized and diffuse forms based on the growth pattern and clinical behavior, the latter is more aggressive. While any location is possible, the localized forms mainly involve the digits and wrist, whereas the diffuse forms mainly involve large joints such as knee, hip, ankle, and elbow. Histopathological examination is accepted as the gold standard for the final diagnosis of PVNS.Pigmented villonodular synovitis (PVNS) and tenosynovial giant cell tumor are considered to be one disease because of identical histological and genetic features.,13 Arthroscopic synovectomy and open synovectomy are the most widely used approaches. A small number of cases were treated with total knee replacement.,15 Adjuvant therapy may be considered for patients who have a high risk of recurrence such as with diffuse PVNS.,17 Nevertheless, the disease still has a certain rate of recurrence.The standard treatment for PVNS is surgical excision.Here we report a case of recurrent diffuse intra-articular and extra-articular PVNS in an adult and we review the published literature to identify possible risk factors for recurrence of PVNS.29/L, neutrophil count was 5.27 × 109/L, lymphocyte count was 3.18 × 109/L, and the neutrophil-lymphocyte ratio was 1.66. Magnetic resonance imaging (MRI) revealed intra-articular long T1 and mixed T2 signals, and extra-articular long T1 and long T2 signals in the area of popliteal fossa  has shown some favorable results. Imatinib mesylate is another tyrosine kinase inhibitor that has activity against colony stimulating factor 1 receptor inhibitor, displaying some activities against PVNS in a recent report. Lalam et al applied radiofrequency ablation to treat localized PVNS and achieved certain effects. Nonsurgical treatment is more often used as postoperative adjuvant therapy to reduce recurrence.Many nonsurgical therapies have been tested, including tyrosine kinase inhibitors, radiofrequency ablation, Ottaviani et al recommended intra-articular radiotherapy after partial synovectomy for diffuse PVNS due to the difficulty in completely resecting of all lesions. Gouina et al proposed that adjuvant treatment is necessary after synovectomy for diffuse PVNS. Isotopic synoviorthesis or external radiotherapy may be considered after primary resection, and systemic treatment by targeted therapy or radiation therapy may be an option after synovectomy in cases of recurrence or rapid progression. After arthroscopic synovectomy and radiotherapy, few cases recurred. Adjuvant radiosynovectomy with Yttrium-90 has been used in many patients to reduce recurrence rates. On the other hand, Gortzak et al treated 56 PVNS patients with a mean follow-up of 7.3 years and found that there were no significant differences in the outcomes between the patients treated surgically with or without an adjuvant intra-articular injection of 90 Yttrium. Mazonakis et al found that knee irradiation may result in an inconsequential risk for carcinogenesis irrespective. Another study also found that skin cancer is clearly a potential risk, thus caution is advised when considering radiotherapy for these conditions in children and young adults. A report showed that external-beam irradiation for PVNS might have a role in the development of two aggressive neoplasms at the primary treatment site. These concerns over the side effects of radiotherapy hindered the application of adjuvant radiotherapy after the initial therapy. However, after her lesions recurred, she decided to take adjuvant radiotherapy after the second surgery and her disease has not recurred so far.Radiotherapy is the most widely used adjuvant treatment after surgery. It has been shown that radiotherapy reduces recurrence in diffuse PVNS, especially in cases with incomplete synovectomy. which could be rescued by MRI and postoperative follow-up. Research has shown that two-thirds of local recurrence were diagnosed during the first 2 years and <10% after 3 years, and follow-up MRI every 6 months during the first 3 years might be able to detect >90% of all local recurrences. Therefore, in order to detect recurrence in time, regular and timely follow-up is required.In addition, delayed diagnosis is a crucial risk factor for recurrence and poor prognosis, Jobe et al considerate that it is necessary to excise some otherwise normal-appearing fat and areolar tissue with the synovium in recurrences cases. And external beam radiation is an option as adjuvant therapy. There were no severe complications reported in most studies on recurrence PVNS.For recurrence PVNS of the knee, surgical resection, either open or arthroscopic, is considered the main strategy of treatment.3PVNS is a rare disease which may involve any joints. Standard treatment is surgical resection through open surgery, arthroscopic surgery, or a combination of both. The risk factors for recurrence include diffuse form of the disease, incomplete resection, location of the lesions, the experience and skills of the surgeon, and adjuvant therapy after surgery. Surgical resection plus adjuvant therapy is recommended for patients with risk factors of recurrence.Conceptualization: Yushun Fang.Data curation: Yushun Fang.Formal analysis: Yushun Fang.Methodology: Qingsong Zhang.Project administration: Qingsong Zhang.Supervision: Qingsong Zhang.Validation: Qingsong Zhang.Visualization: Yushun Fang.Writing – original draft: Yushun Fang.Writing – review and editing: Yushun Fang.


