Cavernous hemangioma is a benign vascular tumor, which very rarely occurs in the lung. When appearing as multiple nodules on chest CT, this tumor can be misdiagnosed as metastatic malignancy.A 72-year-old woman presented with incidentally found multiple lung nodules on chest radiograph.Based on information derived from dual-layer spectral CT images, the possibility of slow flow vascular tumor such as cavernous hemangioma was suggested. A pathologic diagnosis of pulmonary cavernous hemangioma was made via video-assisted thoracoscopic biopsy.After tissue confirmation, the patient was discharged without further intervention.The patient recovered without any event. Follow-up chest CT performed 6 months later showed no significant interval change in nodule size and distribution.Material decomposition images obtained from dual energy CT can help physicians understand the character of tumor vascularity for an accurate diagnosis of pulmonary cavernous hemangioma. Multi-energy applications of CT have improved the characterization of pulmonary nodules such as the differentiation between benign and malignant lesions and the assessment of tumor angiogenesis. Here, we describe dual-layer spectral CT findings of multiple PCHs in a 72-year-old woman with pathological correlations for a better understanding of PCH to avoid unnecessary invasive procedures.Pulmonary cavernous hemangioma (PCH) is an extremely rare benign tumor. When PCH presents as multiple nodules in both lungs, it mimics metastatic malignancy.2This study was approved by the Institutional Review Board of Gyeongsang National University Changwon Hospital. The patient provided written consent for publication of this case. A 72-year-old female presented with incidentally found multiple lung nodules on chest radiograph. She was a nonsmoker. The patient was treated with appendectomy due to appendicitis a month before. Other medical history was unremarkable. Chest radiograph showed multiple nodules in both lungs Fig. A. Under Chest CT showed random distribution of variable-sized nodules in both lungs Fig. B. The prVideo-assisted thoracoscopic biopsy was performed for tissue confirmation. Grossly, multiple hemorrhagic nodules were found diffusely distributed throughout in all the lobes and pleura Fig. E. Micros3 A recent literature review of PCH found that <20 cases have ever been reported. The clinical presentation of PCH varies depending on the size and number of tumors. Although some patients present with life-threatening symptoms such as severe bleeding or dyspnea, others show absent or nonspecific symptoms.–6Unlike other organs such as the skin, subcutaneous tissues, and liver, cavernous hemangiomas very rarely occur as primary neoplasms in the lung.–8 Metastatic nodules appear as multiple variable-sized nodules scattered in the lung and pleura. A cavernous hemangioma is an unencapsulated mass of dilated, endothelium-lined vascular channels filled with slow-flowing blood. In contrast to cavernous hemangiomas involving other solid organs such as the liver, a typical centripetal enhancement pattern has not been reported in PCH, hindering preoperative diagnosis.PCH presents as single or multiple solid nodules on imaging studies. Multiple PCHs have been reported to mimic metastatic lesions. The dual-layer detector spectral CT system consists of a single tube and 2-layered detectors, which simultaneously capture high- and low-energy photons during each CT examination. Because energy separation occurs on the detector, the decision to use a single- or dual-energy protocol before scanning is not necessary. Spectral information can be obtained from all examinations using a routine protocol. In the present study, enhancement pattern of nodules was not obvious on conventional CT images, except for a nodule in the right lower lobe because of small lesion size and high density  of the nodules. However, iodine density images derived from spectral based image clearly showed the presence and the pattern of iodine uptake in each nodule, reflecting blood supply. The pattern of iodine distribution in PCHs was similar to the contrast enhancement pattern in hepatic cavernous hemangiomas, peripheral nodular, or entire enhancement with gradual filling. The high-density areas observed in some nodules in the precontrast images were caused by dystrophic calcification in vessel wall as shown in pathology.Recent advances in CT technology have led to improved detection and characterization of nodules. In particular, dual-energy techniques enabled better characterization of nodules via material differentiation. Management of PCH varies depending on the severity of symptoms and extent of the lesions. In a solitary PCH, surgical excision is considered as the most effective treatment. Interferon alfa-2a has been reported to be effective in treating multiple PCHs. However, because of the rarity of cases, the management of PCH remains a topic of controversy. Radiographic follow-up may play an important role in asymptomatic and stable PCH.The etiology of cavernous hemangiomas is not completely understood; however, they are considered to be congenital vascular malformations, which may be attributed to genetic loss-of-function mutations.We presented a rare case of multiple PCHs based on dual-layer spectral CT findings. Since percutaneous biopsy of PCH can lead to bleeding complications, a proper imaging diagnosis is important. To the best of our knowledge, this is the first report of PCH describing spectral CT findings. Despite its rarity, our informative case may help physicians understand the characteristics of the tumor based on CT and correlative pathologic findings, obviating the need for unnecessary invasive procedures.Conceptualization: Kyungsoo Bae, Kyung Nyeo Jeon.Formal analysis: Kyungsoo Bae, Hyo Jung An.Investigation: Kyungsoo Bae, Hyo Jung An.Methodology: Jae Jun Jung, Ho Cheol Kim.Resources: Hyo Jung An, Jae Jun Jung.Supervision: Kyung Nyeo Jeon.Writing – original draft: Kyungsoo Bae, Kyung Nyeo Jeon.Writing – review & editing: Kyungsoo Bae, Hyo Jung An, Jae Jun Jung, Ho Cheol Kim, Kyung Nyeo Jeon.


A 2-year-old female patient with a recent history of head trauma was admitted to the Ophthalmology Clinic with left exophthalmos. A differential diagnosis between traumatic and tumoral etiology was made. The orbitocranial MRI and fine needle ganglion biopsy settled the malignant etiology of the exophthalmia. Further investigations at the Pediatric Oncology Clinic decided on the diagnosis of orbital metastatic neuroblastoma. This case report presented an unusual association: orbital metastatic neuroblastoma becoming clinically positive soon after a head trauma. Neuroblastoma is a malignant tumor of sympathetic paravertebral ganglia that typically affects very young children and it is the most common malignancy of infancy [2]. Usually, orbital neuroblastoma presents with acute exophthalmos, mimicking a traumatic etiology: periorbital ecchymosis, the “raccoon eyes” due to intratumoral spontaneous necrosis [1].Orbital neuroblastoma metastasis is the second most prevalent malignant orbital tumor, after rhabdomyosarcoma [A 2-year-old female patient was admitted to the Ophthalmology Clinic with left exophthalmos. One month earlier, she had suffered a minor head trauma, with frontal hematoma. Two weeks following that episode, she presented a progressive left exophthalmia. She had no significant other medical or family history.The clinical examination revealed bilateral normal visual acuity, normal pupillary reflexes, left exophthalmos, displaced downward, with limited abduction and elevation movements, with exophthalmometry measurements of 7 mm on right and 14 mm on the left side and a firm frontotemporal profoundly adherent tumoral mass without skin modifications. A supraclavicular firm adherent nodule was also found by palpation. Biomicroscopic examination of the fundus showed a deformed upper half of the posterior pole without any obvious mass inside the globe.Fig. 1).The biochemical blood analysis revealed a mild anemia and a mild inflammatory syndrome. The echography of the left eye and orbital-head CT were equivocal and traumatic etiology could not be ruled out. A head MRI was performed and revealed an intra and extraconal tumoral mass with endocranial extension and enhanced contrast uptake .We consulted the Pediatric Oncology Department and they recommended the biopsy from the orbital tumor, which was negative, and a fine needle aspiration of the left supraclavicular adenopathy, which was suggestive of a malignant tumor with small blue cells  utilizes a classification system that takes into account the imaging stage, age on onset and pathology  [Learning points• Due to possible intra-tumoral hemorrhage, orbital neuroblastoma can reveal itself after minor head injury;• In a presentation with acute/ rapid progressive proptosis, a tumoral etiology, such as neuroblastoma and rhabdomyosarcoma, should also be kept in mind;• In case of an orbital tumor, a primary tumor should always be searched for elsewhere. AcknowledgementsThe authors express their gratitude for the histopathology examination performed by Doctor Emil Botan.Informed consentThe authors declare that the right to privacy of the patient was respected and informed consent was obtained.


Giant mesenteric lipoblastoma is a rare benign tumor arising from the adipocytes. It can mimic malignant tumors, and its diagnosis is difficult before surgery. Imaging studies could lead the diagnosis but not confirm it. Those tumors arising in the abdomen are usually larger and can cause symptoms of compression. Surgical excision is the treatment of choice, and a long-term follow-up is necessary to detect local recurrences. Only a few cases of lipoblastomas arising from the mesentery are reported in literature. We present a case of a rare giant lipoblastoma arising from the mesentery of a 6-year-old girl, with a history of postprandial abdominal pain. Adipose tumors are rare in childhood and represent 6% of all the neoplasms of the soft tissue.They can be classified into malignant (liposarcoma) and benign  , 2.Lipoblastoma is a rare, encapsulated tumor arising from the embryonal fat tissue .It is more frequent in children younger than 3 years old, with a male to female ratio of 3 : 1 . . 24]. WeThree out of 18 patients had an acute onset, with volvulus –9. None Mean time of follow-up was 16 ± 12 months. No recurrences have been reported, when mentioned.Lipoblastoma is a rare benign, encapsulated tumor of adipocytes, accounting for 5-30% of all the adipose tumors .It arises from the abnormal proliferation of embryonic fat cells but its etiopathogenesis is not completely understood , 3, 25.It is more frequent in the first decade of life, with a peak of incidence in males younger than 3 years  , 3.These tumors are usually asymptomatic; however, they can cause a mass effect when reaching considerable dimensions , 25.Lipoblastoma is commonly located at the level of the trunk and extremities. Intra-abdominal localizations are rare; nonetheless, intraperitoneal tumors usually reach superior dimensions , 3.Typical symptoms of abdominal lipoblastomas are abdominal pain, constipation, and vomiting, secondary to organ compression. Acute manifestations, secondary to volvulus or intussusception, are also reported, although rare –9.Imaging studies, especially MRI, are useful to define the adipose nature, the extent, and tissue involvement of neoplasia. However, this study is unable to differentiate among lipoma, lipoblastoma, and liposarcoma , 26, 27.Microscopic features consist of lobular architecture and myxoid areas with spindle cells and lipoblasts at various stages of differentiation , 29.Rearrangements of chromosome 8q11 codifying for the oncogene PLAG1 are found in more than 70% of cases –4, 28–30Recurrence rate is reported to range between 9 and 46%, and it is usually secondary to an incomplete surgical excision , 6, 30.A problem related to mesenteric lipoblastomas is the massive size of the mass and its close contiguity to the mesenteric vessels and intestinal loops, which makes a purely laparoscopic excision virtually impossible to perform. In children, laparotomy incision should be as small as possible, to limit the extent of the scar, as we did in our case.Mesenteric lipoblastoma is a rare benign tumor.It can be completely asymptomatic or can cause symptoms related to a mass effect. Imaging studies are unable to reach the definitive diagnosis; therefore, surgical excision is the treatment of choice and leads to a definitive diagnosis through the histopathological examination of the specimen.We stress the importance of a surgery that should be as mini-invasive as possible, considering the localization and the size of the mass. A long-term ultrasonographic follow-up is necessary to detect local recurrences.


