Localized pain in the absence of local lesion may represent referred pain from the spine, in a child, arising from a benign spinal schwannoma. It can be diagnosed by MRI. Surgical excision of the tumor relieves the symptoms. Localized pain in the absence of local lesion may represent referred pain from the spine, in a child, arising from a benign spinal schwannoma. It can be diagnosed by MRI. Surgical excision of the tumor relieves the symptoms. Both radiological and clinical signs led to an incorrect diagnosis of osteoid osteoma. An MRI investigation of the spine confirmed the presence of spinal schwannoma. After surgical management, she had complete recovery.Schwannomas are slow‐growing benign tumors arising from Schwann cells of the neural sheath. These tumors were previously described as neurilemmomas. Spinal schwannomas are solitary firm lobulated and encapsulated tumors arising mainly from the dorsal nerve root. In the spine, they can be located extradural, intradural extramedullary but rarely intramedullary. They are more common in the 4th to the 6th decade in life, being extremely rare in children. Their incidence is 0.3‐0.4 cases per 100 000 persons per year.Schwannomas are largely asymptomatic until they present symptoms. Pain and paresthesia are the main clinical symptoms. Motor disturbances, muscle weakness, or mass protruding are other rare clinical presentations.We present a 10‐year‐old girl that had exacerbating pain only in the right knee, increasing during the night. An incorrect diagnosis of osteoid osteoma (OO) of the right knee was made, in accordance with the clinical symptoms. An MRI investigation confirmed the proper diagnosis of spinal schwannoma. The surgical treatment completely relieved her symptoms.2A 10‐year‐old girl was referred to our pediatric orthopedic department for treatment with RF ablation of an osteoid osteoma of the right knee. Her past medical history was a 6‐month duration of severe pain, localized on the right knee, exacerbating during the night, making her unable to sleep. She was a normally developing girl, participating in sports activities until the appearance of pain. She had a series of blood test investigations  that were all in normal ranges.Two X‐ray examinations of the right knee were taken in an attempt to define a diagnosis for the knee pain. An area of a small subperiosteal lucency of the lateral femoral condyle was reported. The right knee was further investigated with MRI. A consultant pediatric radiologist reported that there was minimal edema, possible small nidus, and absence of bone sclerosis. She suggested a diagnosis of a subchondral osteoid osteoma. The girl was provided with paracetamol and ibuprofen but the pain remained unchanged. Figure The girl was obviously suffering and was continuously grasping the right knee. She could walk normally without signs of limping and was able to hop bilaterally without discomfort. A clinical examination of the right knee revealed a full range of movements, without effusion. Both hips were also normal. Her spine was straight and with full movements of flexion and extension. She had normal bilateral tendon reflexes, a normal sensation in both of the legs and feet.Upon review of the X‐ray and MRI documents, we could not support the diagnosis of an osteoid osteoma (OO). Therefore, an MRI and a CT examination were undertaken with slices of 5 mm, but a nidus or sclerosis could not be identified. A bone scan was performed that had no increased uptake in the right knee. The bone scan had normal uptake throughout the body. We informed the patient's family that we would not precede to ablation. Figure We further examined her with an X‐ray of hips and pelvis, and lumbar spine AP and lateral, with normal findings. On the next day, we performed an MRI investigation of the right femur, pelvis, and lumbar spine in an attempt to find possible pathological signs.In the lumbar spine an oval, intradural extramedullary, tumefactive lesion was observed in the thecal sac, at the level of L1 vertebra. The lesion consisted of a cystic central part  and a solid peripheral part, with intense enhancement of the latter. There is no evident extension of the lesion in the foramina. The mass measured 27.5 mm  X 17.5 mm (transverse diameter) X 13 mm (anteroposterior diameter) Figure 1 and L2, a well‐defined capsulated tumor was resected after clear separation from the nerve roots.The lesion appeared to be mainly located in the central and left part of the thecal sac, causing pressure to the roots of cauda equina. The imaging findings were mostly consistent with a tumor of neurogenic origin (schwannoma). With the diagnosis of schwannoma of the spine, we informed the family about the need for surgical treatment of the tumor. We have not performed biopsy for a tumor with benign characters. Our neurosurgical team performed the operation. After posterior laminectomy of LHistopathological and immunohistochemical analyses confirmed the diagnosis of a cellular neurilemmoma. The tumor showed increased cellularity and the cells were spindle‐shaped and arranged in fascicles. The tumor cells are without nuclear atypia or mitosis. Some show nuclear palisading. The tumor cells were strongly positive for S100 and negative for GFAP and EMA. The positivity for Ki67 in “hot spots” was about 5% of the nuclei. Figure The patient showed impressive recovery, feeling completely relieved. Peripheral neurological examination remained normal. We performed a new MRI of the spine in 6 months, with no elements of recurrence. The girl 8 months after the operation has not experienced any pain. The MRI examination of the brain was normal and we excluded neurofibromatosis.3Neurilemmomas or schwannomas are benign tumors that originate from Schwann cells. Spinal intradural extramedullary tumors are commonly meningiomas or schwannomas. Approximately 70% of spinal schwannomas arise from sensory roots, 20% from motor roots and 10% both from motor and sensory roots.Handa et al report a series of 11 patients with giant sacral schwannomas in patients with mean age 53 years (35‐73) that had delayed diagnosis because it is a rare tumor with nonspecific symptoms.Osteoid osteomas are a common pathology in the 2nd decade of life, presenting with severe pain that occurs primarily at night. OOs mainly affect the long bones, producing typical radiological signs of bone sclerosis around an area of lucency with a central nidus. However, when OOs are located in the subchondral bone, there is minimal periosteum reaction and a diagnosis is usually difficult. MRI investigation of OO is mainly characterized by bone edema and is diffuse; it is not always accurate for obtaining a diagnosis of OO. In our patient, the initial examination was confused with normal subchondral nonossifying areas that are common findings without any clinical significance. But these areas were combined with severe knee pain at night, leading to a false diagnosis of OO. CT scan can provide an accurate localization of the nidus of an OO, assisting in the appropriate diagnosis. The bone scan is positive in active OO. We excluded the diagnosis of OO owing to the negative CT scan and bone scan.4 distribution from torsion and hemorrhage in a healthy 62‐year‐old man.The clinical presentation of schwannomas is mainly pain with neurological impairment according to the area that they originate. In a cohort of 831 patients (44.8 year old ± 13.2 years) with solitary schwannomas, pain was the main symptom (69.5%) followed by paresthesias and numbness (35.5%) and motor weakness (21.7%). Other symptoms such as difficulties in voiding, gait dizziness, fasciculation, and dysphagia were found in 4% of the patients.7 schwannoma. Our patient had a normal peripheral neurological examination and showed no signs of nerve root impairment.4 body and with destruction of the vertebral body.Spinal schwannomas are extremely rare in children. Ustaris et al report a 4‐year‐old girl presented with toe walking pattern and progressive weakness of the lower legs, was diagnosed with a COur patient had only intense pain, without elements of radicular distribution and only her right knee was affected. There were no signs of radiculopathy or myelopathy, thus complicating the diagnosis. Clinical and radiological examination of the spine was normal. Pain is a particular feature in schwannomas of the cauda equine, caused both by compression of the sensory nerves and traction of the root.Spinal meningioma usually presents as a lesion iso‐ or hypointense to the spinal cord in T1W sequences and is mildly hyperintense to the cord in T2W sequences, with intense enhancement after the intravenous administration of paramagnetic agent. A characteristic dural tail sign may also be observed. Intraspinal schwannoma usually presents as a more heterogeneous lesion, which demonstrates low signal in T1W and predominately high signal in T2W sequences, with a high incidence of cystic areas centrally. The lesion also demonstrates intense enhancement after the intravenous administration of paramagnetic agent. In case the lesion extends into the neural foramen, the typical appearance of the “dumbbell sign” is observed, with widening of the foramen and vertebral scalloping. The lesion in our case was confined in the dural sac, with no foraminal extension.In the differential diagnosis of intradural extramedullary lesions, other entities should also be included, such as myxopapillary ependymoma, paraganglioma, hemangiopericytoma, hemangioma, and metastases—which are more common in adults.Surgical excision is the treatment of choice for spinal schwannomas. Complete resection of the tumor is recommended since partial resection has the risk of recurrence. When the tumor originates from motor roots there is a risk for motor deficit. Sridhar et al described surgical steps for giant erosive spinal schwannomas.It is important to extend our investigations, not only to the site of pain but to think also to referred pain from a spinal tumor.None declared.NL: is responsible for writing and editing the original draft. NB: performed surgery and is responsible for the investigation and collection of data. CC and KP: are responsible for the data collection and assisting in editing. LG: is responsible for radiological investigation. KZ: is responsible for the pathological examination.Full consent has been given by the parents for publication of the case report.


