The adenomatoid odontogenic tumor is a relatively uncommon lesion which mainly affects females in their second decade of life, exhibiting predilection for the anterior region of the maxilla. The lesion is usually associated with the crown of an enclosed tooth, most commonly the maxillary canine. In this paper we present a case of adenomatoid odontogenic tumor associated with a dentigerous cyst affecting the left maxillary region in a 13-year-old female. The authors also discuss clinical, radiographic, histopathologic and therapeutic features of the case. The adenomatoid odontogenic tumor is a benign tumor that is keen to involve the anterior region of the maxillary bones, with a larger number of cases in females, in their second decade of life, and that may, sporadically, be associated with odontogenic cystic lesions. The present study aims at reporting an uncommon case of adenomatoid odontogenic tumor, associated with a dentigerous cyst, as well as discussing the clinical, radiographic, histopathological and therapeutic characteristics related to the case.A 13 year old female had a rigid mass in the oral cortical bone of her maxilla, with mucosa integrity, and lacking teeth 23 and 24 on the affected side. Panorama radiographic study revealed a radiolucent lesion, circumscribed, with few radiopaque areas inside, associated to the canine tooth, which was shifted towards the nasal cavity.We carried out an intraoral surgical intervention through a Neumann's incision, from the alveolar and left central superior incisive gingiva all the way to the first ipsilateral molar, shifting the mucoperiosteum. After that, the tumor mass and the unerupted canine were removed , and finThe material removed was then sent to the Pathology Department of the Oral Pathology Division of the Dentistry School of UFRN. After routine histology on the material, under light microscopy they observed fragments of the odontogenic lesion, characterized by the proliferation of fusiform/globular cells, arranged as large islands and solid sheets, as well as numerous structures similar to ducts, lined by low cylindrical or cubic cells, of polarized nuclei . OccasioAfter 12 months, the patient returned to our department, not showing clinical or radiographic signs of tumor recurrence. We did notice bone remodeling and neoformation.The clinical findings presented in this case corroborate characteristic reports present in the literature, such as a higher incidence in women1, especially within the second decade of life 2, and the maxilla lesion associated with an erupted toothThe radiographic findings presented hereby are peculiarities of the adenomatoid odontogenic tumor follicular variant, presenting itself as a radiolucent unilocular lesion, well outlined, associated to the crown of the unerupted toothFew cases of adenomatoid odontogenic tumors associated with dentigerous cysts are reported in the literature. Santos et al.Because of its low tendency to recur, the case hereby presented was treated by conservative surgical enucleation associated with the removal of the unerupted dental element, and such procedure was proposed in numerous papers4,6. In favorable cases, dentigerous cyst associated adenomatoid odontogenic tumor marsupialization provide a conservative character to the treatment, and allow the later eruption of the dental elementThere are very few cases of adenomatoid odontogenic tumors associated with dentigerous cysts reported in the literature. The present investigation describes a case of adenomatoid odontogenic tumor associated with a dentigerous cyst, highlighting the importance of the histopathological exam in the cystic lesions of the maxillary bones. Moreover, we stress the conservative surgical intervention as a treatment of option for adenomatoid odontogenic tumors.


Mediastinal cavernous hemangiomas are extremely rare vascular tumors. To the best of our knowledge less than 20 cases of posterior mediastinal hemangioma have been reported in literature, and this is the first case of mediastinal cavernous hemangioma presenting with massive pleural effusion.We report a case of a 56-year-old female who presented with cough and chest tightness and was found with a massive pleural effusion in chest CT. It was mistaken for a malignant pleural effusion. A posterior mediastinal lesion was observed after thoracic drainage and misdiagnosed again as neurofibroma. The lesion was resected and post-operative histopathology suggested that it was a cavernous hemangioma. Post-operative recovery was uneventful, and a follow-up examination nearly 14 months later showed the patient had no recurrence.Due to the lack of diagnostic specificity and variety of clinical manifestations, CHM is often misdiagnosed prior to resection. This is the first description of mediastinal hemangioma presenting with massive pleural effusion. It is very important to consider mediastinal hemangioma before operation to reduce surgical complications, and it should be in the differential diagnosis of posterior mediastinal masses. Mediastinal cavernous hemangioma (CHM) is a rare benign tumor with an incidence of less than 0.5% of mediastinal masses . Most ofA 56-year-old nonsmoking female presented with cough and chest tightness for 20 days with no past medical history. Vital signs were stable except diminished left lung sounds were noted in chest auscultation. She was then found to have a large left-sided pleural effusion in CT scan Fig. A. PleuroComplete resection was performed by video-assisted thoracoscopic surgery (VATS). On direct visualization, there was a lesion in the posterior mediastinum close to left paravertebral region with moderate hardness, not adhering to the surrounding spine, mediastinum or chest. The capsule was complete and the boundary was clear. Thoracoscopic resection was performed successfully, and the estimated intraoperative bleeding was 200 ml. The size of lesion was approximately 6 cm × 5 cm × 3.5 cm and was sent for routine pathology.Histopathology revealed a cavernous hemangioma composed of varying size and dilated cavernous sinuses, with an inner wall lined with vascular endothelium Fig. A. In addMediastinal cavernous hemangioma (CHM) is a rare disease of mediastinal benign tumor originating from vascular endothelial cells which is caused by abnormal vascular development during embryonic period. The disease mostly occurs in young adults, and the gender difference is not large . It tendPreoperative diagnosis of CHM is particularly difficult. All the cases that have been reported so far were diagnosed after surgical resection. Although most cases demonstrated heterogeneous well-circumscribed masses, punctate, and rounded calcifications, some display a wide range of radiological features like dumbbell tumors or infiltrative appearance . On CT sWe illustrated a case of CHM in the posterior with massive pleural effusion, which is an extremely rare condition. The clinical manifestations are non-specific and can be easily misdiagnosed as schwannoma. The etiology of the pleural effusion is unclear. We speculate that repeated friction of the base of the focus close to the vertebrae leads to fistula and aseptic pleurisy. However, during the operation, the capsule of focus is complete and no visible fistula except the very thin top of the tumor. This is just speculation and real mechanism is still unknown.Misdiagnosis can lead to percutaneous lung biopsy, inappropriate surgical planning and serious complications, especially life-threatening hemorrhage. If hemangioma can be considered before operation, preoperative interventional embolization is a method recently recommended to control intraoperative bleeding and even treat hemangioma , and is Mediastinal hemangioma presenting with massive pleural effusion may be the first to describe to the best of our knowledge. The patient was performed thoracoscopic surgical resection successfully, which demonstrated the diagnosis of posterior mediastinal cavernous hemangioma with no recurrence till now.


Meningeal carcinomatosis is mainly associated with breast cancer, lung cancer, and melanoma. However, meningeal carcinomatosis secondary to a neurenteric cyst with malignant features is extremely rare.We report the case of a 35-year-old woman who was admitted to the hospital with a 10-month history of headache, 6-month history of diplopia, 4-month history of hearing loss, and 1-month history of back pain, suggesting a diagnosis of chronic meningitis. Notably, enhanced brain and spinal cord magnetic resonance imaging (MRI) revealed extensive lesions with enhancement signals in the pia mater of the pons and cervical, thoracic, and lumbar spinal cord. The cerebral spinal fluid profile showed that pressure was significantly elevated, with a slight increase in leukocytes that mostly comprised mononuclear cells and decreased glucose concentration. Cytology evaluation showed a small cluster of atypical nuclei, which were suspected to be tumor cells arising from the epithelium. However, no primary tumor was found through comprehensive body and skin screening. After a histopathological biopsy of subarachnoid meninx of the thoracic spinal canal, the cause of meningeal carcinomatosis of this patient was determined as neurenteric cysts with malignant features, which is extremely rare.This is the first case to ever report neurenteric cysts as a cause of leptomeningeal carcinomatosis and the first ever report of neurenteric cysts presenting as leptomeningeal carcinomatosis without typical cyst visible on brain MRI. This extremely rare case provided a novel view on the pathogenesis of meningeal carcinomatosis and clinical presentation of neurenteric cysts, highlighting the value of meningeal biopsy in chronic meningitis of unknown causes. Meningeal carcinomatosis  is an end-stage complication of cancer with poor prognosis and nonspecific symptomatic presentation characterized by the seeding of metastatic malignant cells on the leptomeninges . MeningeA 35-year-old woman was admitted to the hospital with a 10-month history of headache, 6-month history of diplopia, 4-month history of hearing loss, and 1-month history of back pain. No fever, tumors, or exposure history of specific infections were noted. No significant family history of malignancy was found. Neurologic examination revealed normal cognitive performance, limb motor function, reflexes, sensory and cerebellar functions. Difficulty in bilateral eyeball abduction, diplopia, and mild bilateral facial paralysis were noted. There was hearing loss in both ears by gross hearing assessment. Signs of meningeal irritation, including Brudzinski and Kernig signs, were positive, and nuchal rigidity was present.Cerebrospinal fluid (CSF) pressure was significantly elevated, with a slight increase in leukocytes that mostly comprised mononuclear cells and decreased glucose concentration. No pathogenic microorganisms were found by next-generation sequencing. Enhanced brain magnetic resonance imaging (MRI) showed an abnormal signal on the ventral side of the pons Fig.  B-1. EnhConsidering the possibility of meningeal carcinomatosis, an examination of CSF was conducted Fig.  A-1, in The patient refused radiation treatment and intrathecal or systematic chemotherapy and selected palliative treatment with ventricular abdominal drainage. After the ventricular abdominal drainage surgery, the headache was alleviated, but other symptoms still persisted. Until we submitted the case report, she was bedridden and in an extremely weakened state.Neurenteric cysts are congenital anomalies that are thought to result from a failure of the neuroectoderm and endoderm to separate in the third week of embryogenesis. They are typically located on the ventral side of the cervical or thoracic spinal cord . The neuThe signal intensity features of intraspinal and intracranial cysts vary depending on the protein content of the cyst fluid , 9. TypiA diagnosis of a neurenteric cyst depends on histopathology. The cyst lining observed by microscopy can range from simple to pseudostratified low cuboidal or columnar epithelium, with or without cilia . The patSymptoms and signs of meningeal carcinomatosis mainly depend on the site of invasion, manifested as general symptoms , cranial nerve involvement , spinal nerve dysfunction , and meningeal irritation . IncreasMost patients with meningeal carcinomatosis have no brain parenchymal metastases: tumor cells mostly infiltrate diffusely into the meninges and subarachnoid space. CT findings may be normal, frequently resulting in misdiagnosis. Gadolinium-enhanced T1-weighted MRI of the brain and spine is recommended if there is clinical suspicion, irregular lesion signals, and linear or nodular leptomeningeal enhancement . Our pat2O), increased leukocytes (> 4/mm3), elevated protein concentration (> 50 mg/dl), and decreased glucose level (< 60 mg/dl) [Lumbar puncture is recommended if it can be safely performed. Suggestive abnormalities include increased opening pressure (> 200 mm H0 mg/dl) . A defin0 mg/dl) , 16 and 0 mg/dl) , 18. TheAccording to the time sequence of clinical symptoms, we speculated that the primary neurenteric cysts lesion might be at the pons, then spreading through the arachnoid membrane and leading to extensive cerebrospinal membrane involvement. The limitation of this clinical case report was that we did not conduct a direct biopsy of the pons to confirm the diagnosis because of the high risk for biopsy in this significant brain region.In conclusion, we have reported an extremely rare case that manifested as meningeal carcinomatosis and was diagnosed with pathologically-proven neurenteric cysts with malignant transformation. However, no obvious actual cyst was observed on MRI, which was different from the cases of previously reported neurenteric cysts. This extremely rare case provided a novel view on the pathogenesis of meningeal carcinomatosis and clinical presentation of neurenteric cysts. For chronic meningitis without definite infection or evidence of tumor, meningeal biopsies should be performed if necessary to identify the diagnosis.