Lipoma and its variants rarely involve the oral cavity. Osteolipoma of the hard palate is extremely uncommon with only a few cases reported worldwide. It is important to recognize and give comprehensive diagnosis of this entity, so as to prevent unwarranted medical interventions. Here, in this report, we describe a rare case of osteolipoma arising in the hard palate of a 35-year-old male and the diagnostic conundrum associated with it. The approach to such a case, differential diagnosis, and review of the literature are also presented.  Lipoma is the most common benign soft tissue mesenchymal neoplasm in adults. It has a tendency to occur at almost any anatomical location of the body where fat normally exists, therefore, it is also known as a ubiquitous or universal tumor . AccordiA 35-year-old male presented to the otorhinolaryngology outpatient department with the chief complaint of a painless palatal mass of eight-year duration. His history of present illness revealed that initially a pea-sized swelling was noticed by him inside the mouth on the hard palate. However, it gradually grew over the last four years to attain the present size. There was no history of local trauma, bleeding, pain, sensory changes, disturbance of salivation, any other oral lesions, fever, loss of appetite, or weight loss. The past dental, medical, and personal history were unremarkable. The family history was noncontributory. On general physical examination, he was of moderate built and all his vitals were within the normal limits. There was no regional lymphadenopathy. No abnormality was detected on his systemic examination. Extraoral examination was unremarkable. Opening of the mouth was adequate. Intraoral examination revealed the oral hygiene to be poor. A round to oval mass with irregular margins measuring 4 cm x 2.5 cm in size was seen on the hard palate Figure .On palpation, it was well defined, firm to hard in consistency, nontender, nonfluctuant, nonreducible, nonpulsatile, and immobile. The color of the overlying mucosa was same as that of the adjacent mucosa. On the basis of history and clinical findings a provisional diagnosis of torus palatinus was made. CT scan of the face revealed a well-defined lobulated soft tissue lesion with a peripheral rim of calcification along the inferior aspect of the hard palate. There was no evidence of invasion into the adjacent structures Figure .Based on these radiological features, the possibility of a calcified hamartoma or an osseous choristoma was kept. Simultaneously, after his routine laboratory investigations to arrive at a conclusive diagnosis, fine needle aspiration cytology (FNAC) was performed. However, owing to the hardness of the mass, FNAC attempts failed to yield any material for establishing the diagnosis. The lesion was excised under general anesthesia using nasal intubation and the specimen was sent for histopathological examination Figure .Grossly, the mass was well demarcated, yellowish, hard in consistency, and measured 4 cm x 2.7 cm x 0.8 cm in size. The specimen was decalcified. It was gritty on cut and the sections were yellowish-gray (Figure Microscopic examination exhibited a tissue lined by keratinized stratified squamous epithelium. The subepithelium showed abundant mature adipose tissue comprising uniform adipocytes which were separated by thin connective tissue septa at places. Also, scattered among them were the variably sized and shaped normal bony trabeculae with features of osteoblastic rimming. No nuclear atypia, cell pleomorphism, mitosis, necrosis, or foci of hematopoietic cells were seen Figure .On the basis of all these histopathological features, a final diagnosis of hard palate osteolipoma was established. The postoperative period of the patient was uneventful and no recurrence of the lesion was detected even after three years of follow-up.Intraoral lipoma is quite an uncommon neoplasm, accounting for 2.2% of all the lipomas and has a prevalence rate of 0.0002%. Roux in the year 1848, first described it in a review of alveolar masses, in which he referred it as a “yellow epulis” . It is mIntraoral osteolipoma, as seen in the present case study, is exceedingly rare. On further exploring the existing literature on intraoral osteolipoma, certain clinicopathological features of this condition draw special attention, which in turn have direct diagnostic and therapeutic implications. Clinically, any age group and gender can be involved. However, it is usually seen in adult males over 30 years of age. Various anatomical sites, regardless of any bone proximity can be involved by this tumor. According to the pertinent world literature till date, 15 cases of intraoral osteolipoma have been documented so far, with eight of them being reported from buccal mucosa, three from hard palate, two from floor of the mouth, one from lateral border of the tongue, and one from retromolar trigone ,12. To tThe major presenting symptom is a painless, gradually growing, soft or hard, round or discoid, mobile or fixed, generally well-defined mass, the size of which can be variable and may range from 0.8 to 9 cm. The tumor usually remains undetected by the patient for years as there is usually a long interval between occurrence of the lesion and the time of presentation of the patient to the clinician ,13. ThisTherapeutically, complete surgical excision is the treatment of choice and due to the benign nature of this tumor, the prognosis is favorable. However, a close monitoring and long-term follow-up of such patients is mandatory as the possibility of malignant transformation and recurrence rate of this tumor cannot be commented upon so far due to the scarcity of clinical data available till date.Intraoral osteolipoma is an unusual tumor which occasionally involves the hard palate. Given the rarity, it generally remains unrecognized by the treating clinicians, thus creating diagnostic dilemmas. Hence, osteolipoma should be included as one of the important differentials among the hard palate lesions. Preoperatively, a combination of detailed clinical history, physical examination, cytological, and radiological assessment aid in its diagnosis, but it is the histopathology which is confirmative. Nevertheless, more insight is required in future to understand the genesis and behaviour of this tumor especially in those which occur at atypical sites.


The pituitary gland is an uncommon site of tumor metastasis in the brain, comprising only 1% of all intracranial metastasis. Large cell neuroendocrine carcinoma (LCNEC) is similarly rare, accounting for only 3% of all lung malignancies in adults. We describe a case of LCNEC of lung origin that metastasized to the pituitary gland. The pituitary lesion was found during the workup for a metastatic LCNEC of lung origin in the ovary. Initially thought to be a pituitary adenoma, interval growth of the lesion during imaging follow-up raised clinical suspicion of a second metastatic site. The patient underwent endoscopic resection and pathological examination confirmed the pituitary lesion to be from the lung primary. Post-operatively, the patient developed signs and symptoms of diabetes insipidus that was adequately treated with DDAVP. The patient underwent postoperative radiotherapy one month after the surgery and a repeat MRI at the 12-month follow-up demonstrates no progression of the pituitary lesion. Tumor metastasis to the pituitary gland is uncommon, and found in only 1% of all intracranial metastasis and 2% of all autopsied cancer cases [A 60-year-old woman with a 40-pack-year (former) smoking history was diagnosed with pT1b N1 M0 high grade LCNEC in 2013. Comorbidities include hypothyroidism, migraines, depression, anxiety, and fibromyalgia. She was treated with lobectomy and concurrent adjuvant chemoradiation with 40 Gy in 15 fractions of radiotherapy to the chest with four cycles of cisplatin and etoposide.In January 2018, the patient presented with bilateral ovarian masses and developed severe fatigue, dizziness, unsteady balance, bilateral temporal headaches, memory loss and mild mood alterations. Staging workup revealed bilateral ovarian masses of size 8.1 x 4.8 cm and 6.8 x 5.1 cm on CT scan and a CA-125 level of 114  . LCNECs The main routes of metastasis to the pituitary are hematogenous spread and direct invasion from the skull base . It is tSome authors have suggested some non-specific imaging features of pituitary lesions may help distinguish a metastatic lesion from a pituitary primary. Pituitary metastases typically exhibit fast growth. Other notable MRI features of pituitary metastases include relative isointensity to brain on both T1- and T2-weighted images, thickening of the pituitary stalk, invasion of the cavernous sinus, and sclerotic changes around the sella turcica -15. The Symptomatic pituitary metastases are most often treated locally by surgery and radiotherapy. Transsphenoidal surgery is the preferred surgical approach for debulking and symptom relief . For nonIn our patient, prior to immunohistochemical diagnosis of the surgical specimen, the top differential diagnoses for the pituitary lesion include pituitary adenoma, pituitary carcinoma, metastatic disease, and other non-pituitary origin sellar tumors such as meningioma, epidermoid cyst, germinoma, and chondrosarcoma . Given tPituitary metastasis is rare, but is especially important to consider in a patient with a known cancer diagnosis. While most patients are asymptomatic at presentation, the presence of diabetes insipidus and/or cranial nerve palsies should raise clinical suspicion of metastatic disease upon radiographic findings of a pituitary lesion. Similar to other pituitary tumors and brain metastases, the preferred management approach of pituitary metastases includes surgery and/or radiosurgery and may incorporate primary-specific systemic or targeted treatments.