Undescended testes are associated with an increased risk of malignancy and infertility, and surgical treatment in childhood is recommended.A 35-year-old man presented to the emergency department with abdominal pain and vomiting. Despite a history of surgery for a left undescended testis in infancy, his left-sided scrotum appeared underdeveloped. Contrast-enhanced computed tomography showed a pelvic mass, involving a major axis of approximately 15 cm, with high-density ascites suggestive of hemorrhage. A ruptured gastrointestinal stromal tumor was suspected. As he was in hemorrhagic shock, an emergency laparotomy was indicated. The active bleeding mass was controlled through complete resection. A pathological evaluation of the mass revealed a seminoma arising from an undescended testis. His post-operative course was uneventful, and he was discharged on post-operative day 6. Recurrence on the retroperitoneal lymph nodes was detected 1 year postoperatively, and a retroperitoneal lymph node dissection was performed after chemotherapy. He remains well without any apparent signs of recurrence.Paying close attention to an empty scrotum is advisable, even postoperatively, for undescended testis because of possible subsequent potential malignancy presenting with hemorrhage, as our patient demonstrated. Undescended testes are a common birth anomaly . Approxi3). Contrast-enhanced computed tomography (CT) revealed a large volume of high-density ascites and a large mass, with a major axis of approximately 15 cm in the pelvic area. The mass was poorly attenuated and contained blood vessels , he underwent retroperitoneal lymph node dissection by transperitoneal approach by open surgery. Histological examination of dissected lymph nodes showed fibrous scarring with no residual tumors. One year after the radical retroperitoneal lymph node dissection, he remains well without any signs or symptoms of tumor recurrence.A 35-year-old married father of a newborn infant was transferred to the emergency department complaining of abdominal pain and an approximate 10-h history of vomiting. He reported a surgical history of left undescended testis in infancy. He and his parents had noticed that his left scrotum was still small after the surgery, but they had not paid attention to it and had not seen a doctor. He denied any other significant medical or surgical history, or a history of injury. On admission, he was conscious, pale, and had a tachypnea. His blood pressure was 80/55 mmHg, his pulse rate was 130 beats/min, and he was in shock. On clinical examination, he presented with abdominal distention and diffuse tenderness with guarding. His blood test results showed a low hemoglobin concentration 9.2 g/dl) and an elevated white blood cell count (21,200/mm g/dl andThis patient presented with shock due to bleeding from an abdominal tumor, for which the treatment of choice is an emergency laparotomy irrespective of a pre-operative diagnosis of the tumor. Our patient had a history of surgery for a left-sided undescended testis in infancy; however, the medical records for surgery and post-operative follow-up were not available. The intra-abdominal bleeding was due to rupture of a seminoma arising from the remnant testis. Post-operative examination and palpation indicated a left empty scrotum. The potential cause of intra-abdominal remnant testis even after orchiopexy is considered to be due to post-operative testicular retraction  or intraThe pathological staging of this case was stage I. For stage I testicular seminoma, radical inguinal orchiectomy is the first choice. Standard options after surgery include active surveillance, radiation therapy or 1–2 cycles of carboplatin . In thisMalignant tumors arising from undescended testis have no characteristic symptoms; therefore, early determination can sometimes be challenging . EnlargeA precise pre-operative diagnosis can offer reasonable or ideal surgical strategies for abdominal tumors. According to the condition of a patient with a ruptured abdominal tumor, interventional radiology may affect the post-operative course in terms of temporal hemostasis or reduction of blood inflow. Stabilization and recovery from the shock status generally allow for pre-operative therapies or less invasive surgery, including laparoscopic resection. A pre-operative diagnosis is critical to perform an appropriate urgent surgical procedure to control intra-abdominal hemorrhage immediately. For this patient, the necrotic and ruptured tumor had a thin distorted stalk containing the left gonadal artery and vein, which were connected to the inguinal region. Thus, torsion of the undescended testicular tumor’s pedicle was suspected immediately following the laparotomy. Our pre-operative diagnosis was not sufficiently precise, even on second look and review of the pre-operative CT. He was in shock on admission preoperatively, so we were unable to perform the full physical examination, including the scrotal examination. If we had noticed his empty scrotum before surgery, we would have suspected an intra-abdominal testicular tumor and first found and ligated the gonadal artery and vein, the feeding vessel of the mass, when we opened the abdomen.Intra-abdominal hemorrhage from a seminoma arising from an undescended testis located in the abdominal cavity is a rare condition, with only five reports since 1970 of bleeding due to an intra-abdominal seminoma –16 (TablWe report a patient with an intra-abdominal testicular seminoma who was in hemorrhagic shock due to tumor rupture. An intra-abdominal seminoma may develop, even after previous orchiopexy surgery for undescended testes, and careful observation of an empty scrotum is advisable.


Pancreatic cancer is a disease with a poor prognosis, requiring multidisciplinary treatment combining chemotherapy and surgery for effective management. Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical intervention performed for locally advanced pancreatic cancer, but the benefit of arterial reconstruction in DP-CAR is unclear.2) plus nab-paclitaxel (125 mg/m2) every 4 weeks were followed by irradiation  together with S-1 administration (80 mg/m2/day). A partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) was achieved, so surgical intervention was considered. Because the tumor had invaded the root of the gastroduodenal artery, we performed DP-CAR with resection of the gastroduodenal artery, followed by arterial reconstruction of the proper hepatic and left gastric arteries, anastomosed with the abdominal aorta using a great saphenous vein graft in the shape of a “Y”. Histopathology showed that 60% of tumor cells were destroyed by the chemoradiotherapy, defined as grade IIb in the Evans classification. No malignancy was detected at the surgical margin, including the celiac artery, gastroduodenal artery or pancreatic stump; thus R0 surgery was successful. S-1 (80 mg/day) was administered as adjuvant chemotherapy for 6 months. The patient is now doing well without recurrence for > 2 years after the initial treatment (more than 16 months after surgery).A 49-year-old man with pancreatic cancer was referred to our hospital. Imaging revealed a 54-mm tumor mainly in the pancreatic body, but with arterial infiltration including into the celiac, common hepatic, left gastric, splenic and gastroduodenal arteries. Distant metastases were not detected. The patient was diagnosed with unresectable locally advanced pancreatic cancer and chemoradiotherapy was planned. Three cycles of gemcitabine (1000 mg/mFor locally advanced pancreatic cancer, multidisciplinary treatment combining gemcitabine/nab-paclitaxel-based chemoradiotherapy and then DP-CAR surgery with gastroduodenal artery resection and arterial reconstruction using saphenous vein grafting enabled R0 resection in this patient and led to a favorable long-term prognosis. Pancreatic cancer (PC) is a fatal disease with high malignancy and a very poor prognosis. It is often advanced at the time of definitive diagnosis and surgical intervention is then challenging . EffectiDistal pancreatectomy with celiac axis resection (DP-CAR) is a surgical method for locally advanced cancer of the pancreatic body. In this approach, the tissue surrounding the pancreas and retroperitoneum, including the celiac artery (CeA) and common hepatic artery (CHA), is removed to achieve R0 status . GeneralHere, we present a successful case of DP-CAR with arterial reconstruction of the left gastric artery (LGA) and the PHA using great saphenous vein grafting (SVG) for UR-LA PC after chemoradiotherapy following chemotherapy with GEM/nab-PTX.A 49-year-old man complained of left abdominal pain. He had a past medical history of duodenal ulcer and appendicitis, no smoking history, and no alcoholic history. Abdominal ultrasonography revealed a 33-mm tumor located in the pancreatic body, and he was referred to our hospital for further evaluation and treatment.Laboratory data showed elevated tumor markers including CEA (6.0 ng/ml) and CA19-9 (72.9 U/ml). Computed tomography (CT) revealed a 54-mm hypovascular tumor in the body to tail of the pancreas  guidelines version 2.2018, resectability was determined as UR-LA. We planned conversion surgery (CS) after multidisciplinary treatment, including chemotherapy and chemoradiotherapy.2) and nab-PTX (125 mg/m2) every 4 weeks). Adverse events were general fatigue and Grade 3 neutropenia, so chemotherapy was omitted twice . After chemotherapy, CT imaging showed tumor size reduction to 40 mm, indicating stable disease (SD) according to the Response Evaluation Criteria in Solid Tumors (RECIST). Next, we performed radiotherapy together with S-1 administration. Radiotherapy consisted of 2 Gy per fraction given 5 days per week for a total of 50 Gy. S-1 was administrated orally at 80 mg/m2/day for 28 consecutive days. This treatment was not accompanied by any significant adverse events.First, three courses of chemotherapy were proposed. The regimen was standard . CT imaging showed tumor size reduction to 31 mm, indicating partial response (PR) according to RECIST, but soft tissue density around CeA, CHA, LGA, SpA and GDA was still detected  branched off from the LGA, and the right hepatic artery (RHA) from the PHA. Proximal balloon occlusion of the CeA showed that RHA blood flow from the SMA was maintained. However, LHA blood flow could not be detected since the balloon blocked blood flow to the LGA, and a definite arterial connection between the right and left liver could not be observed.In the preoperative evaluation, we considered that R0 status could be achieved by DP-CAR with arterial reconstruction, even if tumor invasion to the GDA or PHA had occurred. Surgery was then carried out 8 months after the initial start of treatment.Intraoperative findings revealed that the tumor was located mainly in the pancreas body, but had also invaded into the arteries around the pancreas, including the CeA, CHA, LGA, SpA, and GDA Fig. a. The GDIntraoperative frozen section pathology findings confirmed tumor-free margins of the CeA, GDA and pancreas stump. Based on these findings, we performed DP-CAR with arterial reconstruction using SVG to achieve R0 resection. The total duration of surgery was 754 min, and blood loss was 660 ml.Postoperative complications included decreased appetite, although no clinically significant pancreatic fistula was identified. Postoperative gastrointestinal endoscopy showed erythematous mucosal surface and stenosis from the pyloric region to the duodenal bulb. These complications were treated with drug therapy (Clavien–Dindo classification IIIa). Postoperative CT imaging clearly showed blood flow through the aorta–LGA bypass, but the aorta–PHA bypass did not Fig. . The incHistopathological findings showed a 52-mm moderately differentiated tubular adenocarcinoma in the body to tail of the pancreas Fig. d, e.Fig.The patient completed 6 months of S-1 adjuvant chemotherapy (80 mg/day) and has been doing well without recurrence for more than 2 years after the initial treatment (> 16 months after surgery).PC is one of the deadliest cancers, and has a very poor prognosis . Here, wApproximately 30–35% of patients with PC are initially diagnosed as UR-LA PC , 8. It iRecent data suggested several factors influencing the beneficial prognosis after surgery. In a large cohort study, including PC with distant metastasis, preoperative CA19-9 level, lymph node involvement, metastasis status, and vascular involvement were all found to be prognostic factors for survival after CS . DonahueDP-CAR is a surgical procedure to ensure achieving negative margins of the celiac artery, periarterial plexus, and retroperitoneal tissue in locally advanced cancer of the pancreatic body . Recent On the other hand, reconstruction using the SVG carries problems of graft patency or varicose veins due to long-term arterial pressure. No coherent reports have showed the incidence of graft occlusion or varicose veins in the SVG after abdominal arterial reconstruction. However, the incidence of varicose veins was reported to be less than 1% in coronary artery bypass grafting using the SVG , and theFor UR-LA PC after chemoradiotherapy, DP-CAR was achieved after GDA resection in this case by reconstruction of the PHA and LGA using the SVG. This treatment strategy could be an excellent option for very advanced PC such as UR-LA PC with arterial reconstruction after pancreatectomy.