Isolated jejunal Crohn’s disease (IJCD) is a rare manifestation of small bowel inflammatory disease described in a few case reports. Due to challenges in diagnosis, this condition is overlooked or misdiagnosed in many instances. We present a case that was initially diagnosed as gastroparesis due to a gastric emptying study (GES) revealing delayed stomach clearance, with additional normal imaging and endoscopic examinations. After several imaging studies and a double-balloon enteroscopy (DBE), isolated Crohn’s disease was diagnosed and managed with surgical intervention. Isolated Crohn’s disease should be considered as a diagnosis in patients with gastroparesis to avoid delays in appropriate treatment and improve prognosis. Crohn’s disease (CD) is a chronic inflammatory condition with variable clinical manifestation due to its ability to affect any part of the gastrointestinal (GI) tract . Isolate2, temporomandibular muscular wasting, and a soft, non-distended abdomen with tenderness to palpation in the upper abdominal area. She was started on domperidone with little success. Repeat laboratory tests revealed albumin of 2.9 g/dL, and a repeat upper endoscopy showed esophagitis, but it was otherwise normal. She was recommended to have repeat imaging with MRE; however, before completion, she presented to the emergency department with symptoms of generalized abdominal pain and emesis. A CT scan of the abdomen showed thickening of the proximal jejunum with stricture formation and proximal dilation, consistent with partial small bowel obstruction  of the abdomen and pelvis, magnetic resonance enterography (MRE), esophagogastroduodenoscopy, and pancolonoscopy with ileoscopy. Further evaluation with a gastric emptying study (GES) showed 68% of residual food content in the stomach at four-hour intervals. She was diagnosed with idiopathic gastroparesis and managed with dietary changes, antiemetic therapy, a trial of metoclopramide as a prokinetic, and chlordiazepoxide-clidinium for abdominal pain. At our initial clinic visit, she reported ongoing nausea, vomiting, abdominal pain, and only being able to tolerate oral liquids but denied diarrhea or bloody stools. She had lost 165 pounds in the past 10 months. Physical examination showed normal vital signs, a BMI of 24 kg/mCD is an inflammatory bowel disease characterized by chronic transmural inflammation that may involve any part of the digestive tract, mostly found in the terminal ileum and proximal colon. Isolated jejunal disease is a rare clinical manifestation that represents approximately 1% of CD cases . Early dIn conclusion, our case highlights the importance of excluding small bowel CD in all patients with refractory gastroparesis, even in cases of unremarkable endoscopy and imaging. Combining and repeating multiple imaging and endoscopic modalities may be necessary to adequately diagnose small bowel CD without ileocolonic involvement, such as in IJCD. It is very important to look for mechanical causes such as IJCD as management, complications, and the overall prognosis are very different from idiopathic gastroparesis.


Intracranial germinomas are germ cell tumors that commonly develop in the pineal or neurohypophysis regions. As ectopic germinomas are rarely observed within the cerebrum and are associated with atypical image findings, diagnosis is challenging.A 14-year-old boy was admitted to our hospital with complaints of vomiting and headache. Gadolinium-enhanced magnetic resonance imaging revealed ring-enhancing lesions in his left frontal lobe and basal ganglia. Susceptibility-weighted imaging indicated that the subependymal veins passing through the lesion centers were engorged, while electrophoretic analysis of cerebrospinal fluid identified oligoclonal bands (OCBs); both were typical of multiple sclerosis (MS). Tumor biopsy revealed many cells with atypical mitotic figures and nuclear enlargements, suggesting malignant disease. As the tumor rapidly proliferated, we opted for surgical excision of the lesions. Histopathological analyses revealed “two-cell patterns” characteristic of germinoma. Immunohistochemistry was positive for placental alkaline phosphatase and c-KIT. The definitive diagnosis was germinoma. After chemoradiotherapy, the patient was discharged without neurological deficits.OCBs and several magnetic resonance imaging features  are useful diagnostic signs for the radiological discrimination of MS from germinoma. However, owing to these factors, some cases are difficult to diagnose.Our case report of an unusual ectopic cerebral germinoma illustrates the difficulty of distinguishing it from MS. Therefore, we recommend proper tissue sampling in such cases, especially in adolescent patients, to make definitive germinoma diagnoses. •We report a rare case of intracranial germinoma in the frontal lobe and basal ganglia.•The engorged subependymal vein in the lesion center is atypical in intracranial germinoma.•Proper tissue sampling is required for germinoma diagnoses, especially in adolescents. These tumors predominantly develop during adolescence and account for approximately 10 % of pediatric brain tumors in Japan Tumefactive multiple sclerosis (MS) is a disease characterized by tumor-like lesions in the CNS that are generated by the demyelinating process. The presence of immunoglobulin oligoclonal bands (OCBs) isolated from cerebrospinal fluid (CSF) and several radiological observations are useful for differentiating MS from germinomas 22O. The CSF samples showed an elevated protein level (105 mg/dL) and an unremarkable cell concentration and immunoglobulin G index (1.01). Cytological diagnosis could not be performed because it was not possible to drain the required amount of CSF. We observed five unique OCBs, which indicated MS  T2-weighted imaging revealed extensive edematous changes to his left frontal lobe a with nocated MS .Fig. 1, and whole-brain irradiation (23.4 Gy in 13 fractions). Over the 6-month follow-up, the patient remained recurrence-free, performing activities of daily living without neurological deficits.We subsequently administered postoperative chemoradiotherapy, a combination of three cycles of carboplatin/etoposide therapy : None.Keisuke Masuda, Nayuta Higa substantially contributed to the manuscript drafting. Keisuke Masuda, Nayuta Higa and Hiroyuki Uchida treated and operated on patients. Hajime Yonezawa and Ryosuke Hanaya analyzed and interpreted the patient data. All authors read and approved the final manuscript.None.


Superficial angiomyxoma (SA) is a rare benign tumor that occurs either in the superficial dermis or subcutaneously. It often occurs in the trunk, neck, or limbs, and grows slowly. The diameter of the tumor is usually less than 5 cm. A giant SA of the perineum in men is very rare. We detailed the diagnosis and treatment of male patients with perineal SA and performed a literature review. We report a case of a 42-year-old male patient. He was admitted to hospital with a perineal mass found more than 1 year previously. A pelvic contrast-enhanced computed tomography scan in our hospital suggests that a round slightly hypointense foci of about 6.0 cm × 8.6 cm × 4.5 cm in size with still clear borders was seen below the penile corpus cavernosum in the perineum. We performed a perineal mass excision under continuous epidural anesthesia. A postoperative pathology report diagnosed perineal SA. There was no recurrence at follow-up for 27 months up to May 2022. Perineal SA is rare and should be combined with patient history and imaging to ensure complete excision of the mass margins. Adherence to long-term postoperative follow-up is the key to curing this case. Superficial angiomyxoma (SA), also known as a cutaneous mucinous tumor, is a rare benign soft tissue tumor of the skin. SA was first reported by Carney et al. in 1985, with an incidence in the range of 0.008%–3% , which iA male patient aged 42 years was admitted to the hospital after “finding a perineal mass for more than 1 year.” The patient complained that he found a mass the size of peanut rice in the perineum 1 year previously, without tenderness and discomfort from ulceration. At that time, he did not pay attention to it, and the mass then gradually increased. A color Doppler ultrasound in the local hospital showed a slightly hypoechoic mass in the perineum, which was not treated at that time. During the physical examination, a hard and fixed mass of about 8.5 cm × 6 cm was palpable in the patient's perineum.To understand the nature, blood supply, and anatomical location of the mass, a contrast-enhanced computed tomography (CE-CT) scan of the pelvis was performed. A round slightly hypointense foci of about 6.0 cm × 8.6 cm × 4.5 cm in size with still clear borders was seen below the penile corpus cavernosum in the perineum , with a After communicating with the patient, he underwent a perineal mass resection under continuous epidural anesthesia. A lithotomy position and indwelling catheterization were used. A vertical incision was made in the middle of the lower part of the scrotum. After cutting into the superficial perineal muscle layer, the tumor capsule could be seen, which was free along the tumor capsule. The tumor was close to the urethral cavernous body above the tumor, and there were tumor nutrient vessels on the inner side. After carefully ligating the vessels, the tumor was completely removed and observed. The size of the tumor was approximately 8.5 cm × 6 cm × 5 cm in size ; the speSA is a rare benign skin tumor, which is considered a special type of soft tissue tumor. They are difficult to diagnose because they lack unique features like fibroepithelial polyps . In receSimilar to other interstitial masses in the perineum, SAs are cystic in nature and are easily misdiagnosed as polyps or epidermoid cysts during physical examination . The surThe preoperative diagnosis of SA is difficult, and imaging helps to clarify the relationship between the SA and the surrounding tissues. On ultrasound, the SA appears as a confined round or oval mass with heterogeneous internal echogenicity. The CT/magnetic resonance imaging (MRI) scan of SA mostly shows a rounded/lobular soft tissue mass with well-defined borders and superficial lesions, with hypodense/low signal foci without significant enhancement. Its substance is the mucus-rich stromal component of the tumor. The separation of collagen bundles is also seen, showing isointensity (CT)/low signal (MRI). The literature reports a slightly dense or mixed signal with focal hemorrhage .Clinically, SA usually has good boundaries and often extend to subcutaneous fat . HistoloComplete surgical excision is the best treatment for superficial hemangio mucinous tumors. Although SA is a benign tumor of the skin, there is a 30%–40% chance of local recurrence after surgery due to incomplete excision or blurred margins . A regulThe incidence of SA is low and the clinical presentation lacks specificity, but SA should be considered when painless pelvic and perineal swellings without other features are found in young and middle-aged men. A pathological examination is the gold standard for diagnosing this disease. However, the relationship between the mass and the surrounding tissues and whether it invades deep tissues can be clarified by ultrasound, MRI, and CT auxiliary examination, which is a reliable guide for judging the benignity and malignancy of the tumor and its prognosis. Extensive surgical excision is currently the main method of treatment, ensuring that the edges of the mass are removed intact to avoid postoperative recurrence. Although SA has a good prognosis, patients still need to be informed of regular follow-ups.