Pneumatosis cystoides intestinalis (PCI) is a rare clinical pathology characterized by sub-mucosal and/or sub-serous cysts of free gas, forming cystic lesions usually ranging from 0.5 to 2.0 cm in size within the gastrointestinal tract. About 3% of patients with PCI develop complications such as pneumoperitoneum, intestinal volvulus, obstruction, or hemorrhage, these cases need immediate surgical intervention. Cyst rupture can produce peritoneal irritation and pneumoperitoneum.A 65-years-old woman was admitted to the Emergency Department for epileptiform convulsions. Her medical hystory included epilepsy, diabetes, lichenoid dermatitis, hypothyroidism, severe cognitive impairment. Abdominal CT scan revealed a dilated large intestine with parietal pneumatosis from the appendix to the transverse colon associated to extensive pneumoperitoneum. The patient underwent emergency laparotomy which revealed the presence of gas within the wall of right and transverse colon and distension of great omentum. No resection was needed as normal blood supply to the bowel present.Pneumatosis coli can be both asymptomatic or life-threatening condition associated to bowel infarction; this situation can mimic a bowel perforation causing pneumoperitoneum - that sometimes is a non-surgical pneumoperitoneum - and it could be a misleading indication to surgical exploration especially in the case of uncertain origin of a septic shock.We report a case of pneuomoperitoneum due to PCI. Surgical intervention was required for patient’s conditions and unclear origin of the sepsis. PCI can be detected in all parts of the gastrointestinal tract and was first documented by Du Vernoy in 1783 [The term secondary PCI was termed by Koss in 1952 , who ana23), blood acidosis , both signs of a sever septic shock and initial multiorgan failure (creatinine 0.87 mg/dL) and hypotension. On clinical examination her abdomen was tender and swollen to palpation without any signs of ongoing peritonitis. An abdominal CT scan revealed a dilated large intestine with parietal pneumatosis from the appendix to the transverse colon associated with extensive pneumoperitoneum , that needed a temporary tracheostomy. The patient was unresponsive, GCS 8. Laboratory tests revealed a severe leukocytosis . The clinical exam of abdomen, apparently negative, and the absence of abdominal or digestive signs before admission  didn’t support the suspicion of abdominal origin of the sepsis.4This patient presented a nonsurgical pneumoperitoneum, but it was difficult to understand the fact that the surgical intervention was unneeded in this case because of the unconsciousness of the patient and the impossibility to get a complete anamnesis. The clinical exam of the abdomen was apparently negative, but the laboratory tests showed severe leukocytosis and acidosis and the vital parameters showed hypotension. In addition, the TC scan documented the presence of pneumoperitoneum. Because of all these findings, we first thought to a septic state, due to a bowel perforation. Intra-operatively we found out the presence of pneumatosis of the right colon and of the right colic flexure and distension of the great omentum, with no signs of bowel ischemia or perforation, so no resection was needed. The signs and symptoms that led to a suspicion of septic shock caused by intestinal perforation were ascribed to epileptic seizures and dehydration.This case highlights the importance of careful consideration of clinical and radiographic findings in the diagnostic and therapeutic approach to pneumoperitoneum. The surgeon has to consider all the potential causes of non-surgical pneumoperitoneum in his decision-making process for surgical versus non-surgical management ,26.None.No need of ethical approval.Author obtained the consent for publication from the patient’s kin.EB was responsible for the surgical intervention. LC and MR conceived the case report. MR, LC and GP researched and drafted the manuscript. CG, MDD, FB, EB and PC revised the manuscript. All authors read and approved the final manuscript.NA.Luigi Conti.Not commissioned, externally peer-reviewed.None.