The arc of Buhler (AOB) is a rare anatomical variant. Rupture of an AOB aneurysm is exceedingly rare. In this study, we report a case of AOB aneurysm rupture, which was successfully treated by transcatheter coil embolization. A 74-year-old man presented with symptomatic AOB aneurysm rupture. A computed tomography scan and subsequent angiography revealed the aberrant connection between the common hepatic artery and the superior mesenteric artery. A fusiform AOB aneurysm with focus of active bleeding was detected. This was successfully treated through embolization and sacrifice of the AOB. This suggests that conventional embolization with sacrifice of AOB is a feasible and safe approach. The anastomotic network exists between the celiac artery (CA) and superior mesenteric artery (SMA) and provides crucial blood supply to the foregut and midgut. The two most common anastomoses are via the pancreaticoduodenal arcade and dorsal pancreatic artery. Rarely, a third connection can exist in the form of an arc of Buhler (AOB).The AOB is an anatomical variant first described by Buhler and Tandler . It is bAneurysm arising from the AOB is a rare entity, and literature surrounding the incidence and management remains sparse. In contrast, patients with AOB aneurysms are commonly symptomatic and can present with nonspecific abdominal pain or rupture –4 and arIn this case report, the authors describe a case of AOB aneurysm rupture and how conventional coil embolization with sacrifice of the entire anastomosis is a feasible management option.A 74-year-old man presented with near-syncope and abdominal pain and was then found to be hypotensive 95/62 mmHg) with abdominal guarding. Sonography revealed free fluid in the right hypochondrium which on CT revealed a large retroperitoneal hematoma, predominant in the paraduodenal region . The ini mmHg witSuperior mesenteric arteriography was then performed to detect any retrograde perfusion and bleeding from the pancreaticoduodenal arcade. It was at this time that an aberrant artery communicating between the common hepatic artery and the SMA separate from the pancreaticoduodenal/GDA was detected. The appearance was consistent with an arc of Buhler. In addition to brisk hepatopedal flow, a fusiform aneurysm with a focus of active bleeding was detected . The arcThe patient had an uneventful recovery and was discharged well on postoperative day 2 and remained well at 1-month follow-up, with no symptoms of hepatic or bowel ischemia.In the current literature, unruptured or incidentally discovered AOB aneurysms are treated with prophylactic coil embolization or surgical resection –9 Table. RuptureIn contrast, our case is the first where there is complete sacrifice of the AOB. Theoretically, this technique has several potential risks, such as resultant hepatic or bowel ischemia. The aneurysm of the AOB has a fusiform morphology as opposed to the saccular morphology in the prior publications , 9. The In our case, we were uncertain of the cause for the hepatofugal flow through the AOB. Retrospective review of both the CT and angiography reviewed no stenosis of the celiac axis or definite imaging evidence of MALS.The above case adds to our understanding of the rare occurrence of AOB aneurysm rupture and that coil embolization sacrificing the entire anastomosis is a feasible treatment option.


Spinal ganglioneuroma occurs mostly in the thoracic spine causing various manifestations including scoliosis that can be misdiagnosed as idiopathic scoliosis. Few reports exist in the literature on the diagnosis and management of scoliosis secondary to huge ganglioneuroma and usually staged treatment is preferred. In this report, we present a 17-year-old female patient presented with back pain, lower limbs numbness, spinal deformity, and shortness of breath. Plain X-rays showed a 50° right thoracic scoliotic curve. MRI and chest CT revealed a huge extra pulmonary mass shifting the mediastinum with intra spinal extension through the left neural foramina compressing the spinal cord. Percutaneous US guided needle biopsy confirmed the diagnosis of ganglioneuroma. One-stage posterior instrumented correction of scoliosis, spinal cord decompression, and excision of the whole mass from the mediastinum and the spine through posterior approach was done for the patient with smooth postoperative recovery. Chest CT scan was done 2 years after surgery and excluded any local recurrence. Ganglioneuroma (GN) is a slowly progressing benign neural tumor arising from sympathetic ganglion . Spinal Few reports exist in the literature on the diagnosis and management of scoliosis secondary to giant ganglioneuroma and usually staged treatment is preferred .In this report, we present a 17-year-old female patient with giant ganglioneuroma in the thoracic spine causing scoliosis with intra thoracic extension treated by one-stage posterior excision from both the spine and the chest together with instrumented correction of associated scoliosis.To the best of our knowledge, this is the first report on one-stage posterior excision of giant mediastinal GN with intra spinal extension together with scoliosis correction.A 17-year-old female patient was presented to our institute on April 2016 complaining of occasional back pain and spinal deformity. On examination, the patient had no limitation of physical activity, occasional pain, no neurological deficits with mild thoracic scoliosis. Reassurance of the patient and her family was done with conservative treatment. Six months later, the patient presented back with worse pain, numbness of both lower limbs, progressive deformity, and shortness of breath. MRI was ordered for her, and revealed a giant extra pulmonary mass shifting the mediastinum to the opposite side, extending opposite T6 to the lower border of T10 with intra spinal extension through the left neural foramina compressing the spinal cord. Full-length spinal PA and lateral X-rays showed left thoracic scoliotic curve extending from T5 to T9 with apex at T7 and measuring about 50° with Cobb method with thoracic kyphosis of 65° –3.Percutaneous US-guided needle biopsy was done, and the histopathological report confirmed the diagnosis of ganglioneuroma. One-stage posterior instrumented correction of scoliosis, spinal cord decompression, and excision of the whole mass through posterior approach was planned for the patient after a multidisciplinary team approval in our institute comprising spine surgeon, anesthesiologist, and cardiothoracic surgeon.The patient was operated under general anesthesia in prone position over a radiolucent table. Standard posterior approach to the thoracic spine was done exposing the posterior elements subperiosteally. Then pedicle screws were inserted using the free hand technique from T3 to T11 and their position was checked by intra operative radiograph. A rod was connected to the screws on the right side and then wide microscopic decompression of the spinal canal was done exposing the mass and the spinal cord. Careful dissection of the mass from the spinal cord was done and the nerve root connecting the mass to the cord was identified and ligated. Ponte osteotomy was done at the apex and then correction was done by rod derotation technique. The second rod was inserted, then Wake-up test was done, and after confirming neural integrity, posterior spinal fusion was done using local bone graft.After completion of the correction of scoliosis and excision of the intra-spinal extension on the tumor, thoracic surgeons approached the intrathoracic part of the tumor through the same incision by retraction of the back muscles medially and entering the left hemithorax through the 6th intercostal space posteriorly. Exploration of the chest showed no infiltration to the adjacent lung or mediastinal structure. Using an energy sealing device , the feeding branches from the descending aorta to the tumor were sealed and divided and then the tumor was removed en-bloc. Chest tube was inserted from a different stab in the anterior axillary line for drainage and ribs were approximated in the standard fashion; then back muscles were approximated and wound closed in layers .Patient was successfully extubated on table and transferred to ICU where she was monitored for vital signs, chest tube output, and neurological manifestation and she was on IV opioids for the first 48 h. Mobilization was possible from the second day postoperative and chest tube was removed on the 4th day. Postoperative radiograph showed the correction of the scoliotic curve to 30° and the thoracic kyphosis to 32°. Patient was discharged home on the 6th day postoperative uneventfully .The tumor was a firm white mass measuring about 20 × 15 × 8 cm with smooth outer surface. Serial cut sections showed homogenous soft to firm white cut surfaces. Microscopic examination revealed sweeping long and short fascicles with wavy spindle cells and numerous mature ganglion cells in-between surrounded with hyaline and myxoid stroms. The histopathological diagnosis was consistent with ganglioneuroma. The patient was followed up at 2 weeks, 2 months, 1 year, and 2 years postoperatively. Chest CT scan was done 2 years after surgery and excluded any local recurrence.Spinal ganglioneuroma constitutes about 10% of all ganglioneuromas and most commonly occurring in the thoracic spine . Spinal The mechanism by which GN can cause scoliosis is still not clear . A misdiD’Eufemia et al.  reportedAs GN can reach a huge size while asymptomatic due to slow progression, he identified red flags to suspect secondary scoliosis that needs MRI to avoid delay on treatment. Those red flags included back pain not responding to anti-inflammatory treatment, curve progression and stiffness, neurological deficits, and atypical curve patterns .Yang et al.  reviewedWang et al.  describeIn this study, Single posterior approach was done to correct scoliosis, decompress the spinal cord, and excise the whole mass from the mediastinum and the spine. The posterior approach to the spine is simple, extensile, and familiar to all spine surgeons with little risk of vascular or visceral complications . This saThe aim of the surgery was to excise the tumor completely and stabilize the curve to prevent further progression after laminectomy with restoration of the thoracic kyphosis. The scoliosis curve was rigid and we accepted partial correction of the curve to avoid more aggressive corrective maneuvers like asymmetrical PSO that would increase the operative time, manipulation of the cord, and blood loss.Using the same incision for approaching the intrathoracic part of the mass ensured that the mass was excised in continuity en-bloc with proper intercostal space entry to the chest as we started the incision from the medial aspect of the mass. Prone position also helped dissecting the feeding vessels arising from the aorta easily instead of making too much tension on the mass with anterior retraction in case of the conventional posterolateral thoracotomy. Same incision provides a very good cosmetic result added on to the correction of scoliosis and better patient overall postoperative pain experience.Spinal GN had low recurrence rate with no need for postoperative chemotherapy or radiotherapy with good prognosis after complete resection . A multi


Mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) accounts for approximately 5% of non-Hodgkin lymphomas, and the gastrointestinal (GI) tract is the most common site of involvement. The stomach and small intestine are the most common sites of involvement in the GI tract. Colonic MALT lymphoma is a rare condition that comprises only 2.5% of MALT lymphomas and less than 0.5% of all colon cancers. They usually present as colon mass or polyps. In this case report, we present a case of colonic MALT lymphoma diagnosed on random colon biopsies which is very rare. Mucosa-associated lymphoid tissue (MALT) lymphoma, which is also referred to as extranodal marginal zone lymphoma, is a form of non-Hodgkin lymphoma (NHL) that predominantly involves the gastrointestinal tract ,2. The sA 54-year-old female with a past medical history of hypertension underwent screening colonoscopy that revealed mild left-sided diverticulosis but was otherwise unremarkable. She was completely asymptomatic. No family history of colon cancer. Her recent blood work was unremarkable, and she had normal hemoglobin, normal white cell count, and platelets. Liver enzymes and renal function tests were also normal. During colonoscopy, random biopsies were taken from the cecum. To our surprise, pathology showed dense and focally destructive lymphoplasmacytic infiltrate which was positive for CD3, CD20, and CD43, consistent with MALT lymphoma Figures , 2.Helicobacter pylori (H. pylori). After a multidisciplinary team meeting with surgery and oncology, the final decision was to perform hemicolectomy without any need for adjuvant chemotherapy. She received a right hemicolectomy without any complications and recovered well. Subsequent imaging and colonoscopy one year later did not reveal any recurrence.CT scan of the chest abdomen and pelvis did not demonstrate any suspicious lymph nodes or any signs of spread of lymphoma outside the colon. Repeat colonoscopy was performed after the biopsy results, random biopsies were taken from the rest of the colon, and there was no involvement of the left side. Esophagogastroduodenoscopy was also unremarkable. Biopsies taken on upper endoscopy and colonoscopy were negative for Helicobacter pylori infection is strongly associated with gastric MALT lymphoma, but no association is seen between H. pylori and colonic MALT lymphoma. The mean age at diagnosis of MALT lymphoma is 60 years. Some studies show twice the incidence in females than males [MALT lymphoma is a relatively uncommon subtype of NHL, which comprise 5%-10% of total NHL. It primarily involves the gastrointestinal tract but can also occur in lungs, ocular adnexa, and skin [Most patients with colonic MALT lymphoma present with gastrointestinal bleed which can range from mild to massive . It rareH. pylori treatment [Due to the rare occurrence of colonic MALT lymphoma, there is no clear consensus on treatment. Surgical resection and chemotherapy have been widely utilized. There are rare case reports in which resolution occurred with reatment ,13. Varireatment . In thisOur patient had a diagnosis of MALT lymphoma on random biopsies of the cecum and underwent right hemicolectomy without any chemotherapy. There are no signs of relapse to date. This case report emphasizes that colonic MALT lymphoma can present in various different ways, and since this condition is so rare, there are no standard guidelines for treatment. More data are needed to have definitive guidelines for the treatment of this rare disease.


