T2-weighted image (T2WI), the lesion in the prostatic urethra was identifiable, but the lesion in the right TZ was difficult to identify. On diffusion-weighted image (DWI), both lesions showed hyperintense signal and could be identified, and there was continuity between them. Urethroscopy was performed, there was the lesion with papillary excrescences developing from the right dorsal side of prostatic urethra. Transurethral resection of the prostate was performed. The pathological diagnosis was DCa (pure type). A review of previous literature showed that DCa had a slightly hypointense signal on T2WI. It may be difficult to identify DCa in the TZ because DCa and the TZ show similar signals on T2WI. DWI may be useful to accurately assess DCa arising from primary duct.Ductal adenocarcinoma of the prostate (DCa) is the histological variant of prostatic carcinoma. The macroscopic finding of DCa arising from primary duct by urethroscopy is papillary excrescences in the prostatic urethra. But the finding of MRI remains poorly understood, since there is no coherent report on the MRI finding of DCa arising from primary duct. We herein report a case of DCa arising from primary duct and forming papillary excrescences in the prostatic urethra. The patient was a male in his 70s and presented with gross hematuria a few days ago. Blood test showed elevated prostate specific antigen (PSA). Prostate MRI was performed. There were two lesions in the prostatic urethra and the right transition zone (TZ). On  DCa arising from primary duct often protrude into the prostatic urethra at or near the verumontanum, forming friable gray-white papillary or polypoid excrescences that are visible urethroscopy and may create urethral obstructive and haematuria.2 In this study, we report our experience of a case of ductal adenocarcinoma of the prostate of primary duct origin with papillary excrescences within the prostatic urethra that could be identified by MRI, with some literature reviews.Ductal adenocarcinoma of the prostate (DCa) is the most common histological variant of prostatic carcinoma. The incidence of ductal adenocarcinoma is 3.2% of all prostatic carcinoma.−1; normal range,≤4.0 ng ml−1).The patient was a male in his 70s. Gross hematuria appeared a few days ago. Since there was no improvement, the patient visited a department of urology in our hospital for further examination and treatment. Urinalysis was positive for occult blood in urine (2+). Urine cytology was negative. Blood test showed that there was no anaemia but elevated prostate-specific antigen (PSA) . The prostatic urethra was dilated, with an occupying lesion inside. The lesion was 9 × 12 × 23 mm on T2-weighted image (T2WI). The lesion showed hyperintense signal on diffusion-weighted image (DWI), hypointense signal on apparent diffusion coefficient (ADC) map, and slightly inhomogeneous hypointense signal similar to hypertrophic nodule in the transition zone (TZ) on T2WI (Prostate MRI (3.0T) was performed according to Prostate Imaging Reporting and Data System (PI-RADS) ver2.1. on T2WI . There w on T2WI . The nod on T2WI . Chest a−1, and the patient has uneventful course without recurrence for about 2 years.Urethroscopy was performed, there was the lesion with papillary excrescences developing from the right dorsal side of prostatic urethra . Transur1 There are two types of ductal adenocarcinoma: mixed type, which includes acinar adenocarcinoma, and pure type, which does not. Mixed ductal adenocarcinoma is more common than pure ductal adenocarsinoma.1 Our case was considered to be pure type, because no acinar adenocarcinoma was found in the pathological diagnosis. DCa is more prone to distant metastasis and has a lower elevation of PSA level than conventional acinar adenocarcinoma of the prostate (CCa).4Ductal adenocarcinoma of the prostate (DCa) is a histological variant of prostatic carcinoma. Microscopically, DCa is characterized by pseudostratified columnar epithelium.5 DCa resembles low grade CCa on T2WI, which underestimates tumour grade and renders the tumour occult.6 In previous reports Coffey N et al and Schieda N et al reported imaging findings of MRI in 8 and 11 cases of DCa, respectively, but only 2 cases included DCa located in the transition zone (TZ).4. 5 Therefore, the details of MRI findings of the DCa located in the TZ have not been revealed. In our case, it was difficult to identify the part of DCa in the TZ on T2WI, since the lesion showed equal signal to the surrounding TZ. The slightly hypointense signal on T2WI of DCa can be identified in the peripheral zone (PZ) showing hyperintense signal. It may be difficult to be identify DCa in the TZ showing slightly hypointense signal. In contrast, the part of DCa in the TZ was clearly identifiable on DWI and ADCmap, since the lesion showed clearly hyperintense signal on DWI and hypointense signal on ADCmap.On MRI, DCa shows hyperintense signal on DWI, hypointense signal on ADCmap and T2WI, just like CCa. However, there are some differences between DCa and CCa. DCa shows a strong hyperintense signal on DWI, similar to that of high (Gleason score≥7) grade CCa, although a slightly hypointense signal on T2WI, similar to that of low (Gleason score 3 + 3=6) grade CCa.1 However, the finding of MRI remains poorly understood, since there is no coherent report on the MRI findings of DCa arising from primary duct with papillary excrescences in the prostatic urethra. In our case, the papillary excrescences in the prostatic urethra were identifiable on MRI, showing hyperintense signal on DWI, similar to that of the lesion in the TZ, and slightly inhomogeneous hypointense signal similar to hypertrophic nodule in the TZ onT2WI.DCa arising from primary duct often characteristically present with papillary excrescences in the prostatic urethra on urethroscopy.The continuity between the part of DCa in the TZ and those in in the prostatic urethra was not clear onT2WI because the part of DCa in the TZ could not be identified. On DWI, both the part of DCa in the TZ and those in the prostatic urethra showed hyperintense signal and could be identified. MPR coronal image with the prostatic urethra as the axis on DWI showed a clearer continuity between the part of DCa in the prostatic urethra and those in the TZ. This MRI findings was consistent with the urethroscopic findings.Ductal adenocarcinoma of the prostate (DCa) arising from primary duct often protrude into the prostatic urethra, forming papillary excrescences. In our case, on T2WI, the papillary excrescences in the prostatic urethra could be identified, but the lesion within the TZ could not be identified. DWI were useful to evaluate the entire lesion. MPR images with the prostatic urethra as the axis on DWI may further aid in assessing the continuity between the part of DCa in the prostatic urethra and those in the TZ.Ductal adenocarcinoma of the prostate arising from primary duct often protrude into the prostatic urethra with forming papillary excrescences.It may be difficult to identify the part of prostatic ductal adenocarcinoma in the transition zone on T2WI.To evaluate the continuity between the ductal adenocarcinoma of the prostate in the prostatic urethra and those in the transition zone, it may be useful to create MPR images with the prostatic urethra as the axis on DWI.