Bladder leiomyomas are rare and benign tumors of the bladder. They account for 0.43% of all bladder tumors, and only 250 cases have been reported in English literature. Based on the size and localization of the lesion, their symptoms vary considerably. Women seem to be more affected, and obstructive symptoms predominate. Surgical treatment is almost always highly effective, leaving a low recurrence rate.We present a clinical case of a 52-year old man with macroscopic hematuria and obstructive lower urinary tract symptoms due to a large bladder trigone leiomyoma. CT and MRI showed a well-defined large bladder leiomyoma and cystoscopy established the initial findings. The patient underwent successful transurethral resection of the lesion, and pathology findings confirmed the diagnosis.This case report demonstrates that transurethral resection of a large bladder trigone leiomyoma is a feasible and successful procedure. Long term follow-up proves that there is neither scarring distortion of the bladder trigone area nor damage in the ureteral orifices, even though there was a thorough removal of the trigone wall. Leiomyoma describes a benign growth of smooth muscle tissue. These tumors can occur anywhere in the body where smooth muscle is found, but are frequently located in the uterus  or the gastrointestinal tract. Bladder leiomyoma is a rare, benign tumor with an incidence rate of about 0.43% among all types of bladder tumors . ApproxiHere we report a case of a large bladder trigone leiomyoma in a 52-year-old Caucasian male who presented with complaints of lower urinary tract obstruction, sporadic hematuria, and dysuria. To our knowledge, this case is one of the few reported cases of bladder trigone leiomyoma mimicking the median prostate lobe and distorting the left ureteric orifice. Our primary concern was that scar tissue following the procedure could further change the bladder trigone area, thus exacerbating patient's dysuria.A 52-year-old man presented at our clinic with gross macroscopic hematuria, and a 12-month history of the lower urinary tract symptoms. He reported frequency, urgency, nocturia, straining at voiding, dribbling at the end of urination and inability to empty the bladder. He had diagnosed with a urinary tract infection 3 months earlier. Although he had received antibiotic therapy, his urinary complaints persisted. As prescribed by a General Practitioner, his treatment was tamsulosin 0.4 mg/daily, for 2 months with limited success for the reported symptoms.During the initial evaluation, no abnormalities were found on physical examination or in routine laboratory studies. Ultrasound of the lower urinary tract revealed a smooth endovesical bladder lesion in the bladder trigone area which mimicked the median prostate lobe as well as mild prostate hyperplasia (prostate volume 43 cc). The tumor presented peripheral hyperechogenicity. There was also mild hydronephrosis in the left kidney with no indication of kidney stone.Given that asymptomatic macroscopic hematuria requires extensive investigation and the questions concerning the existence of a prostate median lobe, the patient was scheduled for computed tomography (CT). CT confirmed the presence of a solid, well-delineated mass measuring 41 × 24 mm that appeared to arise from the bladder trigone wall, independent from prostate, without any evidence of distant metastasis Fig. .Fig. 1CTThe patient underwent cystoscopy, which revealed a protruding mass in bladder trigone next to bladder neck with normal covering urothelium. There was a distortion in the area of the left ureteric orifice, which was displaced by the mass posterior to its normal position Fig. .Fig. 4ApThe patient underwent an uneventful TURBT. After the resection, a yellowish well-defined adipose tissue was revealed in the region of the bladder trigone. There are specific anatomical variations of the bladder trigone; muscularis propria bundles are nearer to the suburothelium and become smaller in caliber towards the surface. Adipose tissues can be seen in between muscularis propria bundles, which may continue