Hortaea werneckii, a halophilic and halothermic yeast-like fungus capable of producing a melanin-like substance. This pathogen infiltrates the stratum corneum in the setting of microtrauma and produces an asymptomatic brown to black macule or patch that appears similarly to melanocytic nevi or melanoma. We present a case of a 52-year-old woman who presented to clinic several months after developing a painless, nonpruritic dark brown patch in her left foot inside the fourth toe web. The coloration and location of this lesion would typically prompt biopsy; however, Wood’s lamp examination and potassium hydroxide (KOH) preparation were pursued first and demonstrated evidence of infection by H. werneckii. The patient was treated with topical clotrimazole cream and miconazole powder for one month, and her lesions cleared completely. Her lesions did not recur at her three-month follow-up appointment.Tinea nigra is an uncommon superficial dermatomycosis precipitated by  Hortaea werneckii, a melanized yeast-like fungus formerly classified in the literature as Exophiala, Phaeoannellomyces, and Cladosporium [Tinea nigra is a superficial dermatomycosis precipitated by osporium . This paosporium ,2. For tosporium .Patients present with asymptomatic, unilateral, enlarging, well-demarcated, brown to black macules with irregular borders on the palms or soles . The lesA 52-year-old woman presented several months after developing a painless, nonpruritic dark brown patch in her left foot inside the fourth toe web. She had never developed a lesion of this nature before. The patient’s past medical history was significant for lentigos, angiomas, and basal cell carcinoma on the nose treated two years earlier. No family members or close contacts had developed these lesions.Physical exam revealed a brown irregular patch in her left fourth toe web Figure . Wood’s A KOH examination of scrapings showed colonies of brown fungi both in spores and hyphae Figure . The patient was instructed to utilize clotrimazole cream and miconazole powder for one month. After one-month follow-up, her lesion resolved; after three-month follow-up, her lesions did not recur.H. werneckii inoculates the stratum corneum in the setting of microtrauma and incubates for two to seven weeks. The fungus thrives in the humidity and has affected individuals living in tropical and subtropical areas, such as Mexico, Venezuela, Chile, Brazil, India, Japan, and Panama [Tinea nigra develops when d Panama ,5-9. Casd Panama . Texas aH. werneckii proliferates and develops a melanin-like substance within itself [Once the fungus has infiltrated the lipid-rich, warm, and humid environment of the stratum corneum, n itself . The pign itself ,12. The n itself . KOH pren itself .Topical keratinolytic and antifungal agents are typically utilized to treat tinea nigra; hence, there is no need for systemic therapy. Remedies include undecylenic acid, Whitfield’s ointment, retinoic acid, ketoconazole, itraconazole, clotrimazole, or miconazole . In our H. werneckii, the underlying fungus, develops a melanin-like substance in the stratum corneum, resulting in the development of asymptomatic brown macules and patches with irregular borders. These pigmented lesions are concerning for melanocytic nevi or melanoma. This case highlights the concern and importance in differentiating H. werneckii from melanoma, especially in patients with a past history of skin cancer. While biopsy can aid in diagnosis, Wood’s lamp and KOH preparation can allow for efficient and noninvasive assessment of a pigmented lesion.Tinea nigra is an uncommon dermatomycosis typically presenting on palmoplantar surfaces of the body and rarely occurs on interdigital surfaces.


Neuroendocrine tumors (NETs) are benign tumors of the autonomic nervous system that rarely occur in the spinal canal. The gold standard treatment is gross total resection while preserving the patient’s neurologic functioning as complete surgical resection is curative. The surgical management of NETs could pose a challenge given their friable consistency, hypervascular nature, and proclivity to adhere to the cauda equina nerve roots.We present a case of a 62-year-old female with an incidental primary NET arising from the filum terminale internum, review the literature, and describe the surgical technique including the benefits of using an intraoperative ultrasound and some of the pitfalls of relying “blindly” on neuromonitoring. Early identification and disconnection of the tumor’s vascular pedicle, which usually runs through the cranial filum, devascularizes the tumor, prevents systemic complications from catecholamine release, and facilitates circumferential dissection off the en passage cauda equina nerve roots. Our patient remains neurologically intact and asymptomatic two years postoperatively and neuroimaging confirmed complete resection. Neuroendocrine tumors (NETs) or paragangliomas are rare tumors of neural crest origin that occur predominantly in the head and neck, mediastinum, adrenal gland and para-aortic ganglia, and very exceptionally in the spinal canal. Lumbar NETs have been reported and usually arise from preganglionic autonomic cells within the cauda equina nerve roots, accounting for <4% of all tumors in this region ,2. A verWe present a case of a 62-year-old female with a past medical history of treated hepatitis C and cirrhosis. An abdominal MRI obtained in the workup of hepatic duct dilatation revealed an incidental lumbar spine mass. A dedicated lumbar spine MRI Figure  showed aThe intraoperative ultrasound Figure  aided atWe identified the major blood supply to the tumor coming along the cranial filum terminale Figure  and thisThe patient recovered well and was discharged home on postoperative day 2. Further neuroendocrine workup included chromogranin A testing which was within normal limits. An octreotide scan and MRI of the neuro-axis showed no lesions. A follow-up MRI confirmed total resection Figure . The patNeuroendocrine tumors, also known as paragangliomas, are very rare tumors of neural crest origin that arise from autonomic extra-adrenal paraganglia . The terNETs of the lumbar spine are exceedingly rare, accounting for less than 4% of all tumors in this region ,2, and tNETs cannot be accurately and reliably differentiated based on neuroimaging alone as there is no pathognomonic finding. There are, however, a number of useful MRI findings attributed to the hypervascular nature of these tumors, venous congestion, and small foci of hemorrhage that aid in the differential diagnosis. Important T2 MRI findings include the classic “salt and pepper” appearance, serpiginous flow voids between the conus medullaris and the lesion, and a peritumoral hypointense hemosiderin rim suggestive of prior hemorrhage ,2,9,13. The definitive diagnosis is based on histopathology with the classic “zellballen” pattern, which are small nests of neuroendocrine chromaffin or “chief cells” with eosinophilic staining surrounded by a fibrovascular stroma containing supporting or “sustentacular cells”. Chief cells stain positively for both chromogranin and synaptophysin while the surrounding sustentacular cells stain positively to S100 on immunohistochemistry ,14.NETs of the filum and cauda equina are usually benign, well-encapsulated, and slow-growing World Health Organization (WHO) grade I tumors. The gold standard is surgical GTR, which can be achieved with good margins by removing the filum cranially and caudally, like shown in this case. We also advocate sending a small piece of cranial filum for immediate frozen histopathologic analysis to confirm clean margins as this would dictate if more filum has to be removed. Adjuvant radiation can be considered for any residual tumor. There is currently no role for chemotherapy . ApproxiWe utilized IOUS and IONM to methodically resect this tumor en bloc through a single level L4 laminectomy. The IOUS helped visualize the tumor in real time and confirmed adequate bony exposure prior to opening the dura  as the cWe present the successful microsurgical management of a NET originating from the FTI. GTR is curative and early devascularization is key for safe and effective resection. In this case, the tumor’s vascular pedicle reached the tumor through the cranial FT.