The ovaries are a common site of metastasis from a variety of solid organ malignancies. These tumors most commonly originate from the gastrointestinal tract. Neuroendocrine tumors of the small bowel are unrelenting in their tendency to exhibit this type of distant spread, which poses a challenge for curative treatment. Whether metastatic disease to the ovary or primary ovarian malignancy, this is a major cause of morbidity and mortality for women of various ages. Currently, a mainstay of palliative treatment for advanced-stage disease resides in surgical debulking and chemotherapy. At times, these patients may not be surgical candidates due to various reasons which may include a large disease burden. Computed tomography-guided percutaneous cryoablation is a minimally invasive technique that has shown promise in treating solid organ metastatic lesions by exposing them to lethal temperatures. We describe a novel technique of palliative cryoablation of a primary small bowel carcinoid tumor that metastasized to the ovary. Hydrodissection was utilized to create a window for safe percutaneous treatment. At the end of freeze cycles, intraoperative CT was performed, demonstrating greater than 90% incorporation of the ovarian tumor within the margins of the lethal ice zone. Our team decided that this was a maximum percentage of freeze due to neighboring vessels and bowel. The patient tolerated this treatment well, and there were no reported post-operative complications. The procedure was clinically successful at shrinking the tumor as demonstrated on a nine-month follow-up CT. Percutaneous cryoablation is already a widely utilized method for treating tumors in various locations including the kidneys and liver. The application of cryoablation can be expanded as an effective and safe palliative technique for treating ovarian tumors. This may be especially useful in patients that are not surgical candidates. Many women experience the uncertainty associated with the discovery of an ovarian mass. In patients undergoing a surgical procedure for removal of a mass, only 6-7% will find that their presumptive primary ovarian disease is a nongenital primary malignancy with metastasis to the ovary . In the Carcinoid malignancy is among the etiologies that may exhibit this characteristic distant spread to the ovary. These neuroendocrine tumors arise from the enterochromaffin cells found within the gut. They metastasize through lymphatic channels and traditionally spread to the liver. Within the liver, the symptoms of carcinoid syndrome are exhibited by the excretion of serotonin . These sComputed tomography-guided percutaneous cryoablation (PC) is a minimally invasive technique for treating soft tissue tumors. As the PC probe cools, crystals of ice form within the extracellular space within the surrounding tissue, which creates an area of hypertonicity that draws water out of cells. This action causes the lysis of cell membranes ,8. In arThe patient is a 67-year-old female that was diagnosed with a small bowel carcinoid tumor. Hepatic metastasis was detected after initial resection demonstrated incomplete margins. In the nine years since the discovery of distant metastasis, the patient underwent five PC hepatic cryoablations, five intra-arterial hepatic chemoembolizations, and trans-ventral hernia mesenteric cryoablation. Standard surveillance imaging throughout that time demonstrated a normal-sized ovary without evidence of metastasis Figure .Subsequent follow-up cross-sectional surveillance imaging showed a mass on her ovary that measured 6.0 cm and biopsy confirmed carcinoid tumor metastasis Figure .The patient was positioned left lateral recumbent on the CT gantry and prepped and draped in the usual sterile fashion. Limited CT images were performed to delineate the right adnexal lesion for procedure planning. The skin was marked. Utilizing a 22-gauge spinal needle, saline was instilled around the lesion to provide hydro-dissection from adjacent colon and iliac vasculature. The cranial and caudal aspects of the mass were bracketed with two 17-gauge cryoablation probes inserted under CT guidance. Cryoablation was performed with a 10-minute freeze, followed by an eight-minute thaw, and followed by a 10-minute freeze. Imaging was obtained at five-minute intervals to evaluate the progression of the ice ball which ultimately demonstrated near-circumferential coverage of the right adnexal lesion Figure .Following removal of the cryoablation probes, post-ablation CT revealed persistent hypodensity within the region of treatment without obvious injury to adjacent structures. The patient tolerated the procedure well and was discharged the same day after a brief period of post-procedure observation. Follow-up five-week CT demonstrated a decrease in the size of the ovarian lesion to 4.9 cm. The three-month CT showed a further reduction of the mass's size to 4.3 cm. At nine months, the mass decreased in size to 4.1 cm (Figure In patients with metastatic carcinoid tumors to the ovary that received oophorectomy, median survival was only 2.5 years with a five-year survival of 25% . This isPercutaneous cryoablation's analgesic effect due to freezing tissue and nerves makes for a less painful post-operative experience . CryoablFew cases have been published on the use of cryoablation to treat primary malignancy of the esophagus, stomach, and colon. Rather, percutaneous cryoablation is most effective in the treatment of metastatic lesions of GI malignancy. Its efficacy, safety, and cost-effectiveness have been documented in increasing survival time in patients with metastatic colorectal cancers . In a reThe patient described in this article has been treated with multiple procedures over nine years to treat hepatic, mesenteric, and now ovarian metastases. She was deemed a poor surgical candidate because of the advanced tumor burden and a large ventral hernia. The utilization of percutaneous cryoablation has likely prolonged this patient's survival time. As far as these authors are aware, this is the first reported instance of PC being used to treat an ovarian neoplasm.The current gold standard for treating ovarian tumors is chemotherapy and open surgical debulking. As an alternative to traditional surgical debulking, CT-guided cryoablation served as a safe and effective means of treating nongenital metastatic ovarian malignancy in this patient.To our knowledge, this technique has never been published in the literature. It is a viable debulking strategy for patients that are not surgical candidates. The preceding patient is currently alive and doing well 17 months after the procedure when traditional means of open surgical palliation were not offered. Future studies regarding the use of percutaneous cryoablation for the debulking of nongenital ovarian metastasis may prove it to be a proficient technique and new tool in palliative oncology.


Umbilical hernia is a common cause for patient presentation to the surgeon, often on a nonemergent basis for a bulge at or lateral to the umbilicus but occasionally under emergency circumstances for pain or bowel obstruction when the hernia contents become incarcerated or strangulated. Risk factors for umbilical hernia include female gender, obesity, and ascites. A defect in the abdominal wall fascia at the umbilicus allows the preperitoneal adipose tissue, omentum, or small or large bowel to protrude through the defect. Rarely described is herniation of the appendix through an umbilical hernia, though appendix-containing femoral hernia (de Garengeot hernia) and appendix-containing inguinal hernia (Amyand hernia) are more common. There are 10 available case reports in the medical literature that describe an appendix-containing umbilical hernia; in this case report, we present the 11th case report of appendicitis within an umbilical hernia. Umbilical hernia is very common in the United States, with an estimated prevalence of 23% to 50% of the population, with a 3:1 female-to-male distribution . AppendiA 57-year-old male presented to the emergency department complaining of a mass at his umbilicus with pain in the mass. He reported developing an umbilical hernia seven months prior to admission but that he was able to reduce the hernia with direct pressure. Four days prior to the day of admission, the patient developed worsening pain at the hernia and was unable to reduce the hernia. He denied any other symptoms including fever, nausea, vomiting, diarrhea, constipation, and urinary changes. The patient had no prior surgical history, took no medications, worked as a bartender, and drank alcohol socially. There was no pertinent family history.2 of 94%, and a BMI of 37.59 kg/m². The abdomen was obese and soft, with a large, firm, and tender umbilical hernia, which obscured the umbilicus, with overlying skin changes of erythema and ecchymosis , respiratory rate of 20 breaths/minute, SpOCT imaging and laboratory evaluation were obtained, which revealed a large umbilical hernia, with suspected strangulated small bowel with pneumatosis intestinalis Figures , 3. HoweGiven the CT findings in conjunction with the patient’s pain, the patient was taken urgently to the operating room due to concern for strangulated small bowel in the umbilical hernia. Exploratory laparotomy was undertaken, with the incision initiated superior to the mass and extended to the patient’s right around the hernia and then inferior to the hernia. The dissection to the fascia was undertaken with a no. 10 blade and blunt dissection to prevent thermal injury to underlying structures due to the thin hernia sac. The hernia sac was dissected free, incised, and explored. A tubular blind-ended structure was encountered Figure , which wThe appendix, omentum, and hernia sac were sent to pathology, which later reported the appendix to show changes consistent with acute appendicitis. The excised portion of the omentum revealed fat necrosis, and focal acute and chronic inflammation.The small bowel was examined and found to be normal in appearance. The resultant fascial defect was 6 cm x 9 cm, and a 12 cm x 20 cm underlay bioscaffolding resorbable mesh was placed and secured with 0 PDS® suture  Figure . Given tThe usual process of development of appendicitis is obstruction of the appendiceal lumen and increase in intraluminal and intramural pressure, which leads to small vessel occlusion and lymphatic stasis, distension of the appendix, and appendiceal wall ischemia and necrosis . WhetherAlthough the base of the appendix is reliably found at the cecum, the course and location of the appendix are variable, with the most common location being retrocecal . In thisAppendicitis presenting in an incarcerated umbilical hernia is an extremely rare phenomenon, with only 10 case reports of similar nature being available in the medical literature -8. In thAppendicitis containing umbilical hernia is a very rare phenomenon. Symptoms of an incarcerated or strangulated hernia along with CT imaging showing a blind-ended tubular structure in the hernia contents make appendicitis within an umbilical hernia likely. The principles of treatment of an incarcerated ventral hernia apply, as do the principles of management of acute appendicitis. Regardless of contents, the hernia contents must be fully explored and addressed at the time of operation and the defect must be closed appropriately.