extravesically or extend superficially to the lamina propria. Conversely, the outer boundary of muscularis propria with perivesical soft tissues  is irregular and not well defined.Special care was taken as regards the left ureteric orifice. Both ureteric orifices were seen to be intact. There was a significant concern about the future formation of scar tissue in the trigone area that could distort normal anatomy. The catheter was removed on the second postoperative day and the patient was discharged without any problem. Pathology proved that the lesion was a benign submucosal leiomyoma. The material consisted of interlacing fascicles of spindle-shape cells. The cells displayed no pleomorphism and contained bland-looking central spindle nuclei and eosinophilic cytoplasm. Microscopic examination of the whole tissue fragments did not reveal mitotic activity or coagulative necrosis. Immunohistochemical analysis showed an extended and robust cytoplasmic expression of smooth muscle actin (SMA) stain applied to the tissue.Six months after surgery, an ultrasound revealed no recurrence of the tumor. A 12 month ultrasound follow-up also confirmed that the patient had no remaining lesions. Since a benign condition had already been confirmed, a usual postoperative evaluation involves the ultrasound scan. However, our concerns about a probable scarring in the blabber trigone area and distortion of ureteral orifices made a postoperative cystoscopy necessary.Bladder leiomyoma is a rare, benign, mesenchymal tumor of the bladder, with an incidence rate lower than 0.5% among all types of bladder tumors. It was first described by Kretschmer et al. in 1931 . During The etiology of leiomyomas is still unknown, and multiple theories try to explain their origin. Blum’s irritative theory suggests that the reason is the presence of chronic inflammatory stimuli over the bladder wall and the detrusor smooth muscle. Some speculate that leiomyoma may arise from perivascular inflammation or chromosomal alterations . Piegel’Leiomyomas are classified according to three different locations, i.e., endovesical, intramural, and extravesical. Endovesical is the most common location, and it corresponds to 63–86% of cases, while intramural leiomyomas are present in 3–7% and extravesical in 11–30% [Patients with bladder leiomyomas can be asymptomatic, but the majority of them present with obstructive symptoms 49%), irritative symptoms (38%) and hematuria (11%) . Larger %, irritaTraditional detection methods of bladder leiomyoma include ultrasound, CT, MRI, and cystoscopy. Ultrasound findings include homogenous, smooth lesions with peripheral hyperechogenicity , 11. CT Leiomyomas are grossly clear-bordered, thin-capsuled solid masses with yellow-colored sectional surface. Microscopically, leiomyoma is made of intersecting smooth muscle fascicles surrounding vascular structures lined with normal endothelium and arranged as bundles extending in various directions. No mitotic activity, hemorrhage or necrosis foci are observed in these lesions. Immunohistochemically, they have positive staining with smooth muscle actin (SMA), muscle-specific actin (MSA), desmin, h-caldesmon, and vimentin. They are negative with keratins and epithelial membrane antigens (EMA). Detrusor muscle invasion is the most significant factor in differential diagnosis with leiomyosarcoma , 16. LakThe treatment of leiomyomas is determined primarily by their size, anatomic location, and relationship with the bladder wall . SurgeryIn some exceptional cases, specific operations were developed, such as vaginal resection for bladder leiomyoma . Other mRecurrence after surgical removal is rare, and recurrent cases have been successfully managed with repeat enucleation or transurethral resection . Having This case report demonstrates that transurethral resection of a large bladder trigone leiomyoma is a feasible, safe and effective procedure. Long term follow-up proves that there is neither scarring distortion in the bladder trigone nor damage in the ureteral orifices, even though there was a thorough removal of trigone wall.