Roux-en-Y gastric bypass (RYGB) is considered the gold standard for weight loss surgery and is an effective, safe treatment for morbid obesity and associated metabolic derangements. Complications such as small bowel obstruction are rare with a reported incidence of 5%. Obstruction caused by hiatal herniation of the gastric pouch and alimentary limb occurs even less frequently. Prompt recognition and treatment are imperative as delayed intervention may result in significant morbidity. At the time of this manuscript there have only been four reported cases in the literature highlighting a paucity of clinical guidance for the recognition and management of this complication. Here we present a case of acute small bowel obstruction secondary to hiatal herniation of the gastric pouch and proximal Roux limb. Furthermore, we review the literature and discuss the key aspects for the management of this complication. Roux-en-Y gastric bypass (RYGB) is effective in the treatment of morbid obesity and its associated metabolic derangements ,2. HowevA 68-year-old female presented with a one-year history of progressive nausea, emesis, and sharp epigastric abdominal pain leading to eventual acute intolerance of oral intake for four days. She previously underwent a retro-colic Roux-en-Y gastric bypass (RYGB) surgery 12 years prior for treatment of her morbid obesity. Eight weeks prior to presentation, she underwent magnetic resonance cholangiopancreatography for evaluation of her chronic symptoms. Imaging revealed a large hiatal hernia containing the gastric fundus and the absence of any additional acute processes Figure  and B. GAn optical trocar was utilized to gain entry into the abdominal cavity. Exploration of the esophageal hiatus was performed. A type IV hiatal hernia involving the entire gastric pouch and proximal Roux limb was identified. The bowel was distended and edematous but viable. The pars flaccida was opened with a laparoscopic bipolar vessel sealer, which demonstrated the left crus being densely adherent to the Roux limb. After careful dissection, the hernia sac and contents including gastric pouch and proximal Roux limb were reduced out of the hiatus. The gastric pouch and Roux limb were closely inspected, both of which appeared viable. The anterior and posterior hernia sacs were separated from the bilateral crus and mediastinal structures until the contents were reduced and adequate esophageal length was obtained. A posterior cruroplasty was performed with 2-0 Ethibond suture. Intraoperative upper endoscopy confirmed smooth passage along the length of the esophagus, a normal appearing gastric pouch, patent gastrojejunostomy free from stricture and ulceration with a dilated yet viable Roux limb. Upper gastrointestinal study on post-operative day one demonstrated no leak or obstruction of contrast passage. She was discharged on post-operative day three with resolution of her symptoms except mild nausea.At one-, nine-, and 27-month post-operative follow-up visits, the patient reported complete resolution of symptoms, improved tolerance of liquids and solids, and regular bowel function.According to the American Society for Metabolic and Bariatric Surgery, 252,000 metabolic operations were performed in 2018 for obesity and its associated metabolic derangement, with RYGB accounting for 17% of the total operations . UtiliziHiatal hernia occurrence after RYGB can occur quite frequently after gastric bypass . The relA review of the literature identified four reported cases making our patient only the fifth reported case of bowel obstruction from a hiatal hernia after gastric bypass Table  4-7]. O-7. O4-7]In the presented case, a diagnosis of obstruction was suspected based on the patient’s history of protracted, intermittent abdominal pain, nausea, vomiting, and constipation. Although a large hiatal hernia containing gastric pouch was identified on MRI, the Roux limb was not within the hernia, suggesting spontaneous herniation of the alimentary limb leading to the patient’s acute-on-chronic symptoms. This would explain the patient’s prior intermittent symptoms, which worsened upon Roux limb incarceration a few days prior to presentation. This phenomenon of acute-on-chronic symptoms has also been observed with internal hernias leading to acute presentation requiring operative intervention ,14.A laparoscopic approach to this patient was undertaken for the demonstrated benefits of laparoscopic versus open paraesophageal hernia repair in the non-bariatric surgery patient . Key tenSmall bowel obstruction after RYGB often requires urgent surgical intervention as compared to small bowel obstruction in non-bariatric patients where a period of non-operative therapy can be trialed. Therefore, timely diagnosis is critical to provide timely operative intervention. In the absence of more common causes of bowel obstruction after RYGB, such as internal hernia, abdominal adhesions, or even small bowel intussusception, the treating physician must be aware of the possibility of hiatal herniation of the alimentary limb as a possible cause to avoid a delay in diagnosis and treatment.Bowel obstruction after RYGB is not uncommon. Obstruction from a hiatal hernia containing the gastric pouch and Roux limb is infrequent but carries the potential for significant morbidity. Treating physicians must remain cognizant of this possibility as prompt diagnosis and treatment are crucial. Laparoscopic repair is safe, effective, and can permit fast recovery. This case report demonstrates an appropriate course of management for patients to consider when treating this condition.


This study describes a conservative approach to surgical management of root canal perforation in maxillary lateral incisors. A patient was referred for retreatment of a maxillary lateral incisor. Her chief complaint was discomfort in the buccal mucosa. Periapical radiography showed radiopaque material consistent with sealing material inside the root canal. A CBCT scan was acquired and revealed a gutta-percha cone outside the root canal, from the middle third to beyond the root apex. The imaging examination showed that the pulp cavity had not been affected. Thus, we took the clinical alternative of surgically managing the perforation by sealing with MTA, thereby avoiding endodontic treatment, and followed up with only clinical and radiographic control. At the two-year follow-up, after the surgical procedure to remove the extruded filling material, we observed bone tissue formation and positive response to pulp tests, without any clinical signs or symptoms. Root perforation is considered an unpleasant error in an operative procedure. Once a perforation is properly diagnosed, located, and sealed with biomaterial, a favorable prognosis is often achieved. MTA offered good sealing of the perforation, with promising results. Decision-making using the CBCT scan enabled us to adopt a conservative approach and favored more reliable treatment predictability. Root perforation results in communication between the root canal system and the external tooth surface . When coIn clinical practice, pathological perforations are frequent. Iatrogenic root perforations may occur at any time in root canal treatment, during access cavity opening, root canal preparation, or post preparation. All these procedural operative errors may lead to treatment failure –6.In this respect, previous planning for root canal treatment becomes essential, particularly clinical and radiographic examination. Operative procedures prior to access cavity preparation involve removal of all carious tissue, restoration of defects, and weakening of the dentin structure, actions which could change the coronal references. Careful analysis of the coronary chamber based on 3-dimensional imaging exams, well-planned selection of a drill compatible with the coronary volume, and good lighting and magnification are essential procedures, because they favor visualization of the cavity during coronary opening, and prevent unpleasant accidents , 6.The advent of new technologies incorporated into imaging exams in endodontics, such as cone beam computed tomography (CBCT) –9, have An 11-year-old female patient in good general health sought treatment at the Public Dental Specialty Center, Brazil, with the chief complaint of mild discomfort in the buccal mucosa of the maxillary lateral incisor. The patient and the caregiver reported that endodontic treatment was carried out on this tooth 1 year prior, owing to a history of dental traumatism with coronary fracture.Clinical examination revealed no signs of swelling, fistula, or change in the tooth color . No painBased on the radiographic aspect of the patient's history, and the favorable condition of pulp vitality, a conservative surgical approach was considered the best choice. Surgery was limited to removal of the extruded gutta-percha and subsequent sealing of the root perforation without any endodontic intervention.Once the treatment plan was established, the patient signed an informed consent form agreeing to undergo the study procedures. A 2% lidocaine solution containing 1 : 100000 adrenaline  was administered as local anesthesia for the right infraorbital nerve, followed by the surgical phase, initiated by making a semilunar incision. After the surgical flap was made, the root perforation was located, and the extruded gutta-percha was exposed Figures . RemovalRoot perforations may occur at any time during root canal treatment and require preventive measures, so that unpleasant accidents of this nature can cease to become a risk factor for tooth loss. The consequences of root perforation may result in an inflammatory response associated with periodontal tissue and alveolar bone destruction .Diagnosis of the perforation is usually made by clinical investigation and imaging exams. After the advent of cone beam computed tomography (CBCT), anatomical alterations and pathological conditions not identified by way of conventional radiographic examinations became clearly evidenced and could be measured by volumetric study, a feature offered by CBCT. The accuracy in detecting apical periodontitis using CBCT is significantly greater than that of panoramic and periapical radiographs –12.Periapical radiography offers information on two planes and cannot perform three-dimensional reconstruction. This represents an important limitation that can compromise decision-making and prognosis, mainly in cases of buccal and lingual root perforation, in which overlapping structures can hide the pathological area.Root perforation caused by an operative procedure error represents the vast majority of cases and may be associated with lack of professional ability and factors related to anatomy and dental position, the presence of pulp calcifications, extensive caries, and the presence of intracanal posts , 13, 14.Given these characteristics, the prognosis for this clinical case would have been unfavorable, since the iatrogenic procedure was caused by a drill driven in high rotation in the middle third of the root, and the perforation was sealed only years later. However, after a two-year follow-up, the prognosis was very favorable, especially considering the positive response of pulp vitality. The good response seen in this case may have been related to the patient's age and the great pulp regeneration capability of immature teeth , associaIn the present clinical case, the conservative management of the root perforation, by avoiding the conventional treatment of the root canal, allowed the root to develop without any complications. Furthermore, image monitoring showed that the root was developing according to the classic pattern of physiological apical closure  Figures . This isIn regard to the imaging tests, the use of CBCT scans has brought numerous benefits to endodontics. Because CBCT is a dynamic examination, and images can be viewed in axial, sagittal, and coronal sections, the possibility of navigation represents an excellent resource that significantly improves diagnosis and planning –12. ThisHowever, the production of beam hardening artifacts can hinder the interpretation of the images and consequently compromise the diagnosis and decision-making in complex cases. More recently, software packages have been developed  to aid iIn this clinical case, the CBCT images were crucial in determining the suitable diagnosis and establishing a favorable interventive surgical plan. The sealer material appeared inside the root canal in the periapical radiography but was found to have been extruded by root perforation on the buccal surface of the tooth in the CBCT images, with destruction of the bone cortex. Measurements of the exact location of the root perforation could be made, thus enabling a conservative surgical approach to be performed with minimal damage to the gingival and bone tissues, and ensuring a better postoperative outcome and favorable prognosis for the patient. In the two-year follow-up, e-Vol DX software tools enabled viewing the repair in great detail at the surgical intervention site.dens invaginatus, taurodontism, root fusion, root dilaceration, giro version, microdontia, and palatogingival grooves, as well as physiological endodontic conditions, such as calcified/curved canals and pulp stones, are factors that may jeopardize the endodontic treatment and make it susceptible to iatrogenic maneuvers [Root perforation represents a significant iatrogenic error, committed especially by professionals less experienced in endodontics, but is a procedural error that may also be made by professionals with greater expertise. Anomalies in dental development such as C-shaped canals, aneuvers , 17.The use of modern technological tools and professional updating are attitudes that contribute to improving diagnosis and decision-making and that characterize the recommended conduct for both prevention and management of procedural errors, to ultimately offer better predictability of root canal treatment.