The sternum is considered an unusual tumor site, corresponding to 15% of all thoracic wall tumors. Primary sternal tumors are even rarer and most commonly malignant. We present the case of a young man who consulted with a painful sternal mass, which after its resection is confirmed to be a cavernous hemangioma.A 39-year-old man, with unremarkable medical history besides a 2-year-long sternal pain, non-irradiated, which worsens over the last few months and is accompanied by the appearance of a sternal palpable mass. On physical exam, there was a bulging of the sternal manubrium, with no inflammatory changes. Thoracic CT scan shows an expansive and lytic lesion of the sternum, compromising the manubrium and extending to the third sternocostal joint, without intrathoracic compromise nor cleavage plane with mediastinal vascular structures. The patient is taken to resection of the mass and sternal reconstruction using prosthetic material and pectoral and fasciocutaneous muscular flaps. Histopathological findings: cavernous hemangioma with negative borders and no other malignant findings.Sternal hemangiomas can cause defects in the bone structure and show an expansive growth, challenging the differentiation between a benign or malignant lesion. Therefore, they should be considered malignant until shown otherwise. Management involves radical surgery with curative purposes and posterior reconstruction to improve quality of life, as shown with our patient. The sternum is considered an unusual tumor site, with an overall incidence of 15% of all tumors of the chest wall . Within 2 97%, temperature 36.5 °C, there was no jugular engorgement or neck masses, upon inspection of the thorax, in the sternal area, there was a mass of more or less 10 cm, without inflammatory changes or ulcers, with a hard texture on palpation, without pulsation or collateral circulation on it, the heart was rhythmic without murmurs or gallops, respiratory sounds were normal, he had no abdominal masses, lower limb edema, or neurological deficit. He assists with a bone scan that showed osteoblastic changes in the sternal manubrium, suggestive of tumor vs infectious process. Additionally, he had a thoracic computerized tomography (CT) scan that evidenced an expansive lytic lesion, mainly in the manubrium but extending into to the third costoesternal joint, without compromising intrathoracic organs and with cleavage plane of the mediastinal vascular structures. There were no other associated lesions.A 39-year-old man, without a significant personal history, who consults to the thoracic surgeon for a 2-year history of non-irradiated sternal pain, exacerbated by intense exercise. In recent months, his quality of life worsened and a palpable sternal mass became evident. On physical examination he had, blood pressure 120/80 mm Hg in both arms, heart rate 82 beats per minute, respiratory rate 12 breaths per minute, SOIn a multidisciplinary board, the decision was made to perform a sternum, rib, and clavicle resection, followed by reconstruction. A literature search was carried out to find the best way to reconstruct the sternum, finding several alternatives, so we chose to study in-depth those that we had available in our country. We had to choose between using Polyether ether ketone (PEEK), poly-methyl-methacrylate (PMMA), or titanium. We had experience with PEEK and PMMA in the past, being the latter easier to manipulate intraoperatively, so we decided to go with it. After making the decision we looked into the image archive of our institution for thoracic CT images of patients with similar physical characteristics to our case, to plan the size and details of the prosthesis to be built. Then we compared the designed sternum with the patient's sternum to see if it would fit properly. For this process, the Mimics Innovative Suite software  and then a 3D printer was used to obtain the bio model, from which the prosthesis was made (Figs. Intraoperative findings were that of a large tumor of the sternal manubrium without the involvement of the clavicles or ribs bilaterally. A sternal resection was performed from the third intercostal space until the union between the first intercostal space and the clavicles. A thoracic wall reconstruction using the PMMA prosthesis and the osteosynthesis material to fix it to the thorax was performed, trying foremost to protect the physiological function of the sternum in the respiratory system. A plastic surgeon covered the material using pectoral and fasciocutaneous muscle flaps Fig. . The patPrimary chest wall tumors are very uncommon, corresponding to less than 2% of all new primary tumors. Furthermore, only 15% of the bony chest wall tumors originate from the sternum, and the exceeding 85% arise from the ribs. Osseous tumors tend to show mixed cellularity, in addition to expansive growth, which makes it difficult to establish its benign nature. Any sternal mass in an adult should be considered malignant until proven otherwise . SpecifiTypical clinical presentation includes nonspecific pain, that sometimes becomes evident after chest trauma, and on some occasions a palpable mass , 4. On iAs for the surgical procedure, wide excision is the standard of care, especially in the case of malignant tumors to achieve local control. Nevertheless, the approach is similar for all primary sternal tumors. Sternal resection must be wide enough to obtain a clear margin of at least 3 cm to minimize the risk of recurrence. A partial sternectomy should be done when the mass is limited to the manubrium as in our case. Depending on the extent of the lesion and the compromise of the superior portion of the manubrium and clavicles, then a total or subtotal sternectomy should be chosen. Involvement of the anterior chest wall and chest cavity structures must be carefully checked upon and managed accordingly; lung and mediastinal structures have to be excised in bloc, while vascular structures are ligated and excised. Following the sternal resection, chest tubes must be placed in each pleural cavity . It is oA well-done reconstruction of the skeletal defect is imperative to maintain adequate chest wall stability. There is an extensive list of prosthetic materials for chest wall reconstruction in the market; ideally, they should be rigid enough to avoid paradoxical chest wall motion but malleable enough to allow chest movement, physically and chemically inert, should allow growth of tissue, must be radiolucent to decrease image artifacts, sterile, resistant to infection and inexpensive. No prosthetic material meets all these criteria and a combination of them is required to get the best results . They caAlthough we did choose PMMA, our approach differs widely from the PMMA sandwich technique. Currently, with the possibility of 3D printing, materials such as a PMMA or PEEK are taking the lead in bone reconstruction since they can be designed and printed to suit the patient. PEEK implants are also a great option due to good biocompatibility, biomechanical properties due to similar tensile strength to sternum and ribs, stability, and radiolucency . Our teaDespite the concern of choosing an infection resistant prosthetic material, the main source of complications is not the prosthesis itself, or the wound, but pulmonary infections, mainly pneumonia. Pulmonary complications, which are the main cause of mortality, may warrant not only antibiotics but prolonged mechanical ventilation and tracheostomy . FortunaIn conclusion, bony chest wall tumors are extremely rare, even more when they compromise the sternum, as is the case of sternal cavernous hemangiomas. Due to the tumor's expansive growth and often mixed cellularity, they should always be considered malignant. Wide excision is the surgical gold standard, along with an excisional biopsy to achieve a histopathological diagnosis. Skeletal reconstruction is fundamental for maintaining the chest wall's stability and improving the patient's quality of life. A multidisciplinary approach with pulmonologists, thoracic surgeons, plastic surgeons, and biomedical engineers is needed to ensure the best possible outcome.


Marmota monax) with an ovarian teratoma consisting of mature tissues originating from all three germ layers.Teratomas are germ cell neoplasms composed of a wide variety of tissues. In the woodchuck, only one testicular teratoma has been described in the literature. The objective of this report was to describe the radiologic and pathologic findings in a female woodchuck  imaging. The tumor was predominantly solid and heterogenous on CT with soft tissue, fat, and areas of dense calcification. The teratoma did not enhance with intravenous contrast administration. On ultrasound, the tumor was solid with heterogeneous echogenicity, reflecting the fat content and areas of calcification. Sonolucent areas were present that may have represented cysts. There was heterogeneously increased signal on T1-weighted magnetic resonance imaging (MRI) and heterogeneous hyperintensity in T2-weighted imaging. Fat was evident within the tumor. At necropsy, the tumor was attached to the distal end of the right uterine horn. Histopathology showed mature tissue types representing all three germ layers.Ovarian teratoma should be considered in the differential diagnosis of ovarian or abdominal masses in woodchucks. The tumor displayed mature tissue derived from all three germ layers. CT, ultrasound, and MRI findings were presented in detail and matched the typical imaging appearance of teratomas. There are three main types of ovarian tumors in mammals: epithelial tumors, stromal or sex cord tumors, and germ cell tumors . EpithelTeratomas are germ cell tumors with tissue derived from two or three germ layers: ectoderm, mesoderm, and endoderm. Teratomas can be immature or mature depending on the level of differentiation of each germ layer. Immature teratomas are less common and can be malignant. Mature teratomas, which are generally benign, often present with a variety of organ elements, including hair follicles, hyaline cartilage, and adipose tissue. Most often these neoplasms arise in the ovary but can also arise in the testis .There have been reports of teratoma in multiple laboratory or domesticated animal species, including mice, rabbits, dogs, cats, and ferrets –5. MultiMarmota monax) infected with woodchuck hepatitis virus (WHV) have proven to be valuable pre-clinical models for the study of hepatitis B virus infection and the safety and efficacy of antiviral therapies [Eastern woodchucks  had been infected during the first week of life with WHV  and subNon-invasive diagnostic medical imaging was performed using clinical systems with the animal under general anesthesia. The animal was sedated using 5% isoflurane delivered via an induction chamber followed by a mixture of pre-anesthetics (28.6 mg/kg ketamine HCl and 5 mg/kg xylazine IM) and then maintained on 1–5% isoflurane and 100% oxygen (2 L/min) delivered via rabbit mask for the duration of the procedure. For computed tomography (CT), a 21G or 23G angiocather was inserted into a foreleg vein. At the conclusion of the planned experiments, the woodchuck was euthanized by administration of a combination of pentobarbital sodium 390 mg/mL and phenytoin sodium 50 mg/mL . The tumor was then resected and sectioned for pathology.For CT imaging  an initial planning scan was acquired. Following non-contrast CT of the chest and abdomen, multiphase imaging of the abdomen was performed with power injection  of 3.0 mL of iopamidol i.v.  followed by 3.0 mL 0.9% saline, all at 0.2 mL/sec. The imaging protocol was initiated once contrast appeared in the distal thoracic aorta with early arterial (4 s delay), late arterial (23 s delay), portal venous (43 s delay), and late parenchymal (63 s) phases. Scans were obtained at 120 kVp and a tube current of 225 mA with a 180 mm field of view and image reconstruction of 0.8 mm sections at 0.4 mm intervals , 21. CT Ultrasound imaging was performed with a phased array ultrasound probe  operating at 3.75 or 5.0 MHz. Grayscale and color Doppler sonography were performed.Magnetic resonance imaging (MRI) was performed  with a standard 32-ch cardiac RF receive coil. MR images were acquired in the axial plane using four sequences: T1-weighted High-Resolution Isotropic Volume Examination (THRIVE), diffusion-weighted imaging (DWI), T2-weighted Turbo Spin Echo (TSE), and T2-weighted Volume Isotropic Turbo Spin Echo Acquisition (VISTA). These pulse sequences were selected to represent typical sequences used in clinical MRI liver examinations, both with and without fat suppression .The scout images for the two CT examinations, separated by 5 weeks, showed a large calcified mass that was initially in the left abdomen measured as 5.7 × 3.5 cm Fig. a and subOn gross examination following euthanasia, the teratoma was attached to the right uterine horn and was well demarcated, surrounded by a membranous translucent capsule Fig. a. The HCIn humans, there has been variable diagnostic accuracy for teratomas among the different modalities of CT, MRI, and ultrasound. Buy et al. reported a series of cystic teratomas of the ovary and concluded that CT was the optimal diagnostic procedure . They obThere is sparse reporting of clinical imaging of teratomas in small animals. The reported testicular teratoma in a woodchuck was composed of tissue derived from ectodermal and mesodermal origins partially surrounded by a seminoma. No imaging was performed . While tThe appearance of the teratoma in this woodchuck was consistent with the description in humans and other small animals. The tumor in this animal was well defined with fat present which is diagnostic for teratoma in humans. The tumor was predominantly solid rather than cystic on imaging but with well-defined calcification suggesting a mature teratoma compared to coarse, ill-defined calcification that may be seen in immature teratomas in humans . The dia