Although melanoma is the fifth most common cancer in the UK, muscle metastases are extremely rare, with only a few cases reported in the literature. We discuss the challenge of diagnosing muscle metastasis on radiological imaging and in particular of distinguishing metastatic lesions to muscle from sarcoma. We also review the imaging findings of other published cases in a literature review. We conclude that although certain characteristic features of melanoma metastases can be identified on imaging ( An 83-year-old female was referred by her General Practitioner to our symptomatic Breast Clinic with a right upper arm mass. She was noted to have significant past medical history of right breast cancer and melanoma. Her breast cancer was diagnosed and treated with right mastectomy in 2013 and she continues to take tamoxifen as adjuvant treatment. She was first diagnosed with melanoma in 2015, when she presented with an enlarging and non-healing skin lesion on her right forearm. She was referred to dermatology for urgent excision. Histology demonstrated the lesion to be a superficial spreading malignant melanoma 4.4 mm Breslow thickness with ulceration. She was further treated with wide local excision of the scar on the right forearm. Staging CT of head, chest, abdomen and pelvis showed no evidence of metastatic disease at that time. The option of sentinel node biopsy was offered and discussed; however the patient declined to proceed with this procedure.In 2016, she presented with a right axillary mass which was biopsied and confirmed to be metastatic melanoma. Right axillary lymph node dissection was performed and histopathology confirmed that three out of twelve nodes contained melanoma; however there was no extracapsular extension. The melanoma Multidisciplinary Team (MDT) recommended adjuvant radiotherapy, however after discussion of risks and benefits patient opted not to have this treatment.For the current presentation, the patient described a 2–3 month history of right upper arm swelling, associated with right arm and shoulder pain. She also reported three stone weight loss (approx. 19 kg) over the preceding 12 months. Clinical examination revealed a palpable large right upper arm mass related to the biceps muscle. Mammogram of the left breast was normal. Ultrasound of the right axilla and right upper arm did not demonstrate any abnormal axillary lymph nodes but did reveal an intramuscular soft tissue mass involving the right biceps muscle .i.e., sarcoma) and metastatic disease. Due to the potential diagnosis of sarcoma and risk of seeding, the mass was not biopsied at initial presentation and the patient was referred for further imaging including MRI and staging CT thorax/abdomen/pelvis.This case posed a diagnostic challenge given the patient’s previous medical history of two malignancies (previous right forearm melanoma and right sided breast cancer). The differential diagnosis of the right arm mass included both primary soft tissue lesion . Furthermore, a proportion of patients with malignant disease may not survive long enough for these late muscle metastases to develop.Furthermore, autopsy studiesIn addition to being rare, muscle metastases can present with a broad spectrum of radiological features, generating additional difficulty in making the diagnosis. literature suggests that certain characteristic features of melanoma metastasis can be observed on imaging, particularly on MRI. However, the evidence is sparse given how uncommon these metastases are, with only a few case reports which we review below.Although definitive diagnosis of metastatic melanoma requires biopsy and histopathological examination,T1-weighted MRI. Two mechanisms underlying this radiological appearance have been proposed: 1) paramagnetism of stable free radicals in melanin and 2) methemoglobin in nonacute haemorrhage of the tumour.The evidence suggests that melanoma and melanoma metastases commonly appear hyperintense on  reported a case of intramuscular metastasis in the lower limb from malignant melanoma, where the lesion appeared as intermediate to high signal intensity on T1-weighted images and mixed signal intensity on T2-weighted imaging, containing both high and low signal. Another case report of melanoma metastasising to the lower limb musculature was described by Viswanathan et al, where again MRI showed a necrotic lesion appearing as heterogenous 1T-weighted imaging with enhancement on post contrast sequences, and hyperintense on 2T-weighted imaging. Dalle Carbonare et al described a patient with melanoma of unknown primary, whose presenting complaint was a temporalis muscle lesion, which appeared as a lobulated high signal mass on 1T-weighted imaging with no evidence of intralesional fat, with diffusely low signal on 2T-weighted imaging. A further example a 1T-hyperintense lesion was described by Pirlamarla et al who reported a case of an elderly female with recurrent vulvar melanoma with extraocular muscle metastasis, appearing as a heterogenous hyperintensity on T1-weighted images of orbital MRI, with high signal on 2T-weighted sequences.Several case reports report this finding. Yoshioka et al1T-hyperintense appearance of melanoma metastases is not universal and several other case reports suggest wide variability in radiological findings. Kuo-Feng Hsu et al reported a case of scalp melanoma re-presenting with metastasis to rectus abdominis muscle after a nearly 5-year disease-free period – a timeframe similar to the patient in this report. However, the lesion described by Kuo-Feng Hsu et al was hypointense on T1-weighted image and hyperintense on T2-weighted image, showed contrast enhancement, and demonstrated restricted diffusion. The patient was treated with surgery but passed away six months later due to development of multiple metastases.However, the  reported a case of ocular muscle metastasis from melanoma primary, which on MRI appeared as a multicystic mass with layering fluid-fluid levels.Melanoma metastases can also demonstrate a heterogenous appearance, for example Shih et alThe examples presented above illustrate the variability in imaging appearances of melanoma muscle metastases on MR imaging, thus contributing to significant diagnostic difficulty.The evidence seems to be even more sparse for CT appearances compared to MRI, with only a few studies found in the literature. However, none of the primary malignancies included in those studies were melanomas.Two retrospective cohort studies suggest that muscle metastases from any primary most commonly appear as rim-enhancing intramuscular lesions with central hypoattenuation. reported a case of amelanocytic melanoma spreading to extraocular muscles, where CT showed spindle-like swelling of several muscles in the orbit. In the case described by Viswanathan et al, CT showed a mass in the quadriceps muscle with an enhancing rim and low attenuation centre. In the case reported by Dalle Carbonare et al, CT showed a well-defined subcutaneous enhancing soft tissue mass in the right temporal fossa.Only a few of the case reports reporting metastatic melanoma to muscle included CT findings. Weiss et ale.g., sarcoma). One retrospective study found that there were no radiographic characteristics in any imaging modality that allowed differentiation between metastases to muscle and a primary soft tissue sarcoma. This diagnostic challenge clearly impacts patient care, as the biopsy approach would be different in case of sarcoma compared to muscle metastasis – the current UK guidelines recommend that a mass suspicious for a soft tissue sarcoma should be investigated with a core needle biopsy (as opposed to fine needle aspiration), planned in a way that the biopsy tract can be safely excised at the time of definitive surgery to reduce the risk of seeding.The variability in radiological appearances of muscle metastases contributes to the difficulty in distinguishing a metastasis from primary soft tissue tumour  and reaching the diagnosis.Cooperation between different specialties, in particular input of radiologists at the MDT meetings, is vital in planning investigations of intramuscular lesions (Muscle metastases are associated with variable appearances on imaging, including MRI.