Primary scrotal lipomas are rare. We describe the case of a 47-year-old male with a giant scrotal lipoma who underwent a surgical excision. We report the clinical and radiological approach as well as the treatment of this atypical benign tumor. In urological practice, intrascrotal lesions are frequent, and the major challenge is to distinguish a benign lesion from a malignant one. Lipomas represent a small proportion of scrotal swellings, but it is necessary to have knowledge of this benign entity as a differential diagnosis.The patient was a 46-year-old man with no relevant medical history who presented in our institution with a large left scrotal mass. He first noticed a swelling ten years ago and reported a very progressive growth of this lump that became discomfortable and dysesthetic. No other symptoms were reported in anamnesis. Physical examination revealed a large, nonreductible, soft, and painless left scrotal mass with well-defined margins. Both testicles were not palpable due to the large size of the mass.The patient underwent scrotal ultrasonography  to confiMagnetic resonance imaging (MRI) showed a large extratesticular and extraepididymal mass with smooth margins and no intra-abdominal extension through the inguinal canal Figures . T2-weigAn ultrasound guided biopsy was performed and confirmed the diagnosis of lipoma.Surgical removal of the left scrotal mass was planned under general anesthesia, and a scrotal incision was performed. The lump appeared to be composed of fat, looked encapsulated, and was easily removed . The tesImmediate postoperative course was uneventful, and the patient was discharged on postoperative day one. Unfortunately, postoperative period was marked by the occurrence of a voluminous scrotal hematoma on day four, which required reintervention for drainage.On gross examination, the specimen weighted 480 g, measured 17 × 11 × 6 cm and was roughly oval. It was multilobulated, yellowish with soft to firm consistency. Histopathological examination showed a proliferation of well-differentiated and mature adipocytes of various sizes in all samples.Intrascrotal lesions are a heterogeneous entity. Although benign in most cases, clinical examination alone may not exclude malignancy. Many diagnostic pitfalls exist, and multiple anatomical structures in a confined space with all their own pathologies do not make the clinician's task any easier .Scrotal lipomas can originate from three different regions: (a) from the adipose tissue posterior to the spermatic cord, (b) from the spermatic cord, and (c) from the scrotal wall . The lasIntratesticular masses are 95% malignant while nonepididymal extratesticular tumors, including those originating from the scrotum and spermatic cord, are most commonly mesenchymal benign tumors (97%) . HoweverTo our knowledge, there are very few cases of primary scrotal lipoma described in the scientific literature. Symptoms and patient discomfort vary according to the size of the lipoma: their weight varies from 225 g to 9 kg . Lipoma The biopsy performed in this context does not exclude a malignant focus because of the size of the lesion and its possible heterogeneity. Being an encapsulated and noninfiltrative mass helped us differentiate it from lipomatosis and the absence of abnormal mitosis and cellular atypia to differentiate from liposarcoma. Some very rare cases of malignant degeneration of giant scrotal lipomas have been described in scientific literature .Primary scrotal lipomas are rare and benign tumors but should be kept in mind by the clinician as a differential diagnosis of scrotal swelling.First line imaging remains ultrasound but does not allow differentiating a lipoma from a liposarcoma with certainty and must therefore be complemented by scrotal MRI, especially in the case of a large tumor.The treatment of choice is surgical excision, and the histological analysis of the specimen allows a diagnosis of certainty.


An inflammatory myofibroblastic tumor is a rare tumor of mesenchymal background commonly found in the pulmonary system. It is rarely found as a primary tumor in the gastrointestinal tract. We report an unusual presentation of this rare lesion causing intussusception and intestinal obstruction in a 39-year-old male. Inflammatory myofibroblastic tumor (IMT) belongs to a class of rare spindle cell tumors and was previously called inflammatory pseudotumor or plasma cell granuloma. The World Health Organization classifies IMTs as tumors of intermediate biological potential since both local recurrence and metastases are possible.A 39-year-old male presented to the surgical outpatient department with complaints of abdominal distension and pain for 3 to 4 days. He also reported vomiting and obstipation for the same duration. His past medical and surgical history was not significant. Physical examination revealed abdominal distension with tenderness in the right lower quadrant. Bowel sounds were hyperperistaltic. Laboratory investigations were normal. Abdominal ultrasound revealed bowel-within-bowel appearance in the right lower quadrant, the segment being approximately 8-cm long with a lead point of approximately 50 × 29 × 28 mm in the cecum.We performed colonoscopy and planned colonoscopic reduction and removal of the lead point. A lead point was seen projecting through the ileocecal valve . ThoughAn IMT is a rare tumor of mesenchymal background commonly found in the pulmonary system. Dr. H. Brunn first described IMTs in 1939.Intussusception due to IMT is rare. Diagnosis of IMT involving the GIT requires a high index of suspicion, detailed history, physical examination, and imaging studies that are necessary for early recognition and diagnosis. Surgery is the cornerstone of treatment. Long-term follow-up is required to detect recurrence.


Peripheral odontogenic keratocyst (POKC) is a rare soft tissue entity showing the same histological characteristics of odontogenic keratocyst. Herein, we report two cases of POKC affecting the gingiva/alveolar mucosa. Case 1. A 43-year-old female was referred for evaluation of a painless well-defined nodular, sessile, non-tender swelling in the right maxillary buccal gingiva. No radiological alterations were observed. The patient was submitted to excisional biopsy and histological diagnosis was POKC. There were no signs of local recurrence after a 4-year follow-up. Case 2. A 63-year-old female was referred for evaluation of a painless well-defined nodular, sessile, yellowish swelling in the anterior mandibular alveolar mucosa. No radiological alterations were observed. The patient was submitted to excisional biopsy and histological diagnosis was POKC. Patient recovery was uneventful but she did not return for follow-up. POKC should be considered in the differential diagnosis of gingival cystic swellings and can be managed through conservative surgery. Key words:Odontogenic keratocyst, peripheral, gingiva, alveolar mucosa. Odontogenic keratocyst (OKC), a potentially aggressive odontogenic cyst, accounts for 12-14% of all odontogenic cysts and show a predilection for the posterior mandible . Therefo-Case 1A 43-year-old woman was referred for evaluation of a 4-year lasting oral swelling in the right maxilla. Medical history was non-contributory and the patient denied any tobacco or alcohol consumption. Extraoral clinical examination showed no alterations. Intraoral clinical examination revealed the presence of a single painless well-defined nodular, sessile, non-tender swelling covered by normal oral mucosa, measuring 15 mm and located in the in the upper right buccal gingiva between the second premolar (#15) and first molar (#16)   . Most caPeriapical and panoramic radiographs are essential in the diagnosis of any gengival swelling in order to exclude central intraosseous location of the lesion. To confirm the peripheral extraosseous location of the lesion no bone medullar destruction should be present, as shown in both present cases . In someAs most POKC are located in the gingiva, differential diagnosis usually includes other odontogenic cysts that could affect this region, especially the gingival cyst of the adult and the peripheral calcifying odontogenic cyst. Both can produce a cup-shaped painless swelling filled by a bluish or bluish-gray fluid and superficial cortical bone resorption . The secDue to the limited number of reported cases, there is still some controversy on the biological behavior of POKC. As conventional intraosseous OKC can be locally infiltrative, presenting a higher local recurrence rate when comparing to other cysts, many therapeutic options have been suggested for this condition ,7,23. NeIn conclusion, POKC is a rare condition that mostly affects adults and can affect both the posterior and anterior gingival/alveolar mucosa. It can clinically mimic other peripheral odontogenic cysts and should be managed by conservative surgical removal.


Gastric Schwannomas are rare benign slow‐growing tumors and warrant treatment/resection only when symptomatic. Watchful waiting is recommended for incidental or asymptomatic schwannomas. Gastric Schwannomas are rare benign slow‐growing tumors and warrant treatment/resection only when symptomatic. Watchful waiting is recommended for incidental or asymptomatic schwannomas. An 84‐year‐old lady with a 4‐year history of severe acid reflux, peptic ulcer disease presented with 1‐month history of epigastric abdominal pain, nausea, and vomiting. There was no history of weight loss, foreign travel, or sick contacts. Computed tomography of the abdomen done in emergency room showed a 4 × 4.1 × 4.1 cm mass in the gastric fundus of indeterminate nature  is a benign tumor made up of Schwann cells primarily affecting the peripheral nerves. Given their nonmalignant potential, no further treatment other than resection of a symptomatic Schwannoma is required. Stomach is an unusual location for presentation of a Schwannoma.None declared.SM: helped in writing the manuscript, revised submission, did literature search, and is corresponding author. NG: did endoscopy, and actively managed the case and guided in writing manuscript. AB: is Hematology‐Oncologist who was actively involved in patient care, helped in getting pathology slides, and gave valuable suggestions in writing the clinical image. RV: took care of the patient through the hospital course, helped in writing manuscript, took pictures of pathology, endoscopy slides, and did final proof reading of the submission.


Renal cell carcinoma (RCC) classically presents as a triad of hematuria, loin pain, and a palpable mass. However, Renal cell carcinomas (RCCs) nowadays are more commonly present as incidental findings rather than symptomatic. Wunderlich syndrome is a rare first presentation of RCC.We present a clinical case of spontaneous renal hemorrhage with unclear etiology that was treated with therapeutic embolization and was found to have renal mass after long follow up.In regards to treating Wunderlich syndrome, some authors favor angioembolization and follow up. Others proposed radical nephrectomy in conditions with no apparent etiology and normal contralateral kidney because of the high incidence of small renal tumors. Spontaneous perinephric hematoma of unknown etiology should be followed up regularly with a CT image for concerning of impending renal tumor The spo2A 39-year-old man presented to the emergency department with severe left flank pain. He reported a six-hour history of severe, non-radiating but constant pain, with a sudden onset, which progressively worsened. There was no history of trauma or stone disease. He did not have any previous history of medical disorder, and presently, was not on any medication. He was a heavy smoker (2 packs per day). On examination, his vital signs were stable. Abdominal examination showed generalized abdominal guarding and tenderness over the left costovertebral angle. Bowel sounds were present, and a poorly defined, palpable mass was present on the left side of the abdomen. Results of blood tests showed a decrease in serum hemoglobin levels (from 14.8 g/dL to 10.1 g/dL) within an hour, with a concomitant decrease in hematocrit level (from 37% to 29%). Intravenous fluid administration was initiated and two units of cross-matched blood was transfused. Thereafter, a computed tomography (CT) scan was performed, which revealed a 9.7 × 9 × 11 cm left perirenal hematoma mainly occupying the lower pole of the left kidney A, B. TheAfter four days of observation and attaining a stable hemoglobin level, the patient was discharged home and scheduled for a follow-up abdomen CT scan in the outpatient clinic.The follow-up CT scan showed reduction of the hematoma by 50 percent as compared with the initial CT scan, and no other abnormality or lesion was noted A, B. TheThe patient was routinely followed up with serial ultrasounds for two years, and the cause of the perirenal hematoma could not be identified. Therefore, a decision was made to perform an abdominal MRI, which showed a heterogenous mass measuring 6 × 5 × 4 cm in the left renal lower pole; the mass was suspected to be a RCC A, BFig. Thus, a left laparoscopic radical nephrectomy was performed with no perioperative complications . The patResults of histological examination of the surgical specimen revealed chromophobe RCC, which was 5.8 cm in its largest dimension, negative for sarcomatoid and rhabdoid features, negative for tumor necrosis, but positive for lymphovascular invasion. The tumor was assigned a pathological stage of pT3a pNx cM0.3With the advent in sophisticated imaging techniques, the classical presentation of loin pain, palpable mass, and frank hematuria are less commonly seen in clinical settings. However, RCCs are now more commonly discovered as ‘incidentalomas’ on radiological imaging for alternative abdominal pathologies . The spoIn the treatment of Wunderlich syndrome, some urologists favor an early or immediate exploratory surgery . Other uAnother concern is the efficiency of CT to diagnose renal tumors at the time of bleeding. CT remains one of the most reliable modalities to diagnose retroperitoneal hemorrhage and RCCs . KendallIn contrast, Morgentaler et al. proposed nephrectomy only in patients with nonfatty lesions other than hematoma. All other patients were followed up with serial CT scans . BosniakFor malignant tumors diagnosed on initial CT, radical nephrectomy is eventually required. However, in the renal hemorrhages thought to be benign, embolization may be the sole modality used. If these patients were later found to have a malignancy on the follow-up CT, delayed surgery would not only affect the overall resect ability of the tumor, but also the clinical staging of the disease ,11.When CT is contraindicated , magnetic resonance imaging (MRI) may be useful, especially for follow-up after an initial improvement in acute hemorrhage. Even if a patient undergoes multi-modal imaging both before and after evacuation of the hematoma, the tumor causing the hemorrhage may be extremely small to be visualized by CT or angiography. This finding was observed in one patient in our series in whom the initial imaging (performed both before and after the evacuation of the hematoma) did not show any abnormality. The patient presented 1 year later with hematuria, and follow-up imaging demonstrated a small, lower pole RCC, which was similar to our present case ,11. PrevMoreover, the pathological type of the RCC plays a major role in tumor growth and progression. In our case, one of the explanations that the chromophobe tumors had slow progression rate compared to other types.4Patients with spontaneous perinephric hematoma due to unknown etiology should be followed up regularly with CT scans to assess the risk of an impending renal tumor. If the etiology cannot be ascertained at initial examination, a follow-up CT scan should be performed with at least 3-month intervals until the hematoma resolves and a definite diagnosis is possible. Furthermore, MRI might be useful to diagnose the uncertain findings in such patients.No conflict of interest.This research did not receive any specific grant from funding agencies in the public.Case reports are exempted from IRB/ethical approval at the institution.Patient has given his consent for the case report to be published. A copy of the written consent is available, at anytime.Abdullah W. Aldughiman: draft of the manuscript and primary author.Abdulrahman Alsunbul: draft of the manuscript and review of the literature.Abdullah Al-Gadheeb: grammar and spelling and review of the literature.Muaiqel Almuaiqel: collection of figures.Ahmad Alzahrani: review of the literature.Tarek Alzahrani: review of the literature.Abdullah Alghamdi: review of the literature.Hamad Alakrash: primary consultant & Surgeon final modification.NA.NA.Not commissioned, externally peer-reviewed.