Liposarcomas are malignant mesenchymal tumours usually located in the retroperitoneum, rarely occurring as a single lesion in the kidney. We present a case of a 59-year-old male patient with a left renal mass detected by computed tomography scan. He underwent radical nephrectomy and the histopathological study reported a primary undifferentiated liposarcoma of the kidney without nodal involvement. After 15 months of surgery, he remained asymptomatic and without evidence of disease recurrence. The objective of this report is to present a case and literature review with current evidence of treatment options and prognostic factors for survival. Liposarcomas are malignant neoplasms of mesenchymal origin that belong to the group of soft tissue sarcomas, constitute less than 1% of all malignant tumours and have a high infiltrative and metastatic potential . In contRenal liposarcoma is an extremely rare neoplasm . It belongs to the group of sarcomas of the genitourinary tract, of which leiomyosarcomas are the most common, followed by liposarcomas. Liposarcoma of the kidney tends to be diagnosed incidentally in patients who present with renal mass, thoraco-lumbar pain and dyspnoea. Radical nephrectomy is the treatment of choice .The aim of this article is to report a rare case of a patient who was diagnosed as having undifferentiated renal liposarcoma based upon pathology examination of his radical nephrectomy specimen, and to provide an updated review of the literature description of renal liposarcoma, its treatment according to scenarios  and prognostic factors that have been documented to be related to survival of patients.A 59-year-old male patient, from Peru, with no relevant medical history, presented in September 2019 with a history of back pain, weight loss of about 5 kg, early feeling of fullness and night sweating of 8 months of evolution. His physical examination revealed a mobile mass without defined margins, located 12 cm from his left ribcage. The results of his routine haematology and biochemistry laboratory blood tests revealed moderate anaemia with a haemoglobin of 9.0 g/L and hyperkalaemia with a serum potassium of 5.8 mmol/L.He had computed tomography (CT) scan of abdomen which showed a left renal mass of heterogeneous density of 19 × 12 × 9 cm, which had defined borders and contours and which was not associated with any nodal or vascular involvement . Kidney In October 2019, he underwent a surgery , and during the procedure he was noted to have a left kidney dependent tumour that measured 20 × 19 cm with associated hilar and para-aortic lymph nodes.Macroscopy pathology examination of the specimen was reported to have identified a left renal tumour that measured 23 × 12 × 10 cm which was noted to have a solid component, and which was soft in consistency, and which was light brown in colour and which contained areas of myxoid and haemorrhagic necrosis of 30% and 10%, respectively . MicroscThere was no evidence of metastatic spread to the Gerota’s fascia, renal pelvis, adrenal glands as well as there was no evidence of lymphovascular invasion by the tumour.Immunohistochemistry staining study of the tumour with MDM2 showed that the tumour had exhibited positive nuclear immunostaining expression within the neoplastic cells , which dAfter 15 months of follow-up, the patient has remained well with no evidence of local recurrence or distant metastases based upon the results of his clinical examination, laboratory blood tests and CT scan images. He will continue to have regular follow-up assessments.Renal liposarcomas are extremely rare solitary neoplasms described in case reports. Literature reviews have reported 17 cases (14.3%) out of 119 reported cases of kidney sarcomas , 6. LipoMost published cases of liposarcoma of the kidney had reported well differentiated tumours, with an average tumour size of 5 cm and the reported symptoms had included: pain, abdominal mass (most frequent), weight loss and haematuria (rare presentation) . The mosRadiology imaging studies that have been utilised for the evaluation of liposarcoma of the kidney do include: ultrasound scan of renal tract which does show hypo- or hyper-echoic lesion within the kidney, CT scan of kidney with contrast and magnetic resonance imaging scan of renal tract with contrast. Utilisation of pathology examination including microscopy examination of the kidney tumour supported by immunohistochemistry staining studies of the kidney tumour is the means by which a definitive diagnosis of primary liposarcoma of the kidney is definitely diagnosed.There are five histological sub-types of liposarcoma of the kidney including: well-differentiated liposarcoma, myxoid liposarcoma, round cell liposarcoma, undifferentiated liposarcoma and pleomorphic liposarcoma. The myxoid type is the most frequent (60%), followed by the well-differentiated 25%), pleomorphic (10%), undifferentiated and round cells (<5%). Well-differentiated liposarcomas of the kidney have a high local recurrence rate and 15% rate of distant metastasis, with a 5-year mortality of 30%, whereas pleomorphic liposarcoma of the kidney, those of pure round cells and undifferentiated types of liposarcoma of the kidney tend to metastasise widely %, pleomo.et al [The immunohistochemistry studies of renal liposarcoma tend to show tumour cells that exhibit positive staining for murine double-minute type 2 (MDM2) and cyclin-dependent kinase 4 (CDK4) , 20. In et al  reportedet al . The hisThe differential diagnoses of primary liposarcoma of the kidney include: angiomyolipomas (their main one since both are large lesions with fat content), dedifferentiated pleomorphic sarcoma, pleomorphic liposarcoma and myxoid liposarcoma, all of which lack the differentiated liposarcoma component and do not express MDM2. Another one is well-differentiated liposarcoma, however mitotic activity in these tumours is usually low or absent and histologically smooth with conspicuous lipoblasts, and also do not express MDM2 , 22.de novo metastatic disease and large tumour size at the time of their initial presentation [The main management of primary liposarcoma of the kidney is radical nephrectomy. Few cases have reported the use of adjuvant treatment (chemotherapy or radiotherapy) in the management of primary liposarcoma of the kidney with discordant results. In general, an operated sarcoma with appropriate tumour-free resection margins (complete resection of tumour and any invaded organ with negative margins) has been the most common treatment option which is ensued by continuous and regular follow-up with clinical assessment, laboratory blood tests and radiology imaging at regular intervals. It has been reported that postoperative radiation therapy has no impact on recurrence rate , 12. Surentation , 7.et al [p = 0.668). Livingston et al [n = 82) which was divided in two groups: one receiving neoadjuvant chemotherapy for localised or locally advanced disease (n = 31) and another receiving chemotherapy for unresectable/metastatic or recurrent disease (n = 51). With regard to the result of the study, Livingston et al [Chemotherapy is used in liposarcoma of kidney tumours that cannot be completely resected, in recurrent disease or in distant metastases. However, its benefit is minimal and not many studies have been undertaken. Perez et al  reportedon et al  performeon et al  reportedon et al .et al [It has been iterated that the most important prognostic factors for this pathology include: the degree of differentiation, the tumour size, the histological type, the anatomical location of the tumour and completeness of resection of the tumour , 18. Theet al  documentet al .Renal liposarcomas are extremely rare tumours that develop from mesenchymal tissue. Their asymptomatic onset does limit the diagnosis of primary liposarcoma of the kidney and the manifestations of the disease tend to be non-specific symptoms. The treatment of choice of primary liposarcoma of the kidney is radical nephrectomy. Chemotherapy and radiotherapy have not shown survival benefit in neither the neoadjuvant nor the adjuvant setting. Prognostic factors of primary liposarcoma of the kidney are related to the tumour characteristics and the type of surgery that has been undertaken.Because primary liposarcoma of the kidney is an extremely rare disease, data related to the tumour is limited; therefore, it is very important to encourage prospective and randomised clinical trials that are focused on treatment of the tumour.The authors have no conflicts of interest to declare.No funding was received for this work.P Rioja, G Valencia and Centurion-Rodriguez were involved in manuscript preparation, reference hunting and final editing. Z Morante was involved in reference hunting and final editing. Dr Bravo M and Huanca L were concerned with the histopathologic and immunohistochemical diagnosis. Dr C Morante was involved in final editing.


A case of Burkitt’s lymphoma with bilateral jaws involvement in a 5-year-old boy is reported discussing the dentist’s role in the diagnosis and management of this disease. The initial clinical diagnosis established of maxillary swelling causing trismus was a dentoalveolar abscess. The incisional biopsy was performed and histopathological analysis, including immunohistochemistry, confirmed the Burkitt’s lymphoma. The patient underwent treatment and remains free of the disease for 36 months of follow-up. The occurrence of intraoral bilateral jaws involvement of Burkitt’s lymphoma in child is unusual and its accurate diagnosis avoids complications in the patient’s treatment. Key words:Burkitt’s lymphoma, Non-Hodgkin’s lymphoma, Oral cavity, Maxilla, Child. In 1958, Denis Parsons Burkitt, an Irish surgeon, published the first study about mandibular tumors that affected African children, until then called “small round cell sarcoma” . The extraoral examination revealed facial asymmetry due a bilateral volumetric increase Fig. A. The inUnder general anesthesia and with nasotracheal intubation, an intraoral incisional biopsy was performed in the region of the cul-de-sac and alveolar ridge of the right maxilla. Histopathological analysis revealed atypical monomorphic lymphoid proliferation with the involvement of the adjacent bone tissue Fig. A. ImmunoThe patient underwent treatment in a Specialized Oncology Center following the protocol of the Brazilian Society of Pediatric Oncology, with cytoreduction therapy of conventional chemotherapy and intrathecal chemotherapy. Clinical images after 12 and 24 months of treatment are shown in Figure The three main groups of oral and maxillofacial lesions that often affect children are represented by pathologies of salivary glands, reactive lesions and odontogenic cysts . Malignaet al. , fibro-osseous lesion or other neoplasms with aggressive behavior . In the et al. , presentet al. (Despite the intraoral involvement by the neoplasm, it was possible to maintain the child’s oral hygiene. The follow-up between chemotherapy sessions to maintain oral care and reinforcement with the patient and family are conducts that must be adopted as recommended by Padmanabhan et al.  to avoidThe destruction of the cortical bone of the maxilla and mandible was an important finding in the imaging examination of the present case. The hypodense tumor mass occupied regions such as peribuccal spaces, maxillary sinuses, nasal floor and partially the infraorbital region. Likewise, the involvement of these regions by Burkitt’s lymphoma has been described in the literature ,12,13. IThe accurate diagnosis of this malignancy is challenging, but it avoids complications in the management and treatment of the patient ,6. In asThe chemotherapy cycles to treat Burkitt’s lymphoma, as in this case, allow the complete remission of the disease. The chemotherapy treatment adopted in pediatric patients provides a relative survival rate of 90.4% in five years of follow-up . AdditioIn summary, the occurrence of maxillary malignancy in children is rare and in conditions of rapid tumor growth, as in the case reported, the dentist must be promptly trained to make decisions based on medical history and clinical and radiographic aspects. The microscopic analysis in association with immunohistochemistry allows for accurate diagnosis, as well as providing adequate management.