Pancreatic pseudocyst (PPC) with massive gastrointestinal bleeding is rare, especially in children. Inadvertent intraoperative examination and damage to the gastric mucosa and malformed blood vessels by the fluid content of PPC can lead to massive bleeding, which may endanger the patient's life.Here, we present a case of an 8-year-old boy who was diagnosed with a massive gastrointestinal haemorrhage caused by PPC complicated with Dieulafoy's disease. At his first admission, his complaint was being hit to the stomach by the handlebar while riding bicycle 24 h before admission. After being hospitalized, he was diagnosed with pancreatic injury by abdominal CT. Conservative treatment lasted for 1 month in the Department of Pediatric Surgery. Then, a pancreatic pseudocyst was formed. Under the guidance of ultrasonic endoscopy, cyst puncture and drainage of pseudocysts through the gastric wall were performed. Unexplained hematemesis occurred 8 days after surgery. Emergency gastroscopy was performed, and abnormal submucosal vascular haemorrhage was found at the gastric fundus. Gastric Dieulafoy's disease was diagnosed. The boy underwent gastroscopic titanium clipping of abnormal arteries. He had no complications during the 3-month follow-up. Then, the patient returned to the hospital, and the stent was removed under endoscopy. No bleeding was found, and the patient was discharged. The patient recovered smoothly and was followed up for half a year without any complications, and hematological indicators were normal.Endoscopic ultrasonography-guided gastric puncture and internal drainage of cysts is a safe and effective surgical method for the treatment of pancreatic pseudocysts. However, at the same time, it is necessary to thoroughly and carefully explore the stomach cavity to prevent adverse consequences caused by a missed diagnosis of gastric Dieulafoy's disease or other abnormal abnormalities. Dieulafoy's disease (DD), also known as Dieulafoy ulcer, Dieulafoy injury, or submucosal artery rupture and haemorrhage, is a rare and fatal cause of massive gastrointestinal bleeding. The disease was named after Dieulafoy, a French surgeon who reported three cases of this fatal digestive tract haemorrhage from 1896 to 1898 and described its characteristics in detail . Since tOur patient is an 8-year-old boy. At his first admission, his complaint was being hit to the stomach by the handlebar while riding bicycle 24 h before admission. He was admitted to the Department of Pediatric Surgery after 1 day of abdominal pain with vomiting. He did not receive any special treatment before admission. Physical examination showed abdominal tenderness under the xiphoid process, mild local muscle tension, no rebound pain, a soft rest of the abdomen, and normal bowel sounds. Abdominal CT  showed tOn the third day after admission, abdominal CT showed that there was an injury in the body and tail of the pancreas, accompanied by hematoma formation and multiple exudative changes around the pancreas, and the hematoma had grown. Then, conservative treatment was continued for 3 weeks. Finally, abdominal CT was reviewed and suggested PPC formation with a maximum cross size of ~6.5 cm × 6.8 cm, accompanied by a small amount of peripheral exudation and effusion . The patHowever, on the 8th day after surgery, the child vomited blood, and the blood clot was bright red with a volume of ~220 ml. Then, he vomited blood twice again, ~220 ml and 180 ml, respectively. Therefore, severe acute upper gastrointestinal haemorrhage was considered, and an emergency gastroscopy was performed. Gastroscopy showed a large amount of bloody gastric juice and old blood clots in the gastric cavity. No obvious active bleeding was found at the puncture and anastomosis, and the stent and drainage tubes were in a good position. After the blood clot was cleaned up by foreign body forceps, a 1.5-cm long malformed blood vessel was observed in the submucosa of the greater gastric curvature, with a blue surface and much blood oozing. The blood vessel was clamped by a titanium clip. Then, endoscopy detection was continued to the duodenum, and no obvious bleeding or oozing was found. As a result, the intraoperative supplementary diagnosis was gastric Dieulafoy's disease . PostopeThe patient was discharged half a month after surgery. In total, 3 months later, the patient returned to the hospital for transendoscopic stent removal . Under ePancreatic pseudocyst (PPC) is mainly caused by acute and chronic inflammation of the pancreas, obstruction or injury of the pancreatic duct, and other abnormal fluid retention in or around the pancreas, which is wrapped by fibrous tissue to form capsular structures. PPC in children are relatively rare and are mostly caused by pancreatic trauma, accounting for 60−70% of all the cases . PPC in In this case, the operation was performed at the stable stage of the cyst, and the postoperative recovery was smooth. Abdominal pain, vomiting, and other symptoms were significantly relieved, blood and urine amylase and lipase decreased significantly compared with the preoperative levels, and ultrasound showed only a small amount of fluid around the pancreatic tail. However, on the 8th day after the operation, the child suddenly developed a large amount of hematemesis, so an emergency gastroscopy was performed. During the operation, the stomach Dieulafoy's disease was diagnosed because an unexpected haemorrhage was found in the submucosal malformed blood vessels of the stomach, and haemorrhage was relieved by a titanium clamp.Dieulafoy's disease occurs mostly in male adults and is rare in children. It is mostly sporadic and characterized by sudden, interstitial, and repeated bleeding , 15, 16.Dieulafoy's disease occurs mostly in the gastrointestinal tract, which is relatively obscure and complex and is an easily missed diagnosis . A case In addition, cases of Dieulafoy's disease accompanied by canceration have been reported , but wheThere are many diagnostic methods for Dieulafoy's disease, including endoscopy, angiography, isotope scan, enhanced CT , etc. , 3, and This case had a clear history of trauma, and the location, symptoms, signs, and CT examination all suggested pancreatic injury. After conservative treatment, PPC was formed. Therefore, before the operation, endoscopic ultrasonography focused on the detection of PPC and their adjacent gastric walls but ignored the possibility of “Dieulafoy ulcer” on the far side of the gastric fundus and did not conduct a comprehensive and careful exploration of the gastric wall, which is also the lesson leading to the first postoperative gastrointestinal bleeding in this case. During the second operation, we learned the lesson and carried out a comprehensive and careful scan of the gastric wall, and no other lesions were found.In this pediatric patient, Dieulafoy's disease occurs after the PPC operation which is a rare situation. Analyzing the reasons, it may be that malformed vessels exist in the submucosa of the greater curvature of the stomach. Although the PPC and malformed vascular lesions were far apart, the fluid content of the PPC might have damaged both the gastric mucosa on the vessel and the malformed blood vessel. When pancreatic fluid, blood, and necrotic tissue flowed into the gastric cavity, causing active vascular bleeding. Therefore, this gives clinicians a very important warning; that is, surgical trauma and corrosion of digestive fluids can induce the occurrence of Dieulafoy's disease when coelomic operations, especially for PPC and other gastrointestinal surgeries, are performed. The key to preventing it is the comprehensive and careful examination of the digestive tract and the elimination of abnormal blood vessels in the body cavity to avoid adverse consequences.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Ethics Committee of the Second Hospital of Hebei Medical University and affiliated to the Second Hospital of Hebei Medical University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.LL wrote the manuscript and assisted in the operation. LZ and WX completed the surgery and reviewed and agreed to submit the paper. XZ and ML collected the patient data and followed up. JC, LJ, and XQ worked on editing the pictures. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Trichobezoars are concretions of retained, undigested material, mostly hair or hair-like fibers in the stomach. Rapunzel syndrome is the condition when trichobezoars extend into the small bowel, leading to various complications including bowel obstruction, and perforation due to pressure necrosis.We present an interesting case of trichobezoar in a 15-year-old female patient, who presented with abdominal pain for one month duration. The exam was notable for a firm palpable mass in the epigastric area associated with localized tenderness and guarding. Contrast-enhanced CT of the abdomen showed a distended stomach with the bezoar, dilated duodenal loops, and clumping of proximal jejunal loops. Upper gastrointestinal endoscopy showed a trichobezoar extending from the oesophagogastric junction to the pylorus. Endoscopic removal of the trichobezoar was not successful. An elective laparotomy was performed, during which the stomach, duodenum, and proximal jejunum were dilated. The trichobezoar, measuring 35 cm in length, extended from the body of the stomach to the proximal jejunum and caused jejunal perforation due to pressure necrosis. The trichobezoar was removed and primary closure of jejunal perforation with diversion gastrojejunostomy and jejunostomy was done. There were no postoperative complications. The patient followed up with psychiatry in the clinic after discharge, she was diagnosed with trichotillomania and started on fluoxetine, with improvement in her behavioral symptoms.In young female patients with nonspecific chronic abdomen pain and a palpable mass, trichobezoar should be considered in the differential diagnosis. Contrast-enhanced abdomen CT is the preferred imaging modality and removal of the trichobezoar with an appropriate endoscopic or surgical procedure is the treatment of choice. It is essential to diagnose and treat the underlying behavioral condition to prevent recurrent episodes. Bezoars are defined as concretions of retained, undigested material found in the stomach, the ingested material in the stomach may include plant fibers (phytobezoars), persimmon (diospyrobezoar), hair (trichobezoar), milk protein (lactobezoar), paper, medications (pharmacobezoar) . TrichobIt is quite rare to have an intestinal blockage during childhood from bezoars, the most frequently found materials are hairs (trichobezoar) and alimentary fibers (phytobezoar) . RapunzeA 15-year-old girl presented with dull abdominal pain for one month, accompanied by multiple episodes of emesis for one week, with no prior comorbid conditions. On physical examination, the patient appeared well nourished, vital signs showed a heart rate of 94 beats/minute, respiratory rate of 15 breaths/ minute, and blood pressure of 110/70 mm Hg. On local examination, the abdomen was tender in the epigastric and umbilical regions. A firm mass was palpable in the epigastric area along with localized guarding. Bowel sounds were audible. Per rectal examination was normal. Lab results revealed a stable complete blood count, basic metabolic profile, liver function test values, normal bleeding time, and a normal coagulation profile. Contrast-enhanced CT of the abdomen showed a distended stomach with the bezoar (Figure Dilated duodenal loops with clumping of bowel loops were noted in the left hypochondrium involving proximal jejunal loops with normal distal flow contrast into distal loops Figure .On upper gastrointestinal endoscopy, bezoar was found just below the oesophagogastric junction, extending through the body of the stomach, its antrum, and pylorus Figure .Despite best efforts during the endoscopy, only a few hair strands could be removed. An elective laparotomy was performed. During the operation, the stomach, duodenum, and proximal jejunum were found to be dilated. Trichobezoar with clumped hair and thread of about 35 cm was identified which extended from the body of the stomach up to 6 cm beyond the duodenojejunal flexure (Figures Stomach mucosa and proximal jejunal mucosa were found to be inflamed. Unhealthy sloughed-out tissue of about 2×1 cm, indicating mucosal perforation was found at the proximal part of the jejunum at about 7 cm distal to duodenojejunal flexure. This was the point where the trichobezoar ended. Trichobezoar was removed, and primary closure of jejunal perforation with diversion gastrojejunostomy and jejunojejunostomy was done. There were no postoperative complications and the patient was discharged home with outpatient psychiatry follow-up. At the outpatient psychiatry appointment, the patient was started on fluoxetine 10mg daily, then the dose was increased to 20mg daily at the second follow-up. The patient reported improvement in her behavioral symptoms.Trichobezoar is a condition that is often underdiagnosed and should be considered in the differential diagnosis of chronic abdominal pain and palpable abdominal mass in young female patients, especially if there is a history of behavioral disorders. Trichotillomania is a psychiatric disorder associated with other psychiatric conditions such as kleptomania, pyromania, obsessive-compulsive disorder, skin picking disorder, etc., which are known to be characterized by impaired impulse control . DSM-5 iIn these patients, ultrasound has a relatively low sensitivity in diagnosing gastric bezoars because of the high echogenicity of hair, the presence of trapped air bubbles, and numerous acoustic reflections . AccordiAs reported by Gonuguntla et al., endoscopic fragmentation, gastric lavage, enzymatic therapy, or a combination of these methods can be used to extract small trichobezoars . Larger As reported by Memon et al, recurrence in Rapunzel syndrome usually happens when the underlying trichotillomania is not treated . The patTrichotillomania-related trichobezoars should be considered as a differential diagnosis in young patients with a history of psychiatric disorders, who present with abdominal pain. Abdominal CT with contrast is the diagnostic test of choice and if indicated upper gastrointestinal endoscopy should be considered for removal of the bezoar. Surgical intervention may be needed if endoscopy is unsuccessful. It is important to treat the underlying behavioral disorder to prevent a recurrence.