Myospherulosis develops as the result of a reaction between exogenous lipids and red blood cells (RBC) of the patient, being the latter injured when perceived as a foreign body by the immune system, triggering an intense inflammatory response.A 63-year-old man with a history of dyslipidemia, Barret’s esophagus, and coronary disease, who was taken to thoracoscopy and left inferior lobectomy due to the presence of a pulmonary mass. A primary pulmonary adenocarcinoma was diagnosed. On follow up a PET-CT was performed, in which a metabolically active lesion was described adjacent to the prior lobectomy, suggesting a local relapse. EBUS-TBNA was then performed, obtaining a sample from which histopathological pattern compatible with myospherulosis was obtained.Although it is a rare entity, myospherulosis has a well-defined morphological pattern. By not recognizing myospherulosis as a benign lesion, a patient’s risk of invasive cancer can be overestimated. It is a phenomenon found with increasing frequency and has been reported in different tissues, however, this is the first report in the literature of myospherulosis of the lung. Greater awareness is required regarding the existence of this phenomenon. Later o tissue) . DespiteMyospherulosis develops as the result of a reaction between exogenous lipids and red blood cells (RBC) of the patient, being the latter injured when perceived as a foreign body by the immune system, triggering the inflammatory response described above . It is u2 97%, temperature 37 degrees Celsius. On physical examination, there was no jugular engorgement or neck masses, the heart was rhythmic without murmurs or gallops, respiratory sounds were normal, he had no abdominal masses, lower limb edema, or neurological deficit. Given the findings in the stress test, the patient was taken to cardiac catheterization plus angioplasty due to trunk disease associated with the compromise of three major vessels. A multidisciplinary board determined he was a candidate for myocardial revascularization; during the pre-surgical evaluation, a mass in the left inferior pulmonary lobe was found. The patient was taken to revascularization without complications. Subsequently, further studies were performed to stratify the lung mass, considering the patient was a good candidate for surgical resection. He was then taken to left lower lobectomy by thoracoscopy with mediastinal lymph node emptying. The histopathological diagnosis yielded a primary pulmonary adenocarcinoma, T2aN2M0, stage IIIA. He received chemotherapy and adjuvant radiation therapy with good evolution. After completing the oncho-specific therapy, a PET-CT was performed, where a metabolically active lesion was detected at the left perihilar level and para-aortic area with a Standardized Uptake Value (SUV) of 3.5, plus diffuse pulmonary basal opacities which could be secondary to radiotherapy  or an oily carrier found in hormones and antibiotics IM injections. There are a few reported cases in which there is no history of petrolatum exposure and emulsified human fats are responsible. In our case, we believe that vaseline-impregnated gauzes during cardiac revascularization were responsible for the disease. Myospherulosis is usually asymptomatic and requires no specific treatment, except when it produces, requiring symptomatic relief .Regardless of the cause, myospherulosis has a well-defined morphological pattern, which explains why the diagnosis is made mainly by biopsy . When thMyospherulosis has been described with an increasing frequency outside muscle tissue; it has been reported in various lesions found in paranasal sinuses, jaw, mastoid, breast, prostate, salivary glands, skin, eye, liver and peritoneum. Also, it has been found surrounding soft tissue tumors, and tumors found in gynecological and otolaryngologic tract , 4, 6, 7It is important to highlight that in our case, the detection of a hypermetabolic lesion in the left lung on the PET-SCAN hindered the diagnostic process since it led to suspecting relapse of the pulmonary adenocarcinoma. In the case of not being able to recognize myospherulosis as a benign lesion, the risk of invasive cancer would be overestimated, leading to inappropriate treatment. It is of utmost importance to recognize that the main differential diagnosis of myospherulosis is carcinomas and metastasis as well as infections by fungi and algae due to radiographic and even histopathologic similarities. Hence the importance of carrying out a complete histopathological study, including different stains and immunohistochemistry profiles.In conclusion, we believe greater awareness of the existence of this phenomenon is required, as its incidence appears to be increasing, affecting diverse tissues. Its recognition as a benign process is key to reduce misdiagnosis of malignant diseases, and therefore unnecessary and potentially harmful treatments.