Alveolar soft part sarcoma is a rare malignant soft tissue neoplasm of uncertain histogenesis and aggressive clinical behavior. Alveolar soft part sarcoma arises in the head and neck in 27% of cases, with 25% of head and neck cases occurring in the tongue. Herein the case of a pediatric patient diagnosed with alveolar soft tissue sarcoma of the tongue, who received surgical treatment with total resection of the lesion and chemotherapy without radiotherapy, is presented. To date, the patient is in remission of the disease. Alveolar soft part sarcoma (ASPS) is a rare malignant neoplasm of uncertain histogenesis, first described in 1952 by Christopherson . It reprIn adults, the most common location is the lower extremities' deep soft tissues (thighs and buttocks) in contrasts with the presentation in children and adolescents where there is a predilection for the location in the head and neck, in particular, the tongue (where it occurs in approximately 25% of cases) and the orbit ,9,10.Clinically indolent, it presents as a painless, slow-growing mass with great vascularity; the limited symptoms generate delays in diagnosis, which could explain that 80% of adult patients and 37% of pediatric patients present metastases at diagnosis . The disAlveolar soft part sarcoma of the tongue is a highly vascular tumor; diagnostic studies such as ultrasound can misdiagnose this tumor and be mistaken for benign lesions; so magnetic resonance imaging is the study of choice ,11. The A 13-year-old adolescent woman presented with a 14-month history of a non-ulcerated, painless, and lobulated mass on the left lateral ventral surface of the tongue, slow-growing, without other associated symptoms  staging system .The initiation of chemotherapy was indicated; three cycles of ifosfamide and doxorubicin were administered every 21 days. Subsequently, surgical resection was performed to widen the edges. The pathology is reported without residual tumor, with negative resection borders.Three cycles of adjuvant chemotherapy were applied with the same agents, without radiotherapy. To date, the patient has completed treatment and is under follow-up, disease-free, and asymptomatic. Post-treatment MRI shows the scar where the tumor was, with no signs of tumor relapse Figure . Soft part sarcoma is a rare neoplasm in pediatrics, accounting for 5% of all cases of non-rhabdomyosarcoma soft part sarcomas in pediatrics . DespiteThe five-year survival rate for alveolar soft tissue sarcoma in children, adolescents, and adults younger than 25 years is 83% . HoweverIn contrast to what was reported by Shelke et al. , who repThe clinical course was indolent as described in the literature as a hemangioma of the tongue for which a surgery limited to tumor resection with a positive border was performed, which led to an enlargement of the margins and lymph node dissection. In the presence of a non-metastatic tumor and in a location where radical resections leave significant morbidity in the soft tissues of the neck and long-term cosmetic and psychological side effects, conservative management was carried out with neoadjuvant, adjuvant chemotherapy, and surgery. At the end of treatment, the patient is in remission, free of signs of tumor recurrence or relapse.It will always be important to take a detailed clinical history to reach the correct diagnosis of the soft part sarcoma of the tongue. A wrong diagnosis can lead to delay in the initiation of adequate treatment of the patient. The presentation of the disease in children, adolescents, and young adults makes us reflect on the need to form multidisciplinary groups with the active participation of adult clinical oncologists, head and neck surgeons, pathologists, radiation therapists, and rehabilitators.


Gallbladder volvulus is rare and known to occur when there is a rotation of the gallbladder along the axis of the cystic vascular pedicle. Except for isolated cases reported in childhood, this disease is more frequently encountered in the elderly, especially in women. Therefore, most cases in the literature describe the clinical and radiographic features of gallbladder volvulus in this age group. In this subject, manifestations of abdominal pain are variable. Typically, right upper quadrant pain leads towards the diagnosis of cholecystitis, and diagnosis may be performed on imaging such as computed tomography (CT) scan with multi-plane CT reconstruction. However, preoperative diagnosis of gallbladder torsion remains difficult, and in most cases, especially in young women where it is rare, the clinical and radiographic features seem to differ from gallbladder torsion in the elderly. We report a case of gallbladder volvulus in a 26-year-old woman and review the clinical and radiological aspects of this disease. Gallbladder volvulus is a very rare clinical condition of the hepatobiliary system. The most commonly accepted mechanisms for this disease include variant anatomy of the long mesentery gallbladder. In this case, it attaches only at the cystic duct and its associated vascular cystic pedicle, allowing for it to rotate along its axis; this is known as a floating or pedunculated gallbladder . This prAlthough torsion of the gallbladder is a very rare occurrence in young women, we report a 26-year-old woman in whom we confirmed a post-operative diagnosis of gallbladder volvulus. It initially presented as acute appendicitis and a Fitz-Hugh-Curtis syndrome, followed by the findings of acute cholecystitis on imaging. Also, in this case, we would like to contribute enriching the bank of these rare cases and providing a part of the collection of very useful signs that radiologists, as well as surgeons, can memorize in mind in case of differences.A 26-year-old unmarried woman with a history of treated salpingitis eight years ago presented to the emergency department with several hours of sudden onset abdominal pain. This pain was described as sharp and intermittent, localized to the right side of the abdomen, without vomiting or fever. On physical examination, her vital signs were stable, the abdomen was not distended, with mild tenderness of involuntary muscular resistance in the right iliac fossa. The urgent abdominal ultrasonography (US), including the appendix, gallbladder, and pelvic gynecology, were unremarkable. The patient presented vaginal discharge, no missed period, on amenorrhea, and a negative quick stick test. Laboratory studies showed an inflammatory condition with leukocytes of 11 g/L , neutrophils accounting for 87%, and C-reactive protein of 167 mg/L. Other tests, including hepatic and pancreatic enzymes, were within the normal range. The patient was monitored due to atypical appendicitis with intravenous fluid resuscitation.After about the sixth hours of admission, because the patient complained of more pain, including the right upper quadrant and mild hyperthermia, an abdominal ultrasound (US) was performed. This demonstrated no signs of appendicitis but showed a markedly distended gallbladder without gallstones or sludge and slight wall thickening with non-specific pericholecystic fluid that was likely reactive Figure . The US After about 15 hours of admission, the patient had relief from the pain, fever, and abdominal distention. Thus, an abdominal computed tomography (CT) scan was recommended, which revealed a distended gallbladder measuring 82 x 42 mm, a normal fossa with a thickened non-enhancing wall, the presence of pericholecystic effusion, and fluid in the Douglas pouch  and pericholecystic fluid with fluid in the right iliac fossa and the Douglas pouch Figure . HoweverFinally, the patient was operated at the 42nd hour after admission, in light after observing the clinical symptoms, including positive Murphy’s sign of typical acute cholecystitis. Surgical laparoscopy showed the distended gangrenous gallbladder caused by a tightly twisted clockwise direction of 360 degrees on the cystic vascular pedicle, leaving the gallbladder body suspended freely from the liver bed with a long mesenteric attachment Figure , we founGallbladder volvulus patients frequently present to the emergency department with acute abdominal pain. Typically, the symptoms are the sudden onset of severe upper-right quadrant pain. However, although rare, the clinical findings may also appear similar to acute appendicitis, such as that reported, presenting right lower quadrant pain with a palpable mass in an elderly woman that may cause a wrong determination of the location of the distended gallbladder in the right iliac fossa . In our The preoperative diagnosis of gallbladder volvulus accounts for 21% to 27% of cases but remains difficult because the nonspecific clinic and radiographic findings may be similar to those of acute infective pathology ,4,8. MosIn most of the cases, the preoperative diagnosis of gallbladder volvulus was based on radiographic findings such as US, CT, and/or magnetic resonance imaging (MRI). US is the preferred modality due to its convenience. It is possible to monitor the progression of acute cholecystitis, but it might not always be possible to distinguish from gallbladder torsion as both might show distended gallbladder and thickened gallbladder wall as in our case. MRI also helps to add diagnostic signs such as an invagination-like image identified the neck of the gallbladder or a v-shaped distortion of the extrahepatic bile ducts and is therefore considered as the diagnostic method of choice in a pregnant patient ,10.An abdominal CT scan with multi-plane CT reconstruction is a strong indicator of the diagnosis of a gallbladder volvulus. Most of the cases are described in older women with the following criteria: distended gallbladder, floating or pedunculated gallbladder, a beak or whirlpool signs at the cystic pedicle, low and horizontal laying of the gallbladder, thickened and non-enhanced gallbladder wall, and an absence of gallstones ,2,11-13.In our case, as well as in some cases in the literature, gallbladder torsion is extremely rare in young women and often did not see the radiographic features suggestive of gallbladder torsion as in the elderly. It is often only diagnosed after surgery when retrospective images can be identified ,10,15.Clinical manifestations may be confounding factors, and atypical radiographic findings also delay the diagnosis of this disease. Through our case, we have shown that careful image analysis is important to the correct diagnosis. Therefore, although gallbladder volvulus is very uncommon, its diagnosis should be considered in all patients presenting with right side abdominal pain, especially in young women, which could be misdiagnosed with acute acalculous cholecystitis.


Postoperative chylous ascites is a rare complication of abdominal surgery. Chyle depletion results in nutritional, immunologic and metabolic deficiencies, making it a serious and potentially life-threatening condition for which prompt diagnosis and management is imperative. A 72-year-old male was referred for open repair of a 62 cm juxtarenal abdominal aortic aneurysm (AAA). Following resumption of diet, he developed abdominal distention. Therapeutic paracenteses confirmed chylous ascites. Failed conservative management and lymphatic embolization lead to surgical sealance of lymphatic leak using glue. Postoperatively, a full diet was tolerated with no further ascites. Paracentesis is the diagnostic modality of choice in evaluating patients with ascites. Management is challenging and should be multifaceted and tailored to individual patient needs. Cornerstones of therapy include correction of the underlying etiology and conservative measures. When conservative measures fail, other interventions can be considered, such as somatostatin analogs, surgical ligation or glue embolization. Postoperative chylous ascites is a rare complication of abdominal surgery caused by disrupted lymphatics. Chyle depletion results in nutritional, immunologic and metabolic deficiencies, making it a potentially life-threatening condition for which prompt diagnosis and management is imperative . ManagemWe describe a case of chylous ascites post-elective abdominal aortic aneurysm (AAA) repair, followed by discussion of current trends in management. The associated morbidity makes our paper of interest to vascular and general surgeons. Furthermore, the rarity of this pathology, combined with its associated prolonged hospitalization and increased healthcare expenditure, makes our case of interest to healthcare providers.A 72-year-old male was referred for a 6 cm juxtarenal AAA. Due to extensive mural thrombus and calcification at the neck, he was not appropriate for endovascular repair. His past medical history includes chronic obstructive pulmonary disease with a 50-pack-year smoking history, chronic kidney disease, hypertension, hyperlipidemia and carotid artery disease requiring endarterectomy.Intraoperatively, a midline laparotomy was performed to view the aneurysm sac and the neck of the aneurysm was dissected out. As he was very thin, the lymphatics were very visible and divided. The renal vein was also divided and the aortic bifurcation and common iliac arteries were controlled bilaterally. The aneurysm sac was clamped, opened, and a 20 mm Dacron graft was sewn in place. Following completion of the anastomoses, there was excellent hemostasis, strong femoral pulses bilaterally, and the aneurysm sac and abdomen were closed.On postoperative Day 5, diet was resumed and the patient subsequently developed abdominal distention, for which a computer tomography scan was performed . TherapeFailure of conservative management leads to an unsuccessful attempt at lymphatic embolization . TherefoThe patient was transferred to a rehabilitation institution. Unfortunately, he died of ischemic bowel 3 months later.Chylous ascites is the pathologic accumulation of milky, triglyceride-rich fluid in the peritoneal cavity due to obstruction or trauma of the lymphatics . It has Presentation is often insidious, with gradual fluid accumulation causing, in order of frequency, symptoms including, abdominal distention and pain, diarrhea, dysphagia and peripheral edema. Features on physical examination include cachexia, temporal wasting, evidence of pleural effusions or ascites and lower extremity edema . As lympSignificant risk factors for chylous ascites include extent of abdominal surgery, early enteral feeding and manipulation of the paraaortic area . ParacenThe treatment for chylous ascites is multifaceted and should be individualized and based on a stepwise approach, from conservative for up to 2 months to surgical .et al. [TPN has been used to correct nutritional deficits, allow bowel rest and decrease lymphatic production. However, it is associated with numerous adverse effects, including infection, thrombosis and cholestasis , and thuet al.  found reWhen conservative measures fail, hormonal therapy can be considered. Somatostatin, or its synthetic analog octreotide, decreases intestinal fat absorption and lymph flow . EarlierIf refractory to conservative measures, surgical interventions include ligation or glue embolization of leaking lymphatic channels . An openOverall evidence for management of chylous ascites is sparse and randomized controlled trials are lacking. As such, further research is needed to enhance management.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.