To investigate the CT, MRI and pathological features of dysembryoplastic neuroepithelial tumor (DNET).The CT and MRI features of six cases of pathologically confirmed DNET were retrospectively analyzed and compared with pathology.All six cases of DNET were solitary, and lesion in one case was located in the right parietal lobe, one case in the right frontal lobe, one case in the cerebellar vermis, one case in the right temporo-parietal occipital lobe, one case in the left basal ganglia, and one case in the pineal gland. CT and MRI showed cystic solid tumor in all six cases, of which four showed calcification. In CT images, the cystic components appeared low-density, solid nodules, septa, and cyst walls were slightly high-density, and calcifications were high-density. In MRI images, the cystic components were hypointense on T1WI and hyperintense on T2WI, solid nodules, septa and cyst walls were iso-intense or slightly hyperintense on T1WI and T2WI sequences, and calcifications were all hypointense. On enhanced scan, the cystic components were not enhanced, and the solid nodules, septa, and cyst walls were inhomogeneously enhanced.The imaging manifestations of DNET are characteristic, and the combination of clinical and imaging features can greatly improve diagnostic accuracy. Dysembryoplastic neuroepithelial tumor (DNET) is a rare benign tumor of the central nervous system, accounting for 0.2%–1.2% of neuroepithelial tumors . We retrSix patients with DNET were confirmed by surgery and pathology in our hospital from December 2017 to December 2021. Four males and two females were aged 8–29 years, with an average age of 14.2 years. Five patients had epilepsy as their first symptom and were poorly treated with antiepileptic drugs. According to the classification criteria of the International League Against Epilepsy [2 and 1000 s/mm2, respectively; The acquisition matrix was 512 × 512, the FOV was 23 × 23 cm, the layer thickness was 5.5 mm, the layer spacing was 1 mm, and the deflection angle (FA) was 90°. At the same time, Gadobenate Dimeglumine Injection (0.1 mm per kg body weight) was injected into the cubital vein for enhanced scanning at a rate of 2.0 mml/s. T1WI-FFE sequence and TR/TE (155.60/2.44 ms) were used for transverse, coronal, and sagittal scanning.All six patients underwent MRI, CT plain scan and enhanced scan. MRI examinations were performed in a 3.0 Tesla magnet , and 8-channel head coil was selected. Transverse axial T1WI, T2WI, FLAIR, sagittal T1WI and diffusion weighted imaging (DWI) were routinely scanned. T1WI and T2WI were TSE sequences, T1WI repetition time (TR), echo time (TE) were 488 ms and 15 ms, respectively; T2WI TR and TE were 3751ms and 100 ms, respectively; T2WI-FLAIR TR and TE were 7500 ms and 100 ms, respectively; DWI TR and TE were 2678.59 ms and 98.84 ms, respectively. The dispersion sensitivity coefficients  were 0 s/mmCT scans were performed using a PHILIPS 256-slice Brilliance iCT machine. Voltage: 120 KV, tube current: 240 mAs, scanning matrix: 512 × 512, layer thickness at 5 mm, pitch ratio of 0.392, FOV = 25 × 25 cm. Enhanced scanning was performed using a high-pressure syringe. Contrast agent Iohexel Injection (300 mgI/mL) 75–80 mml was bolus injected at a rate of 5–6 ml/s. Continuous upward scanning was performed with the auditory canthal line (OM line) as the baseline at supine position.All images were read by two chief physicians with experienced in the head and neck imaging using a single-blind method. The two chief physicians have been working for 20 years, and each year, there are 1,000 head and neck MRI readings. The location, shape, edge, adjacent relationship, signal or density, and enhancement characteristics of the lesions were analyzed in detail. Consensus was reached after discussion if there was a disagreement. The common signs of the two chief physicians were used as reliable signs.The lesions in all six DNET patients were solitary, and lesions in one case was located in the right parietal lobe, one case in the right frontal lobe, one case in the cerebellar vermis , one casThe cystic components of the lesions on plain CT scan showed low density, the solid nodules, septa, and cyst walls were slightly high-density, and the calcification appeared high-density . EnhanceThe cystic components of the lesions on plain MRI scanning showed low signal on T1WI and high signal on T2WI. Solid nodules, septa, and cyst walls of the lesions on T1WI and T2WI sequences showed equal or slightly high signal, and calcifications showed low signal , 2A–C; FDuring the operation, intracranial gray-yellow nodule-like tissue was seen occupying space. Some pale-yellow liquid was seen in the outflow. Three cases had no capsule, one case had pseudocapsule, and two cases had formed capsule, which was clearly demarcated with the surrounding brain tissue and with blood supply. Specimens from all cases were fixed with 4% formaldehyde, dehydrated in graded ethanol, embedded in paraffin, sectioned at 4 mm, and were stained with hematoxylin and eosin or stained immunohistochemically followed by observation under light microscope. Tumor tissue is formed by mucus-enriched matrix and microcystic cavity, with similar morphology to astrocytes and oligodendrocytes . ImmunohDNET is a rare tumor of the central nervous system, disease onset is before the age of 20 years in 90% of patients, and it is more common in children and adolescents, slightly more in men than in women. The average age of onset is 14.6 years in adolescents and 8.1 years in children . DNET haDNET tissue originates from the second germinal layer during the development of the central nervous system that includes outer cerebellar granules, subpial granules, hippocampal dentate gyrus and subependymal layer, and pial granules are the most likely source. The typical pathological feature of DNET is specific glial neuron components (SGE) which is composed of different proportions of oligodendrocytes, astrocytes and neurons, and there is a rich mucus matrix between the cells. Morphologically, DNET can be divided into mononodular, multinodular, and diffuse types. According to the tissue alternations, it is divided into simple type, complex type and non-specific type: (1) simple type: the tumor is only composed of specific glial neuron components; (2) complex type: the tumor is composed of specific glial neuron components, neuroglial nodules and focal dysplastic cerebral cortical components; (3) non-specific: lack of typical specific glial neuron components . In addiCT manifestations: DNETs are usually located in the supratentorial cerebral cortex or subcortex, with clear demarcation and low-density cystic lesions. When solid nodules or septations are obvious, they can appear as low-density, iso-density/slightly high-density mixed cystic and solid lesions. Patchy and nodular calcifications were seen in 20% of the lesions, bleeding was rare, and there was no edema around the tumor. Enhanced scan showed uneven enhancement in solid nodules, septa or the cyst wall, but no enhancement of the cystic components. All the cases in our group showed mixed cystic and solid lesions with low density, iso-/slightly high density, and three cases were located in the supratentorial. Patchy and nodular calcifications were found in the lesions in three cases, which was basically consistent with the literature.MRI manifestations: DNET is typically characterized by multiple cystic structures or multiple cystic degeneration which show low signal on T1WI and high signal on T2WI. They are mainly located in the cortex with clear boundaries and no edema around . No obviDWI shows the Brownian motion of water molecules. Since different brain tumors have different cell densities and diffusion speeds of water molecules, DWI can reflect the density of tumor cells through the diffusion speed. When the tumor cell density is high and the extracellular space is small, the DWI shows high signal, and the ADC (apparent diffusion coefficient) value shows low signal. In our group, three cases showed low signal on DWI and high signal on ADC diagram. Two DWI showed mainly low signal with solid nodule and surrounding showing slightly high signal, whereas ADC showed slightly high signal and low signal were found in solid nodule and surrounding tissues.DTI reflects the predominant direction of diffusion of water molecules in white matter and shows the course of white matter fiber tracts. It allows the observation of the spatial directionality and integrity of white matter fiber tracts, namely white matter tract imaging. White matter fiber tracts in all the cases of our study were reconstructed with three-dimensional images. The tracts around the lesions were mainly compressed and displaced, reflecting the benign characteristics of DNET.DNET needs to be differentiated from the following tumors: (1) Oligodendroglioma: the oligodendroglioma tends to occur in adults. More than half of them is located in the frontal lobe, curved band-like calcification are its characteristic manifestations. (2) Low-grade astrocytoma: it mostly occurs in children and adults aged 20–40 years and is often located in the deep white matter. Characteristic features include cystic degeneration, calcification, rare hemorrhage and edema, irregular shape, large range, rare occurrence of triangle sign, intratumoral septum, high signal of FLAIR sequence with surrounding ring. (3) Ganglion cell glioma: tumors are more common in adolescents, and usually located in the temporal lobe. The typical manifestation is a single large cyst with calcification of wall nodule. In addition, the MR spectroscopy manifestation of reduced N-acetyl aspartate peak and lack of choline peak can help to distinguish DNETS from other tumors in the brain .There were some limitations in this study. First, the number of cases was small, and statistics analysis were not made. The summary of DNET imaging characteristics was not comprehensive enough. Because the incidence rate of DNET is extremely low, it needs to continue to collect in the future research, so as to facilitate a more comprehensive summary. Second, the treatment of DNET was not discussed. The focus of this study is to discuss the imaging manifestations, so it is not discussed in depth.In summary, DNET is a rare benign tumor of the central nervous system, DNET display characteristic imaging and histopathological manifestations. Correct diagnosis of DNET can reduce unnecessary radiotherapy and chemotherapy, and improve the quality of life of patients. In future work, we will continue to collect DNET cases, and compare imaging such as CT and MRI with histopathology, including sensitivity and specificity, positive and negative predictive values, in order to improve the diagnostic coincidence rate of DNET imaging. At the same time, DNET has the possibility of malignant transformation. Although this risk is very small, it can’t be predicted by using any available biomarkers at present. Therefore, early diagnosis and treatment of DNET can improve the quality of life of patients.