Mature cystic teratoma originating in the pancreas is very unusual, often observed as an incidental finding during routine examinations or recognized perioperatively as the patients present with very unspecific clinical symptoms. The confirmatory diagnosis of a pancreatic cystic teratoma is generally made by histopathology after surgical excision. So, the preoperative diagnosis is very challenging, especially differentiation from the other pancreatic pathologies.A 23-year-old woman was admitted to our hospital with a complaint of mild grade periumbilical abdominal pain. A pancreatic mass was revealed on a preliminary abdominal ultrasound examination. Her medical history was unremarkable with no long-standing illness or malignancy.Mature cystic teratoma in the head of the pancreas.Roux-enY choledochojejunostomy with gastrojejunostomy was performed, excising the tumor from the pancreatic head.The postoperative course was uneventful; the patient was asymptomatic and has no evidence of recurrence on a 2-year follow up.Pancreatic cystic teratoma is a benign, well-differentiated, and extremely rare congenital tumor. MRI is the choice of imaging modality and phase-GRE or fat suppression is the best technique for pre-operative diagnosis. The emergence of a mature pancreatic cystic teratoma was first described by Kerr in 1918. We report the rare case of a primary pancreatic dermoid cyst in the head of the pancreas in a 23-year-old female patient presenting with very unusual non-specific symptoms.Teratoma is a congenital tumor that originates from totipotent stem cells which are derived from all three germ layers namely ectoderm, endoderm, and mesoderm. They probably originate from the aberrant germ cells which are arrested during migration to the gonads in the early embryonic life. They usually emerge along the midline of the body and can be classified as mature, immature, and monodermal or highly specialized types. Mature type teratoma is benign and immature types are malignant. Moreover, mature type teratoma is further subdivided into a cystic and solid types, out of which, the cystic type is most commonly seen in the ovary and testes. However, a teratoma in the pancreas is an extremely unusual primary site of origin.22.1A 23-year-old female patient presented to the out-patient department with a history of intermittent mild grade periumbilical abdominal pain for one day and she was put under observation considering being an acute abdomen. The pain was not alleviated, she was admitted into our hospital for further evaluation and management. Her physical examination and vitals were unremarkable. She did not have any history of long-standing illness and malignancy. There is no history of any abdominal surgeries or trauma. Preliminary ultrasonography (USG) of the abdomen was recommended.3All the materials and methods are carried out according to the guidelines and regulations set by our institution. Based on the provisional findings on USG, a complete radiological assessment was recommended with non-contrast computed tomography (NCCT/Plain) and contrast CT (CCT), followed by an abdominal Magnetic Resonance Imaging (MRI), both plain and contrast-enhanced sequences were obtained respectively.4Abdominal USG revealed a well-defined mass of size 8.3 x 7.4 cm along the head of the pancreas that showed predominant echogenicity within a thin capsule. Non-contrast abdominal CT scan revealed a hypodense mass measuring about 8.3 x 7.4 x 7.1 cm, arising from the head of the pancreas with evident relative mass effect on the surrounding tissues. There were no other corresponding signs like fat stranding and effusions indicative of pancreatitis or no evidence of pancreatic and common bile ducts dilatation. A solid fat component and the focal calcified cystic wall were noted Fig. A-B, as w5Intraoperatively, the tumor was seen to originate from the head of the pancreas and was adherent to the duodenum, common hepatic artery, and portal vein. Roux-en-Y choledochojejunostomy with gastrojejunostomy was performed, excising the tumor from the pancreatic head. An excised specimen sent for further histopathological examination revealed yellowish-white material, evident macroscopically suggestive of caseous necrosis Fig. A. Micros6 Ovaries and testes are the most common sites of origin but can also be found at any site along the route of ectodermal cell migration, usually in the midline, such as the brain, cranium, mediastinum, omentum, retroperitoneum, and sacrococcygeal regions. However, a cystic teratoma in the pancreas is very rare, including this case, there are 51 cases reported in the literature to date. On reviewing the literature of all 50 cases, 54% were male and the remaining 46% were female suggesting a slight male predominance. However, the age groups were 4 months to 75 years old and the mean age group was 37.7 years old within both sexes. Most of the patients typically present with non-specific gastrointestinal symptoms like abdominal pain, nausea, vomiting, lower back pain, and weight loss, and sometimes with completely irrelevant symptoms.Teratoma is a congenital tumor arising from embryonic residues as germ cell tumors which are divided into three sub-types namely mature, immature, and monodermal or highly specialized. Most of the mature types are strictly regarded as well- differentiated benign lesions, so often referred to as dermoid cysts. The present study also showed the slightly elevated label of both CA 19-9 and CA-125 which was 54.54 U/mL and 86.14 U/mL respectively. For the unremarkable routine laboratory results and clinical presentation, the diagnosis of mature teratoma mainly relies on imaging techniques such as abdominal ultrasonography (USG), Computed Tomography (CT), Magnetic Resonance Imaging (MRI). Moreover, the imaging appearance of the lesion depends on the proportions of tissue components such as the presence of fat, fat-fluid levels, and calcifications.With varying rates of sensitivities and specificities, tumor markers like CA 19-9, CA 125, CA 72-4, and CEA have been useful in differentiating benign from malignant. A very high label of CA 125 and CA 19-9 will represent the malignant variety and a small increment from the normal range will represent a benign lesion. The average size of the tumor was approximately 8 cm with a minimum and maximum size of 2.2 cm and 25 cm respectively.,3 Given the unusual location, the pancreas, many are not diagnosed until much later in adulthood, despite originating in utero as congenital tumors.Previous studies have suggested that the most common site was on the pancreatic body (35.6%), along with the head (33.3%) and followed by the tail (15.5%). Since the hyperechoic appearance of the regional fat component overlaps with other types of soft tissues, USG alone cannot be considered as the diagnostic tool.On the abdominal USG, a clear margin without internal septations along with areas of high-fat content appear hyperechoic, whereas calcified tissues are seen as focal areas with posterior acoustic shadowing. So, CT is considered as a sensitive technique and superior to USG for characterization, localization, as well as intratumoral detection of calcification or fat, can be evaluated very easily.On CT scans, they usually appear as a round hypodense lesion with a clear boundary and Hounsfield unit (HU) measuring around −20 HU to −140 HU, which could be due to intratumoral content mainly fat. The intratumoral content like fat, fat-fluid levels, and calcification are highly suggestive of a mature cystic variety of pancreatic teratoma. Some hemorrhagic lesions (containing methemoglobin) will also demonstrate similar imaging features. So, distinction by conventional MR imaging techniques will be difficult. Therefore, the use of techniques like phase-shift GRE or fat suppression is recommended in the differential diagnosis with the hyperintense signal in T1WI. For the differentiation, Phase-shift GRE sequences correspond to in-phase and out-of-phase with the same repetition time (TR) but with two different echo time (TE) values. Microscopic intralesional fat from water within the same voxel can be easily identified and differentiated by observing loss of signal intensity on the phase-shift GRE sequence which shows drop out signal  on the out-phase images compared to the in-phase images. Thus, these techniques should be useful and recommended in the differential diagnosis of such lesions by MR imaging.MRI, on the other hand, provides an excellent soft-tissue contrast resolution and is highly specific for detecting soft tissue lesions. T1WI in-phase (IP) and out-of-phase (OOP) imaging are very useful for the fat-containing lesions and to identify the disease states related to the presence of diffuse or focal steatosis in the liver, pancreas, adrenal glands, etc. Pancreatic lesions like teratoma have high signal intensity on T1WI and T2WI TSE (turbo spin-echo) images similar to that of subcutaneous fat.So, USG plays a very important role in early detection, plain CT, and MRI help in classifying these tumors, contrast-enhanced studies help in analyzing the intra-tumoral characteristics for complete pre-surgical evaluation. However, the imaging features of pancreatic teratoma are often found to be similar to the other pancreatic neoplasm which can be easily misdiagnosed.Surgical excision is the principal method for the management of pancreatic cystic teratoma which is highly dependent on the location and size of the tumor. Tumor resection, pancreaticoduodenectomy or Roux-en-Y choledochojejunostomy, external cyst drainage, or cyst gastric anastomosis are feasible. However, in recent years, simple external drainage of cysts is no longer practiced because of recurrence and emergence of pancreatic fistula. Moreover, internal drainage of the cystic gastric anastomosis is not recommended as it requires a long-term follow-up. Based on our case study, it is convenient to consider that such cystic tumors do not show a malignant potential, so, it is also feasible to choose close observation, anticipating to further evaluate the nature of the tumor completely during follow-up.77.1 It often causes a remarkable indentation on the posterior wall of stomach or adjacent bowel loop, a extrinsic mass effect demonstrating a “pad sign”. A contrast study will demonstrate mild early enhancement of the wall. On MRI, the cysts demonstrate a homogenous low T1 signal intensity center and homogeneous high T2 signal intensity. However, when pseudocyst is complicated due to necrosis, hemorrhage, or infection it will demonstrate the heterogeneous signal intensity.They are the most common complications of acute/chronic pancreatitis and pancreatic trauma. The tumor predominantly occurs in the head of the pancreas. On CT, the presence of limited round or oval shape, well-circumscribed, a homogeneously hypo-attenuating lesion with thick septations, and usually surrounded by a well-defined enhancing margin favors the diagnosis of the pseudocyst.7.2 CT scan typically demonstrates numerous small cysts, sometimes described as a ‘bunch of grapes’, seen in pancreatic head, measuring few millimeters to 2 cm. On MRI, T1WI demonstrates a typical low signal while T2WI shows a high signal if a mass contains cystic components and a low signal if fibrous scar. A fibrous central scar with or without a characteristic stellate pattern of calcifications is considered to be virtually pathognomonic for Serous Cystadenoma at CT or MR imaging.Serous cystadenomas are common benign cystic neoplasms of the pancreas often located in the head of the pancreas. They are usually seen in older women over 60-year-old and uncommonly reported as malignant.7.3 MRI imaging demonstrates heterogeneous high signal intensity on T1WI and homogenous high signal intensity on T2WI.Mucinous cystadenomas often occur in middle-aged women, mainly in the body or tail of the pancreas with high malignant potential. On CT imaging, the lesion manifests as a single round, internal septa with an average size of 10 cm. The wall of the cyst is usually thick and eggshell calcifications may be seen.7.4 The abdominal CT shows large size solitary lesion, heterogeneous density mass with occasional. On MR, the papillary solid part T1WI appears as a low to iso-intensity and hyper to iso-intensity on T2WI moreover on contrast examination, the solid components display heterogeneous enhancement.SPT is an uncommon borderline or low-grade malignant potential tumor, which occurs mainly in women over 20 years old, and can arise anywhere in the pancreas.7.5 in 1980. Since then only case reports have been reported. The age of onset varies from 12 to 70 years, with a slight female predominance. Racial factors have been associated with ECIPAS reported mostly in Asian races, occurring mostly in the tail of the pancreas with a diameter ranging from 1.4 cm to 15 cm. On CT plain scan, it shows a hypodensity in the cystic part, the solid part, and the cystic wall appeared as isodense or slight hyperdensity; on contrast-enhanced scanning, the cystic part does not enhance, but enhancement may be obvious along the solid part, especially along the cystic wall. On MRI, the cystic part shows a hypointense signal on T1WI, a hyperintense signal on T2WI, and a slightly high signal on DWI. The imaging features of the cyst are that the solid components of the cyst show similar enhancement with the adjacent splenic parenchyma on enhanced CT and magnetic resonance T1 images. The correct preoperative diagnosis of ECIPAS required sufficient enhancement of the respective splenic tissue around the cyst.ECIPAS was first reported by Davidson et al7.6LECs are one of the rare non-neoplastic true cysts of the pancreas, predominantly occurring in mostly in men that are aged 20 to 85 (average incidence around 55 years) with no specific clinical manifestations. CT features are slightly low or isodense solitary mass mostly in the body and tail of the pancreas with visible cystic walls and intralesional septations. They can also occur in or around the pancreas. Spotted calcification along the cystic walls, slight enhancement of the posterior cystic walls, and septations might be evident. There will be no dilation of the pancreatic duct. On MR, it is characterized by a high signal on T1WI and low signal on T2WI.7.7Written and informed consent was obtained from the patient for publication of this case report and accompanying images.8Mature cystic teratoma is also called a dermoid cyst of the pancreas. An ovary is the most common primary site and the pancreas is the rarest. A well-defined encapsulated mass with intralesional fat, fluid-fat, and calcifications are highly suggestive of mature teratoma. MRI is the choice of modality and phase-GRE or fat suppression is the best technique. Drop out a signal on the out-phase images compared to the in-phase images indicates intravoxel lipid. Radiologists should be familiar with this entity and include it into the differential diagnosis of cystic neoplasm of the pancreas.Conceptualization: Xin he Zhou.Data curation: Xin he Zhou, Bimbadhar Valluru, Kalyan Sharma, Ling Liu.Formal analysis: Xin he Zhou, Ji Kong Ma, Bimbadhar Valluru, Kalyan Sharma, Ling Liu, Jin Bo Hu.Investigation: Xin he Zhou, Bimbadhar Valluru, Kalyan Sharma, Ling Liu, Jin Bo Hu.Methodology: Xin he Zhou, Ji Kong Ma, Bimbadhar Valluru, Kalyan Sharma, Ling Liu, Jin Bo Hu.Project administration: Ji Kong Ma, Ling Liu.Resources: Bimbadhar Valluru, Ling Liu, Jin Bo Hu.Supervision: Ji Kong Ma, Kalyan Sharma, Ling Liu, Jin Bo Hu.Validation: Bimbadhar Valluru, Kalyan Sharma, Ling Liu, Jin Bo Hu.Visualization: Bimbadhar Valluru, Kalyan Sharma, Ling Liu, Jin Bo Hu.Writing – original draft: Xin he Zhou, Ji Kong Ma.Writing – review & editing: Xin he Zhou, Ji Kong Ma, Bimbadhar Valluru, Kalyan Sharma, Ling Liu, Jin Bo Hu.