Cardiac myxoma is an uncommon diagnosis but presents with common manifestations. There is a wide range of symptomatology from non-specific fever and weight loss to stroke-like symptoms. It is also one of the rare causes of cardiac syncope and thromboembolic events. We present a case of a 67-year-old female who presented with seemingly benign vertigo symptoms which she ignored for years before seeking medical attention. An echocardiogram revealed a 3.5 x 3.0 x 1.0 cm atrial myxoma which was surgically excised. Her symptoms have resolved entirely with no recurrence since surgery. Cardiac myxoma is a benign cardiac tumor diagnosed in adults and accounts for over 50% of all cardiac tumors . The tumA 67-year-old female with a significant past medical history of generalized anxiety disorder and supraventricular tachycardia, which was controlled on a beta-blocker, initially presented in an outpatient setting with complaints of dizziness. The symptoms initially started two years ago but she did not seek medical attention as they were not interfering with her day to day activities. She used to follow up with her primary care physician and was initially prescribed meclizine. Two weeks before hospital admission, her symptoms became progressively worse and persistent. An MRI was ordered by her primary care physician which revealed an acute right parietal and subacute left parietal cerebrovascular accident (CVA). She was referred to the hospital to evaluate the etiology of her stroke. On admission, she described the dizziness as triggered and continuous with increasing symptoms upon bending forward. She denied nausea, vomiting, tinnitus, sweating, fever or a history of recent infections. She also has a history of shortness of breath with moderate to heavy activities, however, denied active chest pain, palpitations or history of atrial fibrillation. Records from her primary care physician revealed a carotid ultrasound which was unremarkable for significant bilateral carotid artery stenosis. Her vital signs were stable on admission. A cardiovascular examination revealed soft S1 and S2 with diastolic murmur over the apex. The rest of the physical examination including orthostatic vitals were negative. Initial laboratory workups including complete blood count (CBC), complete metabolic panel (CMP) and chest X-ray (CXR) were within normal limits. Electrocardiogram revealed sinus rhythm with left axis deviation and poor R-wave progression from V1 to V3. Cardiology was consulted for the evaluation of her shortness of breath and dizziness. An echocardiogram was performed which revealed a large, lobulated mass most consistent with atrial myxoma with normal left ventricular systolic and diastolic function. The mass was occupying about half of the left atrium prolapsing through the mitral valve partially into the left ventricle as depicted in Figures Patent foramen ovale was ruled out with the help of a transesophageal echocardiogram. The plan was to remove the myxoma suspecting stroke as the likely etiology of her symptoms. She underwent cardiac catheterization prior to surgery to rule out concomitant coronary artery disease which showed no evidence of significant stenosis. The patient subsequently underwent removal of atrial myxoma as well as left atrial appendage ligation. Histopathological analysis of the specimen confirmed the diagnosis of benign myxoma measuring 3.5 x 3.0 x 1.0 cm. Biopsy of left atrial appendage muscle showed benign cardiac muscle with no necrosis or thrombi. Pathology slides are illustrated in Figures Her symptoms completely resolved after the surgery and she was discharged with a scheduled follow-up with her primary care physician. The patient was then followed up for six months and did not report the recurrence of symptoms since the time of surgery.Atrial myxoma is the most common benign cardiac tumor  represenIn some cases, it can present with stroke-like symptoms as its initial manifestation . AlthougLaboratory analysis can reveal elevated inflammation markers, leukocytosis, thrombocytosis or thrombocytopenia and normocytic anemia which is why it is essential to differentiate myxoma from other chronic inflammatory conditions such as subacute infective endocarditis . EchocarThe gold standard treatment is surgical excision if symptomatic, however benign symptoms such as the ones present in our patient do not usually require surgical removal . In our To conclude, cardiac myxoma is a benign diagnosis and is an easily treatable disease. There should be a high degree of suspicion if the patient presents with stroke-like symptoms. However, in a few cases such as the one presented above, the seemingly benign symptoms of persistent dizziness can be a manifestation of an underlying myxoma which should not be ignored.


Spontaneous tumor lysis syndrome (TLS) is a rare condition in solid tumors, particularly in endometrial carcinoma. Spontaneous TLS occurs without the use of cytotoxic therapy but is observed particularly in hematologic malignancies. Given the high morbidity and mortality associated with spontaneous TLS, it is crucial to identify and treat it promptly. There have been only four cases of spontaneous TLS reported to date in the literature from a uterine source. We present a 59-year-old female with a recently diagnosed endometrial carcinoma with neuroendocrine features by dilation and curettage who presented to the hospital with somnolence, decreased oral intake, and lower abdominal pain of three days duration. She was found to have sepsis secondary to endometritis and spontaneous tumor lysis syndrome by clinical and laboratory definitions . Signs of disease progression were found such as worsening retroperitoneal lymphadenopathy that corresponded with the suspected increased tumoral activity. We report the case of a solid tumor  presenting with spontaneous TLS, which highlights the importance of the early identification and initiation of treatment. Tumor lysis syndrome is a life-threatening condition where the extensive destruction of tumor cells leads to the release of potassium, uric acid, and phosphate into the blood, leading to life-threatening complications such as renal failure, metabolic derangements, seizures, and death . TLS occWe present the case of a 59-year-old female with a past medical history of essential hypertension, type II diabetes mellitus, obesity, and a recently diagnosed, poorly differentiated adenocarcinoma of the endometrium with neuroendocrine features. She presented to the emergency department with a history of somnolence, decreased oral intake, decreased energy, and lower abdominal pain of three days duration. Two weeks before presenting to the hospital, the patient was evaluated as an outpatient for post-menopausal bleeding and lower abdominal pain. A computed tomography (CT) scan of the abdomen and pelvis showed a distended uterus, an irregular hypodensity, 3.5 cm in diameter; an increased endometrial thickness of 4.3 cm, and retroperitoneal lymphadenopathy. She underwent a dilation and curettage, which yielded abundant blood and fragments of malignant, poorly differentiated carcinoma with neuroendocrine features and necrosis.On initial evaluation in the hospital, she was hypotensive and tachycardic. Her physical exam showed signs of hypovolemia  and tenderness to palpation in the lower abdomen. Her laboratory workup was relevant for leukocytosis (32.000/uL) with neutrophilia, normocytic anemia 10.9 g/dL), thrombocytosis (476 K/uL), acute kidney injury (creatinine 5.8 mg/dL with creatinine at baseline close to 0.9 mg/dL), hyperkalemia (5.8 mmol/L), hyperphosphatemia (7.1 mg/dL), hypocalcemia (6.1 mg/dL), elevated lactate dehydrogenase (2471 U/L), hyperuricemia (22.7 mg/dL), lactic acid elevation (5.1 mmol/L), and an elevated procalcitonin (4.86 ng/mL). A CT scan of the abdomen showed gas within the uterus and worsening retroperitoneal lymphadenopathy when compared to the previous CT scan done a few weeks earlier  . The autTumor lysis syndrome rarely occurs spontaneously in solid tumors. This case reflects the importance of considering tumor lysis syndrome as a cause of kidney dysfunction, seizures, or metabolic derangements, such as hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia in a patient with a solid tumor. Evidence of disease progression is a clue for spontaneous TLS when these metabolic derangements are found. Given the high morbidity and mortality with TLS, it is crucial to identify and treat it promptly.