X-ray and computed tomography (CT) scan of the thorax revealed two irregular lesions arising from the neck of the 5th rib posteriorly and a Fine Needle Aspiration Cytology (FNAC) revealed the lesion to be of chondroid matrix origin, consisting of normal chondrocytes. Through a posterior approach, two pedunculated tumours of size 3.5 x 2 x 1 cm and 2 x 2 x 1 cm, along with the costovertebral junction of the 5th rib were resected. Histopathological examination confirmed the mass to be an osteochondroma of the rib. On 6 months follow up, the patient is stable, has no pain or tingling and there is no evidence of recurrence of the tumour.Osteochondroma is also known as exostosis and is a benign bone tumour. It commonly presents in the first 3 decades of life with a male preponderance. The most common site for the development of these tumours is the metaphysis of long bones, with almost 30% of cases originating from the distal metaphysis of the femur. Origin from flat bones like ilium and scapula is rare, while origin from vertebrae and ribs is unheard of. A 21-year-old female presented with a history of swelling over the left upper back since 2 years, pain in the left upper back and shoulder with tingling since 4 months. On examination, a 3 cm by 3 cm, hard, immobile mass was palpable in the left paravertebral region of the 4


Post-traumatic diaphragmatic injuries can present as diaphragmatic hernia with herniation of abdominal viscera into the thoracic cavity. It is challenging for trauma surgeons to identify the delayed presentation of post-traumatic diaphragmatic injuries which require a high index of suspicion in patients who are at risk. We report a rare case of delayed diagnosis and management of post-traumatic diaphragmatic hernia in a polytrauma patient with a concise review of the literature. The patient presented after two years of post-traumatic thoracoabdominal injury due to a road traffic accident with breathing difficulty. On investigations, it was a large diaphragmatic hernia with herniation of abdominal contents into the left thoracic cavity. Laparotomy was performed with a reduction of abdominal contents from the left side of the chest along with mesh repair of the large diaphragmatic hernia. Postoperatively, the patient recovered well. The literature suggests that there should be a high level of suspicion of diaphragmatic injuries, especially when dealing with thoracoabdominal trauma or polytrauma patients. Post-traumatic diaphragmatic injuries, though rare, can lead to high morbidity or mortality if not treated on time. Post-traumatic diaphragmatic injuries can present with symptoms of diaphragmatic hernia due to the herniation of abdominal viscera into the thoracic cavity. Identifying the delayed presentation of post-traumatic diaphragmatic injuries is challenging for trauma surgeons because it requires a meticulous examination of at-risk patients. A diaphragmatic hernia has been reported in 1-7% of patients with blunt abdominal trauma and 10-15% of cases involving penetrating abdominal injuries [Diaphragmatic injuries should be suspected when dealing with thoracoabdominal trauma or polytrauma patients. Traumatic diaphragmatic injuries can be missed initially due to other associated injuries. The presentation of diaphragmatic hernia is commonly delayed compared with other organ injuries when the abdominal organ herniates into the pleural cavity. Traumatic diaphragmatic hernia is rare, difficult to diagnose, and can lead to delay in the diagnosis resulting in high morbidity and mortality rates .Here, we report the case of a 57-year-old male patient with delayed presentation of post-traumatic diaphragmatic hernia on the left side who presented two years after polytrauma. The case was examined in detail concerning presentation, investigation, and management. In addition, previous case studies of late presentation of diaphragmatic injuries were also reviewed. The patient had a large diaphragmatic hernia with multiorgan herniation  into the left thoracic cavity leading to a collapse of the left lung. Surgical repair of the diaphragmatic hernia was done after repositioning of all the herniated organs into the peritoneal cavity.A 57-year-old male was admitted with complaints of difficulty in breathing, hiccups, and cough for 15 days increasing in intensity. The patient had suffered thoracoabdominal trauma due to a road traffic accident two years ago for which he was admitted to the intensive care unit (ICU) and investigated and managed conservatively. A computed tomography (CT) of the scan abdomen did not reveal any intraabdominal injury at the time. The patient recovered well and was discharged.On examination, the patient was restless and was experiencing difficulty in breathing. His heart rate was 96 beats per minute, respiratory rate was 28 breaths per minute, and on-air oxygen saturation was 70-80%. On chest auscultation, gurgling sounds were heard on the left side, and systemic examination was normal. An X-ray of the chest and abdomen revealed the presence of bowel loops in the left thoracic cavity, while the left dome of the diaphragm was not visualized. The left lung had collapsed Figure .The thoracic ultrasound imaging suggested loculated pleural effusion on the left side with the consolidation of the lung in the mid-lower zone, with a fluid volume of 244 cc and multiple pockets. The contrast-enhanced CT scan of the abdomen and thorax revealed a large diaphragmatic hernia with herniation of the small bowel loops, the stomach, part of the transverse colon, the splenic flexure of the colon, the spleen, and the tail of the pancreas into the left side of the thoracic cavity, as well as the collapsed left lung  are seen on the left side, with 24% and 15% occurring on the right side or bilaterally, respectively . In an eThe exploratory laparotomy approach is the gold standard approach in emergency settings for the repair of diaphragmatic injuries associated with visceral injuries . In delaPost-traumatic diaphragmatic hernias can be misdiagnosed and can remain asymptomatic for months to years. In the case of thoracoabdominal injuries, a diagnosis of traumatic rupture of the diaphragm should be carefully considered because it can be masked by other severe injuries. A high index of suspicion should be kept for diagnosing traumatic diaphragmatic injuries. The CT scan of the chest and abdomen is the preferred imaging investigation for the diagnosis, while the surgical treatment includes the reduction of any visceral hernia, repair of the diaphragm, and restoration of the circulation, breathing, and digestive functions. The type of surgical approach adopted, whether thoracotomy, laparotomy, or minimal access surgery, will depend upon other associated injuries, as well as the surgeon’s preference or expertise.


Epithelioid hemangioma is a rare reactive vasoproliferative disease presenting with painless vascular nodules in the dermal and subcutaneous tissues of the head and neck. Clinical diagnosis can be difficult as, in most cases, the only symptom is a progressively tender swelling next to a vessel course. Thus far, few cases of epithelioid hemangioma localized to the nose have been described in the literature. Herein, we present a case of a 47-year-old woman with just such a lesion of the nose, focusing on its diagnosis and treatment. Epithelioid hemangioma  .As EH is quite rare, it can be clinically misdiagnosed for a number of benign inflammatory conditions such as Kimura disease, IgG4-related skin disease, bacillary angiomatosis, cutaneous epithelioid angiomatous nodule and malignant epithelial vascular tumors such as epithelioid sarcoma-like hemangioendothelioma, epithelioid hemangioendothelioma and epithelioid angiosarcoma . EH can Although the etiology of EH remains unclear, surgical excision with negative margins has proven to be the treatment of choice.Thus far, few cases of EH localized to the nose have been described, rather incompletely, in the literature, but this is the first case reported of a nasal tip involvement. Herein, we present in detail a case of a 47-year-old woman with just such a lesion of the nose, focusing on its diagnostic iter, emphasizing the importance of a radical surgical excision with a one-year follow-up experience.A 47-year-old woman was referred to our department with a solitary, painless but itchy nodule occupying the tip and part of the nasal dorsum. The lesion onset dated 2 years. The patient had no family history of any cutaneous diseases or vascular malformations and no history of trauma. A punch biopsy showed a rich amount of sebaceous adnexa, a periannesial and perivascular lymphoplasmacellular infiltrate with vascular ectasias and mild fibrosis, suggesting the possibility of discoid erythematous lupus.The patient started topical treatment but with no benefits. The patient’s lesion progressively increased in size and after one year, on examination, it had developed into a fixed lump covered by thin whitish skin with small telangiectasias .A Doppler ultrasonography using an 18 Mhz linear transducer revealed a highly vascularized nodular subcutaneous lesion of 23 mm × 16 mm .A biochemistry test, routine hematology and erythrocyte sedimentation rate were all within the normal reference ranges.While refusing another biopsy, the patient requested the total excision of the lesion and, therefore, a definitive diagnosis was postponed until formal lesion excision.Subsequently, an excision under local anesthesia with sedation was performed. The residual defect resulting from the wide excision was covered using a full-thickness skin graft harvested from the preauricular region .At histology, hematoxylin and eosin-stained sections showed redundant vascular proliferation with multilobular architecture occupying the medium and deep dermis consisting of small caliper vessels with mildly hyperplastic endothelium and epithelioid aspects . A rich At the one-year follow-up, the patient had no sign of recurrence and was satisfied with the result . A furthEH is an uncommon benign vascular proliferative lesion of unknown origin with a good prognosis and no reported incidence of metastatic disease. Nevertheless, these lesions have high rates of local recurrence and in some cases can have a simultaneous multifocal presentation, even in different organs . Some auClinical diagnosis can be difficult as, in most cases, the only symptom is a progressively tender swelling next to a vessel course. Skin discoloration may take place, especially in districts with a terminal circulation such as the nose . Pain anThe differential diagnosis of EH should include Kimura disease, pyogenic granuloma and Kaposi sarcoma .Surgical excision is the treatment of choice for EH. Due to its high risk of recurrence, a wide radical excision should be performed . When imOnce completely removed, EH local recurrence is rare; however, with an incomplete resection, almost 33% of patients have a recurrence, either at the same site or a distant site along the course of the blood vessel from where the EH originated ,11.The nasal localization of EH is uncommon and only six cases have been reported in the literature so far ,17,18,19To conclude, HE groupings include a variety of rare vascular lesions that can affect different tissues and organs. Diagnostic investigations should include imaging techniques to determine the extent of the lesion and to confirm vascular involvement. Once the diagnosis of HE is suspected, an early and complete surgical excision of the lesions with a thorough histological and immunohistochemical analysis should be undertaken.