Spontaneous mesenteric hematoma (SMH) is a rare condition characterized by intraperitoneal hemorrhage of unknown etiology. SMH without worsening of general status allows conservative management; however, patients showing chronological changes on imaging require surgical intervention to rule out possible malignancy.A 69-year-old man was referred to our hospital to evaluate an abdominal mass with no associated clinical symptoms. He had a history of chronic hepatitis C and diabetes mellitus. Six months earlier, computed tomography (CT) revealed a 75-mm tumor arising from the jejunum, suspected to be a gastrointestinal stromal tumor (GIST) of the small intestine. Following a further 6 months of observation, the patient was referred to our hospital. Abdominal contrast-enhanced CT revealed a well-defined heterogeneous round tumor with a maximum diameter of 75 mm adjacent to the upper jejunum. The tumor was accompanied by calcification at the periphery, with no evidence of augmentation over the prior 6 months. Diffuse lymphadenopathy was observed around the aorta and splenic artery. Under the diagnosis of GIST arising from small intestine, the patient underwent elective surgery. The resection revealed an elastic soft tumor at the mesentery adjacent to the upper jejunum with severe adhesion between the tumor and jejunum. The tumor origin was unclear; thus, we performed mesenteric excision and partial enterectomy without lymph node dissection.The tumor was surrounded by fibrous capsular tissue containing massive hemosiderin deposits and cholesterol crystals showing partial calcification, resulting in a diagnosis of spontaneous hematoma of the mesentery.We report a case of SMH mimicking small intestinal GIST. It is difficult to diagnose long-established SMH because its radiological features change with time, and more case reports are needed to improve the accuracy of diagnosis. Mesenteric hematoma is a rare condition resulting from localized bleeding in peripheral mesenteric vessels that is generally caused by abdominal trauma, postoperative complications, or aneurysm –3. PreviA SMH patient present with nonspecific symptoms and diagnosis is generally made based on abdominal contrast-enhanced computed tomography (CT), ultrasound, or magnetic resonance imaging (MRI). SMH can be safely observed if the patient shows no sign of worsening general status or exacerbation of symptoms; however, the onset of diagnostic difficulty due to changes in the imaging findings over time requires surgical resection for both diagnosis and treatment.A 69-year-old man, without a remarkable family history, was referred to our hospital with an undiagnosed, asymptomatic abdominal mass. He had a history of chronic hepatitis C and diabetes mellitus, and generally used a proton pomp inhibiter and branched-chain amino acid formula without any anticoagulant. The patient was also a habitual drunkard. Six months earlier, his previous doctor diagnosed chronic hepatitis and detected a 75-mm tumor arising from the jejunum by CT imaging Fig. a. The domax 1.5–2.0) of FDG around the tumor, but no sign of FDG accumulation inside the tumor (Fig. Abdominal contrast-enhanced CT revealed a well-defined, heterogeneous, round tumor, with a maximum diameter of 75 mm adjacent to the upper jejunum, with no worsening for 6 months Fig. b, c. TheBased on the findings to this point, we diagnosed the tumor as GIST arising from jejunum and performed a laparotomy for the purpose of diagnosis and treatment. An elastic soft tumor was located at the mesentery adjacent to the upper jejunum with severe adhesion between the tumor and jejunum. The tumor origin was unclear; thus, we performed mesenteric excision and partial enterectomy without lymph node dissection.Histological analysis of the resected tumor showed a cystic lesion surrounded by fibrous capsular tissue containing extensive hemosiderin deposits and cholesterol crystals with partial calcification Fig. a. The cySMH is a rare condition involving intraperitoneal hemorrhage . The mosTo the best of our knowledge, only 10 reported cases of SHM accompanied by comprehensive and publicly available data appear by MEDLINE searching of English literature (Table Takashimizu et al.  reviewedIn our case, the mesenteric hematoma was accompanied by an enhanced periphery with calcification, but we did not find this feature in previous reports. It is not surprising that chronic hematoma becomes calcified, since similar findings are reported regularly with long-term hemorrhage such as chronic subdural hematoma , 20; howThe usefulness of tumor calcification pattern for distinguishing SMH from small intestinal GIST remains unclear, largely because few reports have investigated the calcified hematoma with the exception of chronic subdural hematoma. Such calcification is estimated to occur in 0.3–2.7% of cases with chronic subdural hematoma, identified by high density at the lesion rim by CT . On the In summary, we described a case of SMH mimicking small intestinal GIST. It is difficult to diagnose long-term SMH because its radiological features change over time, and differ among cases. Further case reports are needed to improve the accuracy of diagnosing SMH.