Schmorls node (SN) are mostly asymptomatic and incidental findings on MRI. However, sometimes they present like acute onset low back pain or acute exacerbation of chronic back pain after minor trauma.We present rare case of symptomatic infected SN in 67 years female patient presented with complains of low back pain radiating to right buttock. After initial conservative treatment failed subsequent imaging showed significant increase in size of lesion with focal signal changes in disc space gave suspicion of underlying secondary pathology. Patient operated for complete excision of lesion. Histopathological report was suggestive of pyogenic vertebral osteomyelitis. Patient improved well postoperatively.Most of the time acute SN responds well to conservative treatment; however rapid deterioration of symptoms or persistent severe pain should give suspicion of underlying secondary pathology. Schmorl’s node (SN) is herniation of intervertebral disc into vertebral body through end plate defect. They first described by Christian Schmorl in 1927. SN are mostly asymptomatic and incidental findings on MRI; however sometimes they present like acute onset low back pain or acute exacerbation of chronic back pain after minor trauma , degenerWe present atypical presentation of acute symptomatic SN with infective pathology. There are no reports in the literature regarding the occurrence, imaging follow-up, treatment and outcome of symptomatic acute infective SN till date.Sixty-seven years female patient presented to our hospital with complains of low back pain radiating to right buttock since 1 month with visual analogue scale (VAS) score 7. There was no associated fever or significant trauma in recent past. She had no other medical or surgical history in the past. Clinically, there was no tenderness over lumbar spine. Patient was neurologically intact.A plain radiograph of lumbar spine was showing L4–5 narrowing of disc space with mild degenerative scoliosis. Dynamic plain radiograph does not show any features of instability. Computed tomography (CT) scan showed osteolytic bone lesion at inferior end plate of L3 vertebral body Fig. . InitialWe performed partial corpectomy L3 and expandable cage insertion through lateral retroperitoneal approach with posterior bone cement augmented percutaneous pedicle screw fixation L2-L4. Sample sent for histopathological examination and microbiology culture. Post operative MRI showed complete excision of lesion with persistent marrow signal changes at anterio-superior part of L4 vertebral body (Fig. Most of the SNs are asymptomatic and incidental finding . It is rVarious theories have been proposed to explain the pathogenesis of SN in which widely accepted theory is axial load model proposed by Dar et al.  They proConventional radiograph has very limited value for diagnosing SNs. It is useful only in late stage of SN where sclerosis appear around lesion. These findings can be seen early and in more details on CT scan. Alternatively, Presence of bone oedema on Dual energy CT can suspect the infective/inflammatory pathology . MRI is Conservative line of management always will be first line of management in symptomatic SN. Symptoms usually resolves within 2 to 6 months; however marrow edema on MRI gradually subsides over period of 3 to 12 months . We alsoPeng et al.  did segmTypical Histopathological examination of pyogenic vertebral osteomyelitis shows inflammatory cell infiltration, vascular proliferations with granulation tissue, fibrosis, thrombosed blood vessels and bony necrosis depending upon stage of disease; as seen in current case report Fig. . It was In this study, we present the first report of infectious SN, which is very similar to acute non-infected Symptomatic SN at the beginning. Therefore, if infected SN is suspected based on laboratory studies Careful follow-up observation is essential. However, the clinical course along with MRI and CT findings and histological images are more suggestive of infective pathology instead of degeneration hence managed aggressively with excision of infective focus.SN is always considered as one of the differential diagnosis of acute low back pain. Most of the time patient responds well to conservative treatment with analgesics and bed rest. Rapid deterioration of symptoms or persistent severe pain despite of conservative treatment should give suspicion of underlying another secondary pathology. It should be aggressively investigated and treated without further delay. MRI is investigation of choice for early diagnosis as well as to differentiate between symptomatic and asymptomatic SN. Currently there is no established treatment modality. Future investigations should address interventions for treating symptomatic SNs.


Retrograde intussusception (RI), although relatively uncommon, has been increasingly seen in adults post Roux-en-Y gastric bypass (RYGB) surgery. The exact mechanism for its occurrence remains unknown but several theories have attributed it to bowel persialtic dysmotility. The increase in bariatric surgery over the last decade has resulted in a proportionate increase in the number of cases of intussusception seen globally. We report a case of RI seven years following RYGB done for morbid obesity. Retrograde intussusception (RI) is a rare long-term complication after Roux-en-Y gastric bypass (RYGB) 0.1%-0.3%), however, its etiology still remains unclear %-0.3%, h. This raA 47-year-old woman presented to the emergency department with epigastric abdominal pain, nausea, and non-bilious vomiting of one-day duration. The pain was predominantly in the upper abdomen and was associated with multiple bouts of non-bilious, non-bloody emesis. She was passing flatus and had bowel movement until one day prior to presentation. The patient reported no significant past medical history except for being operated for laparoscopic gastric bypass seven years ago. Her vitals were stable with a temperature of 36.7 C, heart rate of 67 beats per minute, blood pressure of 155/86 mmHg, and respiratory rate of 18/min. Physical examination revealed infraumbilical and epigastric scar from the previous laparoscopy. There was tenderness noted on palpation in the epigastric region without any guarding or rigidity. It was appreciated on the upright X-ray abdomen that there were multiple dilated small bowel loops in the left upper quadrant  stapling device Figure . The comIntussusception in adults is more frequently caused by structural lesions such as benign polyps, Meckel's diverticulum, intraluminal lipoms, and malignant neoplasms . HoweverAnimal studies replicating RYGB construction have shown that suppression of these ectopic pacemakers by either electrical pacing or by using an “uncut roux” prevents stasis by maintaining enteric myoneural continuity . To dateThe diagnostic tool most useful for detecting this condition is a CT scan. It reveals concentric rings which indicate a classic “target sign” identified in cases of intussusception. Surgical management is the most preferred treatment for intussusception which involves resection and anastomosis of the ischemic bowel. Despite treatment, the recurrence rate is about 0.2% with a mortality range of 1% to 16% .RI is an important cause of small bowel obstruction after bariatric surgery. Correct diagnosis and appropriate treatment in a timely manner can prevent mortality and morbidity.


Neurocysticercosis is the most common parasitic infection of the central nervous system, brain being the most frequent site. Intramedullary location of cysticercus is a rarely described entity in literature. Widespread dissemination of cysticercus is also considered a rare occurrence, and only a handful of cases are documented, almost exclusively from tropical nations. Here we present a case of disseminated cysticercosis with rare initial presentation as acute dorsal myelopathy resulting from intramedullary cysticercus.A 62-year-old male patient from India (Asian) presented with features of dorsal myelopathy as manifested by acute-onset symmetric paraparesis, sensory loss below umbilicus, and double sphincter dysfunction. General physical examination revealed pea-sized nodules in skin and tongue. On spinal cord imaging, it was found that he had intramedullary cysticercus with diffuse perilesional edema. Brain and muscle imaging showed extensive cysticercosis suggestive of dissemination. Histological examination from skin nodule and antibody assay confirmed the diagnosis of cysticercosis. Following steroid administration, our patient showed improvement with observable increase in power of the lower limbs. He was subsequently discharged with antiepileptics, symptomatic therapy, and regular physiotherapy. Antihelminthic agents were initially avoided in view of extensive cysticercosis in brain including crucial areas such as brainstem.Rare manifestation of a rare but treatable disorder makes it an important reportable observation in the context of tropical medicine. Cysticercus cellulose, a larval form of pork tape worm Taenia solium. Humans are the only definitive hosts, and pigs are the usual intermediate hosts. Humans acquire infection following ingestion of T. solium eggs, usually from a tapeworm carrier [Cysticercosis is caused by  carrier . Clinica carrier . Brain i carrier . Owing tDisseminated cysticercosis (DCC) is a rare entity. Dissemination of cysticerci throughout the human body was reported as early as 1912 by British Army medical officers posted in India . Since tAcute dorsal myelopathy is a commonly encountered neurological emergency. Demyelination and vascular pathologies are usually given priority in the list of differentials. Infective causes of acute dorsal myelopathy, however, are also not infrequent, particularly in tropical countries. Intramedullary cysticercus, a rare entity reported almost exclusively from tropical regions, usually presents as chronic progressive myelopathy –9. InterHere we describe a case of DCC with rare initial presentation as acute dorsal myelopathy resulting from intramedullary cysticercus. Rare manifestation of a rare but treatable disorder makes it an important reportable observation in the context of tropical medicine.in situ at the time of admission to our care. On detailed questioning, he revealed that lower limb weakness started from left side in a hololimb manner with rapid involvement of right lower limb within subsequent 24 hours. His sensory symptom, which was in the form of loss of sensation in both lower limbs and lower trunk up to umbilicus, started at around the same time, although in a more symmetrical manner. At the time of presentation, he specifically complained of a girdle-like sensation around the umbilicus, below which he felt diminished sensation to touch or any other stimulus. All his complaints remained approximately static since the onset of illness. There was no history suggestive of any cranial nerve involvement, seizures, headache, vomiting, or loss of consciousness. There was no history of associated fever, cough, hemoptysis, weight loss, trauma, or dimness of vision. He used to eat cooked mutton, fish, chicken, and raw vegetables. General examination revealed multiple pea-sized nodules all over the body, especially both forearms, arms, and chest , farmer by occupation, presented with acute-onset nonradiating low-back pain followed by weakness and numbness of both lower limbs for 1 month. There was associated double sphincter dysfunction, for the same duration, in the form of acute painless retention of urine and constipation. He was put on a catheter on the third day of illness that remained 61L24E12, absolute eosinophil count 852, and platelet of 1.75 lakhs. Liver and renal function tests were within normal limits. Fasting blood sugar was 86 mg/dl. Magnetic resonance imaging (MRI) of dorso-lumbar spine with contrast, which was done outside approximately 1 week following symptom onset, showed small rim enhancing lesion in the spinal cord at D11 level with edema in the surrounding cord as well as diffuse cystic lesions in skeletal muscles and brain parenchyma consistent with cysticercosis. On admission, a repeat MRI of dorsal spine (plain and contrast) showed diffuse cord swelling with edema in the lower dorsal spinal cord extending up to conus medullaris and showing patchy enhancement within. It also showed extensive neurocysticercosis within both paravertebral as well as posterior paraspinal muscles , symptomatic therapy, and regular physiotherapy. Antihelminthic agents were avoided in view of extensive cysticercosis in brain including crucial areas such as brainstem. The patient was unfortunately lost in follow up after 3 months following discharge from our care.NCC is the most common parasitic disease of the human central nervous system. Cysticercal spinal cord involvement, however, is infrequent and varies from 1–5 % of all cases of neurocysticercosis . Spinal To the best of our knowledge, the presented case is the first report of intramedullary neurocysticercosis that manifested as acute dorsal myelopathy mimicking transverse myelitis. The clinical journey of our patient can be interpreted as follows: intramedullary compressive dorsal myelopathy resulting from cysticercus and manifesting as transverse myelitis followed by possible irritation of surrounding cord tissue or cyst rupture giving way to extensive perilesional edema that might have contributed to the static course of neurological deficits in this case. The observable clinical improvement following steroid introduction might have been linked to partial subsidence of edema.Another curious aspect of this case is eventual detection of DCC, which in itself is an uncommon occurrence even in tropical regions. Among the few reported cases of DCC, the majority have been from India . The orgThe treatment of DCC consists primarily of symptomatic therapy accompanied by steroids and antiepileptic drugs. Antihelminthic drugs help to reduce parasite burden faster, although death of parasites may eventually occur without pharmacological intervention as well . PraziquTo the best of our knowledge, this is the first reported case of DCC that presented with acute dorsal myelopathy consequent to intramedullary cysticercus. Although intramedullary cysticercosis itself has been reported earlier in literature, the combination of DCC and acute dorsal myelopathy makes this case unique. Furthermore, the essence of this case lies not only in the fact that it represents a rare manifestation of a rare disease, namely DCC, but also in the certainty of its treatable nature.