MRI provides an opportunity to detect pathologies that cannot be depicted by CT because of its high contrast resolution . This case highlights the importance of considering MRI to diagnose and evaluate complications in suspected cases of wire bristle ingestion prior to endoscopic or surgical extraction.Injuries caused by grill brush bristle ingestion have been documented in the literature, but most existing literature focuses on consumer safety and increasing public awareness of potential injuries. Small bowel perforation is a serious complication and often difficult to diagnose since symptoms are frequently nonspecific and bristle localization can be challenging. We highlight a case where a diagnosis of acute pancreatitis was initially made by computerized tomography (CT) imaging but was later determined to be small bowel perforation with magnetic resonance imaging (MRI). The d in 2011 . Patient in 2011 . Nausea, in 2011 .We describe the utility of magnetic resonance imaging (MRI) as an investigatory tool for determining the true source of perforation in a case initially suspected to be pancreatitis, but which lacked a number of clinical features typically associated with the diagnosis. MRI is increasingly used to diagnose a variety of pancreatic diseases in cases of clinical uncertainty ; in thisThe patient was a 72-year-old male with a medical history of hypertension, paroxysmal atrial fibrillation, gastroesophageal reflux disease, and hyperlipidemia. He maintained a healthy lifestyle, exercised regularly, and did not consume tobacco or alcohol. He presented with fever and epigastric pain for three days. He described his epigastric pain as constant and dull, to the left side of the midline. He initially attributed his symptoms to possible food poisoning, as he recalled eating restaurant food prior to feeling sick; however, his pain became more persistent, and he presented to the hospital. Table Clinical FindingsPhysical exam on presentation was significant for epigastric and left periumbilical tenderness but otherwise normal. He was febrile with a temperature of 38.4° F and blood pressure of 126/80 mmHg, with normal heart rate and oxygen saturation. Laboratory data revealed elevated white blood cells (18.0/μL), elevated inflammatory markers , normal lipase of 27 unit/L, and a triglyceride level of 94 mg/dl. A CT scan of his abdomen and pelvis with intravenous (IV) contrast showed peripancreatic fat stranding around the head and the uncinate process of the pancreas, suggesting acute pancreatitis . There was no evidence of cystic duct obstruction. Abdominal ultrasound showed poor visualization of the pancreas. Otherwise, the exam findings were unremarkable. Immunoglobulin subtype 4(Ig-G4) was normal, signifying low suspicion of autoimmune pancreatitis.The patient’s normal lipase level, lack of risk factors for pancreatitis including alcohol consumption, absence of gallstones, and persistence of symptoms prompted the evaluation of other etiology of his pain. Amylase was not ordered; in a number of studies, lipase has generally been found to be both more sensitive and more specific than amylase for the diagnosis of acute pancreatitis . EsophagAn MRI of the abdomen with and without contrast Figure  was thenTherapeutic InterventionThe new findings on MRI changed the working diagnosis completely and shifted the therapeutic focus from conservative to interventional management. Extraction of the foreign body identified in images became a priority. The patient, who had started on an oral diet at the time, was placed back on nil per os, or nothing by mouth (NPO) and was started on IV antibiotics with piperacillin-tazobactam. Surgical consultation recommended a trial of endoscopic removal, and if unsuccessful, consideration of open surgical extraction. A small bowel enteroscopy was performed and revealed a few localized erosions with no bleeding in the duodenal bulb and the second portion of the duodenum Figure . A foreiFollow-Up and OutcomeThe patient’s symptoms improved greatly after the extraction, and with the addition of antibiotics, his pain became intermittent and he was able to tolerate a regular diet. He required additional non-surgical treatment with extended antibiotic therapy with amoxicillin/clavulanic acid and close follow-up after discharge and eventually recovered completely.In the adult population, perforation of the small bowel caused by wire-bristle ingestion appears to be a relatively common injury, likely due to the bristle’s small diameter and frequent angulation within the small bowel, though it is observed less frequently than oral or oropharyngeal injury . Delays Depending on the site of penetration, the clinical presentation may mimic more common medical conditions, e.g., peptic ulcer disease or gastritis if the bristle lodges in the stomach, or pancreatitis if the bristle is in the pancreas or duodenum . Micro-pCT scans are the preferred method of pre-procedural diagnosis and are recommended for initial localization and evaluation of complications, including bowel perforation . The useDue to the small amount of free extraluminal air in small bowel perforation relative to the perforation of other parts of the gastrointestinal tract, a CT scan may fail to detect small bowel perforation . Free aiMRI has excellent soft tissue resolution . FindingMultiple endoscopic versus surgical procedures may be required for localization and safe removal . Brooks In conclusion, we highlight a case where MRI was utilized to diagnose a grill bristle perforation and exclude other pancreatic pathology. This case also highlights the importance of recognizing alternative modalities such as an MRI to diagnose and evaluate complications in suspected cases prior to endoscopic or surgical extraction.


Spontaneous rupture of the urinary bladder (SRUB) secondary to emphysematous cystitis(EC) in diabetic patients is extremely rare. Clinical presentations are often non-specific and display the signs and symptoms of peritonitis. The diagnosis is usually made after exploratory laparotomy.A 70-year-old diabetic woman presented to the emergency department with sudden diffuse abdominal pain and hematuria of six hours duration. Physical examination revealed generalized peritonitis. Multi-slice abdominal and pelvic CT scans showed free air and fluid in the abdominal cavity. After proper resuscitation, the patient was transferred to the operating room for exploratory laparotomy. A 2 cm full-thickness bladder rupture was noted at the dome of the bladder, which was repaired.We noticed free air in the urinary bladder wall postoperatively in the CT scan, which is the radiological sign of EC. The Pathology result was in concordance with the diagnosis.SRUB in patients with poorly controlled diabetes and EC is highlighted in this case study. Urinary bladder rupture secondary to EC should be considered When a diabetic patient with a history of urinary symptoms presents with an acute onset of abdominal pain suggestive of peritonitis. Uneventful recovery from SRUB is dependent on early diagnosis and treatment. •SRUB should be considered in diabetic patients with a history of urinary symptoms.•An uneventful recovery from SRUB is dependent on early diagnosis and treatment.•EC may be seen in diabetic patients with abdominal pain, and symptoms of cystitis.•Proper antibiotic therapy leads to successful treatment and prevents complications. Although the cause of SRUB is unclear, in most cases, a predisposing factor makes a patient prone to bladder rupture 2A 70-year-old woman presented to the emergency department with sudden diffuse abdominal pain and hematuria of six hours duration. The patient denied any prior history of trauma or intoxication. Her past medical history was significant for type 2 diabetes mellitus from 15 years ago, multiple episodes of urinary tract infections (UTI) in the past five years, and urinary frequency. Her drug history was only metformin, two grams per day from 15 years ago. Upon arrival, vital signs were as follows: blood pressure of 110/70 mmHg, heart rate of 100 beats per minute, respiratory rate of 18 breaths per minute, and body temperature of 38 °C.9/L with neutrophilia, serum creatinine of 2 μmol/L, urea of 55 mmol/L, the elevated blood sugar of 400 mg/dL, serum potassium of 4 mmol/L, serum sodium of 130 mmol/L. Urinary catheterization drained 150 mL of bloody urine. Microscopic urinalysis revealed many RBCs, WBCs, and bacteria per high power field. Multi-slice abdominal and pelvis CT scans showed free air and fluid in the abdominal cavity and air in the bladder wall  and was discharged from the hospital one week after surgery in good condition with an indwelling urinary catheter and a suprapubic catheter. Two weeks after discharge, she was returned for a follow-up visit, and the suprapubic catheter was extracted. A follow-up cystoscopy was performed one month later and noted only mild to moderate trabeculation, and there was a scar at the site of perforation. Pathology came back as transmural infiltration of mixed inflammatory cells with surface ulceration . During 3SRUB is a rare and potentially life-threatening emergency. The incidence of SRUB is around 1 in 126,000, including less than 1 % of bladder injuries, while external trauma is the most common cause The suggested cause of the SRUB is the weakening of the wall of the urinary bladder, primarily due to urine retention Poorly controlled diabetes can lead to UTI, bladder dysfunction, and urinary retention, a major predisposing factor for SRUB Abdominal pain is the most common sign of SRUB Retrograde cystography  has been recommended to evaluate bladder injuries There is a lack of specific guidelines for the management of SRUB. The American Urology Association (AUA) and the European Association of Urology (EAU) recommend surgical repair for intraperitoneal bladder injuries. The AUA recommends urethral catheter drainage without suprapubic cystostomy after the surgical repair. Conservative management has not been recommended for intraperitoneal bladder injuries Escherichia coli is the most common isolated bacteria, as in our case. Major risk factors for EC are diabetes mellitus and urinary retention. It is more commonly seen in older women in their 60s or 70s EC is a unique form of a complicated UTI caused by gas-forming organisms. The diagnosis of EC is generally made in patients found to have air within the bladder wall on abdominal imaging. Early identification of intraluminal or intramural gas in the abdomen can be achieved by abdominal CT, which is a highly sensitive modality Antibiotics are usually effective in treating EC. However, laparotomy is indicated in complicated EC with peritoneal signs, pneumoperitoneum, or perivesical abscess 4SRUB in patients with poorly controlled diabetes and EC is highlighted in this case study. Spontaneous rupture of the urinary bladder should be considered in diabetic patients with a history of urinary symptoms present with acute onset of abdominal pain. An uneventful recovery from SRUB is dependent on early diagnosis and treatment. EC should also be considered in diabetic patients with poor control of blood sugar, abdominal pain, and symptoms of cystitis. Proper and prompt antibiotic therapy leads to successful treatment and prevents further complications.N/A.The ethics committee approved this study at the Iran University of medical science.Written informed consent was obtained from the patient to publish this case report and accompanying images. On request, a copy of the written consent is available for review by the Editor-in-Chief of this journal.N/A.Dr. Foolad EghbaliNot commissioned, externally peer-reviewed.- Conception and design: F E, M B, M N- Analysis and interpretation of data: N/A- Data collection: A V E- Authors participate in drafting the article or revising: F E, M B, H MThe authors declare that they have no competing interests.


Mesenteric cysts are one of the rare causes of intra-abdominal masses. They account for 1 in 100,000 cases in adults and 1 in 20,000 cases in children. Mesenteric cysts are commonly found in the small intestine, up to 60% of cases, and occasionally in the colon. The clinical presentation of patients with mesenteric cysts is so variable and nonspecific. It ranges from being asymptomatic to features of acute abdomen very rarely. Surgery is the treatment of choice. Complete excision with negative margins plays a curative role in avoiding the risk of recurrence as well. Here, we present the case of a 70-year-old woman who came to Hawassa University Comprehensive Specialized Hospital with abdominal swelling for a 5-month duration. She had an abdominal ultrasound, which suggested a calcified mesenteric cyst with internal hemorrhage. The patient was taken to the OR with the impression of an intra-abdominal mass for exploratory laparotomy. The mass was completely excised and was subjected to pathology, which turned out to be a calcified simple mesenteric cyst, and the purpose of this case report is to alert physicians that although the preoperative diagnosis of mesenteric cysts is difficult, it should be considered in the differential diagnosis of a patient presenting with an intra-abdominal mass. Mesenteric cysts are one of the rare causes of intra-abdominal masses. They account for 1 in 100,000 cases in adults and 1 in 20,000 cases in children . Nearly Mesenteric cysts commonly occur in the Caucasian population in their forties, and females are slightly more affected , 6. ThouThe clinical presentation of patients with mesenteric cysts is so variable and nonspecific. It ranges from being asymptomatic to features of acute abdomen very rarely , 3, 8. TAccording to the most widely used classification of mesenteric cysts by Miljković et al. , which tPreoperative diagnosis of mesenteric cysts is often difficult, but it should be considered in the differential diagnosis of a patient presenting with an intra-abdominal mass , 2. A nu“Once diagnosed, all mesenteric cysts should be resected to avoid complications, recurrence, malignant transformation, and possible complications . Internal drainage may be an option when there is a possibility of short bowel syndrome. In selected cases, laparoscopic approach can be used” .We present a case of a 70-year-old woman who came to Hawassa University Comprehensive Specialized Hospital with abdominal swelling for a 5-month duration. She claimed to have a dragging sensation occasionally. She had no abdominal pain. She had no vomiting or bowel habit changes. She had no anorexia. She had no weight loss. She had no constitutional symptoms of malignancy.Her past medical history was unremarkable.She looked comfortable. All the vital signs were within the normal range; on abdominal examination, there was a grossly visible mass in the area of the umbilicus and epigastric area, and it was firm, nontender, and slightly mobile; there was no sign of fluid collection. Digital rectal examination was normal.3/μL; granulocytes = 70.1%; lymphocytes = 21.1%CBC − WBC = 6.1 × 103Hgb = 12.9; platelet = 367 × 10Bg&Rh = o+FBS = 105 mg/dLBUN = 16Creatinine = 0.8ALP = 77AST = 24ALT = 35CXR-normalAbdominal ultrasound. There was a mid-abdomen region, a large well-defined cystic mass with multiple wall calcifications, internal echo debris, and fluid levels. There were also multiple wall calcifications. It measured 13.9∗13.6 cm. No vascular flow was detected. No soft tissue components were noted. The DDx on abdominal ultrasound was a calcified mesenteric cyst with an internal hemorrhage and recommended abdominal CT, and it was done (was done .On the CT scan. There was no evidence of malignancy, and there was no invasion of adjacent organs or major vesselsThe patient was taken to the operating theater with the impression of an intra-abdominal mass for exploratory laparotomy. The abdomen entered through a midline vertical incision. Upon opening the linea alba, the mass was found to be adherent to the anterior abdominal wall, and it was thick walled . The mas5Simple mesenteric cysts are rare, and calcified ones are rarer conditions, and not more than 1000 cases have been reported so far in the literature . They doThere are no symptoms or signs which are considered pathognomonic for mesenteric cysts , 8. CystCommonly, mesenteric cysts are asymptomatic with typical transverse mobility and around the axis of the mesentery, but occasionally, patients may present with nonspecific symptoms like abdominal pain or nausea , 10. OurAccording to 22 patients who were operated between January 2010 and January 2019 after the diagnosis of mesenteric cysts in the General Surgery Clinics of Şanlıurfa Training and Research Hospital, and Mehmet Akif Inan Training and Research Hospital, 12 cases presented with abdominal pain, 3 cases with nausea and vomiting, 2 cases with an abdominal distension, 2 cases with abdominal mass, and in the other 3 diagnosis were made incidentally during abdominal imaging . Our casRegarding sex predilection of mesenteric cysts, previous studies suggested that men were more affected than women, but more recent studies show otherwise. The female-to-male ratio is about 2 : 1 . This waAlthough it is the first imaging that is done, ultrasound is not the first choice of imaging modality for intestinal and mesenteric masses as it lacks precision in detailing the relationship of the mass with the surrounding tissues and viscera . AbdominConcerning the treatment of mesenteric cyst, complete excision with or without bowel resection, depending on the involvement of the mesenteric vessels or the bowel itself, is the treatment of choice , 6. SimpThe choice of surgery depends on the location of the cyst, its size, and whether adjacent organs are involved or not. According to Yavuz, who analyzed 22 cases of mesenteric cysts managed surgically between January 2010 and January 2019, 11 cases had enucleation, 4 cases had segmental small bowel resection and anastomosis, 3 cases had laparoscopic cyst excision, 2 cases had left hemicolectomy, 1 case had right hemicolectomy, and 1 case had appendectomy and cystectomy . Three cOpen surgery is considered the best modality. Despite the well-known benefits of laparoscopy over open surgery, there are very few cases of laparoscopic excision of mesenteric cyst. It is said that advanced skill must do it laparoscopically , 10. Ourrd of the cases, the cysts recurred very rapidly [Where the patient is a poor surgical candidate, cyst aspiration was attempted in some cases, and in about 1/3 rapidly . Drainag rapidly .Mesenteric cysts and cystic lymphangiomas are two rare entities that have almost similar clinical and radiological appearances, but they do differ in histological basis . The preAs most mesenteric cysts are benign, they have an excellent prognosis following a complete surgical excision with little risk of recurrence . Our cas


The literature regarding size descriptions for spermatic cord lipomas is limited. The term “giant” is utilized loosely and seen on case reports for masses as small as 6 cm. Here we present a case of a giant left sided spermatic cord lipoma, found incidentally during a recurrent inguinal hernia repair, that measured 18 × 14 × 10 cm on final pathologic examination.A 59 year old male, with a history of morbid obesity and surgical history of prior bilateral inguinal hernia repair, presented with recurrent left sided groin and scrotal bulging with associated discomfort several months after the initial hernia repair. Following imaging performed on preoperative work up, the patient was brought to the operating room for a robotic inguinal hernia repair.Preoperative physical examination was limited due to the patient's body habitus which precluded a definitive diagnosis of inguinal hernia based on physical examination. Computed tomography of the abdomen and pelvis was performed with findings consistent with bilateral recurrent inguinal hernias. A bilateral robotic inguinal hernia repair was attempted. The procedure was converted to open via a groin incision when an incidental 18 cm left sided spermatic cord lipoma was discovered. An orchiectomy was ultimately performed as the mass was intimately intertwined with the spermatic cord.In our case, the patient had a recurrent inguinal hernia and an incidental finding of an 18 cm spermatic cord lipoma which warranted a left orchiectomy followed by open inguinal hernia repair. We propose standardizing the term “giant” to include spermatic cord lipomas >15 cm. •Elevated BMI is associated with high rate of hernia recurrence.•Adequate exclusion of cord lipoma during index hernia repair is necessary.•Describing benign spermatic cord masses as “giant” should be reserved for masses > 15 cm. Patients with inguinal hernias typically present with a bulge in their groin and possibly scrotal region. Clinically, it is difficult to differentiate herniating intraabdominal contents in an inguinal hernia from the presence of a spermatic cord lipoma. During inguinal hernia repair procedures, cord lipomas have been discovered between 20 and 70 % of the time. Imaging modalities such as ultrasound, computed tomography and magnetic resonance imaging have been utilized to aid in their diagnosis According to Priemer et al., in a 17-year retrospective review of paratesticular soft tissue masses, lipomas were the most commonly found benign neoplasm of the spermatic cord. Their data showed that one third of orchiectomies performed for paratesticular masses were pathologically consistent with benign lesions 2This is a 59 year old male who presented with recurrent bilateral inguinal hernias. He had a medical history significant for morbid obesity (BMI > 45). He had no contributory family history. He was a non smoker and denied routine ethanol use. He underwent bilateral inguinal hernia repair, robotically with mesh, six months prior.Several months after his initial repair, he began complaining of bilateral scrotal swelling, discomfort, and a hard bulge in his proximal left scrotum. CT imaging revealed fat containing bilateral inguinal hernia , left grHe was taken to the operating room for robotic bilateral inguinal hernia repairs. The repair was performed by the director of the Hernia Center for Excellence who was assisted by an experienced consultant general surgeon. His prior meshes were noted to have migrated superiorly and he had visible recurrent bilateral inguinal hernias. A dissection was performed, including explantation of prior meshes, however the hard “bulge” in the left hemiscrotum was not able to be reduced. Due to concern for a pathologic mass in that area the robotic procedure was terminated and an open inguinal hernia repair was pursued. During the open dissection a large lipomatous mass was reduced out of the left inguinal canal.On tactile analysis, the large mass had a softer more normal fatty texture as well as a harder mass with a capsule associated with it . The masFinal specifications by the pathology department at our institution characterized the mass as encapsulated yellow fibrofatty tissue measuring 18 × 14 × 10 cm with histologic characteristics of non malignant adipose tissue with evidence of fat necrosis . Attache3Spermatic cord lipomas are usually an incidental finding and are frequently misdiagnosed as inguinal hernias. In many cases, they can present concomitantly. Physical examination alone can't definitively differentiate between both conditions. This can be further complicated in patients with an increased body habitus, as in our patient Pre operatively, the patient was diagnosed with a recurrent inguinal hernia as the patient had initial hernia repair 6 months prior in a robotic laparoscopic setting. On physical examination, the patient had a groin bulge as well as CT scan findings consistent with recurrent hernia. Intraoperatively, a recurrent hernia was confirmed but on external examination the ipsilateral groin bulge did not resolve with laparoscopic hernia sac reduction. Only upon converting to an open repair were we able to visualize a giant spermatic cord lipoma. Prior literature suggests that in order to avoid missing a spermatic cord lipoma diagnosis, external compression of the superficial inguinal ring should be performed along with internal traction of the cord structures in order to reveal a spermatic cord lipoma during laparoscopic inguinal hernia repair According to Heller et al., post mortem autopsies revealed a 75 % incidence of spermatic cord lipomas in men ranging in age between 24 and 92 years old The range for the term "giant" appears to be loose throughout the literature. Due to the descriptive discrepancy in the literature on size for spermatic cord lipomas, we suggest reserving the term “giant” as it relates to this pathology for tumors >15 cm in size. No case reports were found to describe a giant spermatic cord lipoma with associated necrosis. It is our hypothesis that in our case the spermatic cord lipoma was found to be necrotic on histological analysis likely due to its size and prior hernia repair at that site possibly contributing to tenuous blood supply.4This case highlights the necessity of adequate exclusion of cord lipoma during minimally invasive or open inguinal hernia index repair in patients with elevated BMI in addition to performing necessary measures to prevent recurrence. This case also highlights the inaccuracy in use of terms to describe the size of benign spermatic cord masses. There have been multiple reports of spermatic cord lipomas discovered incidentally during inguinal hernia repair. Masses as small as 6 cm have been previously described as "giant". In light of the above, we suggest both reserving the term "giant" for benign spermatic cord masses that are >15 cm as well as suture mesh fixation in patients with elevated BMI .Not commissioned, external peer-reviewed.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not applicable.None.Kristoffer Wong, DO, FACOS.Not applicable.Alona Salita , Mohamed Hussein (Writing - Review & editing), Qazi Azher (Investigation), Gul Sachwani , Kristoffer Wong .The authors declare that they have no conflicts of interest.