Leiomyosarcoma of the pulmonary artery is a rare but potentially fatal disease. Due to its rarity, the treatment algorithm is not well-established. While there may be a role for both chemotherapy and radiotherapy, surgical management is the most definitive method. Unfortunately, when the disease process is advanced, surgery may not be curative. However, it may still be a palliative treatment option. In this case report, we present a patient who suffered from respiratory symptoms that were initially attributed to pulmonary embolism (PE). However, upon the diagnosis of pulmonary artery leiomyosarcoma (PAL), surgery intervention was undertaken and resulted in an improved quality of life for the patient. Malignant primary pulmonary artery tumors are rare entities and infrequently described in the literature. Among these, leiomyosarcomas comprise 21% of all pulmonary artery tumors, making them the most common primary pulmonary artery sarcomas (PPAS) . FurtherA 67-year-old man presented to the cardiac surgery service after undergoing evaluation by the pulmonology team for shortness of breath and cough. He had been symptomatic for several months and was previously diagnosed with a small spontaneous pneumothorax as well as a pulmonary artery embolism, whereafter he was placed on Coumadin. However, the failure to resolve his symptoms in addition to a 10-lb weight loss prompted a CT of the chest, abdomen, and pelvis. An eccentric filling defect at the level of the pulmonary artery was noted Figure .Subsequently, given the high suspicion for malignancy, the patient's condition was discussed at a multi-disciplinary oncology conference where the decision was made to perform surgical resection. Preoperative transesophageal echocardiography (TEE) performed in the operating room showed moderate pulmonic valve insufficiency Figure . After mOn postoperative day five, a transthoracic echocardiogram (TTE) was performed before discharge, and the findings were consistent with expected postoperative changes. A pathologic evaluation of intraoperative samples was consistent with grade 3 leiomyosarcoma. One month postoperatively, a chest CT scan demonstrated a stable distal right pulmonary artery tumor burden without recurrence of the resected portions. This was re-demonstrated on cardiac MRI at the six-week interval. The pulmonic valve appeared competent at that time as well. Since that time, the patient’s course has only been complicated by pericardial effusions, which have required both pericardiocentesis and surgical drainage. Notably, cytologic evaluation of the effusion did not demonstrate any malignant cells. Four months postoperatively, he underwent a full course of radiation therapy, which he tolerated well. To date, he has remained alive and improved symptomatically.The prognosis of PAL is usually poor, with median survival ranging from 1.5 to 12 months after diagnosis ,5. Part In a 20-year retrospective study, Bandyopadhyay et al. concluded that in confirmed cases of PPAS, the median time from the onset of symptoms until diagnosis was 100 days . The facWith regard to the operation of choice, Wong et al. have described management options including lobectomy and pneumonectomy but ultimately favored pulmonary endarterectomy as a viable option for symptomatic relief and possible long-term survival . This apPAL is a rare diagnosis, and hence its treatment algorithm is not well elucidated in the literature. While a multi-disciplinary approach is likely best for optimal patient outcomes, surgical interventions may be necessary depending on the overall prognostic outlook. As previously stated, the prognosis of PAL is poor. However, surgical intervention may enhance the quality of life and perhaps improve survival with respect to non-oncologic prognostic measures such as acute cardiopulmonary complications.


Of all the thoracic surgical procedures, chest wall surgery is probably the lowest-risk type. In fact, it is not so. Clinical work also often has the trap of chest wall surgery. An operation to remove a mass in the axilla may result in upper limb disability on the affected side. Here, we report the case of a 47-year-old female patient with a left chest wall adjacent axillary mass, which was considered an abnormal structural lymph node on color ultrasound examination and chest CT. Otherwise, she felt no discomfort. The left upper limb moved freely without being affected by the mass. A routine resection of the tumor was performed after the preoperative examination was completed. After the operation, the incision recovered well. However, the day after the surgery, she developed numbness and pain in her left little finger and ring finger, pain that often kept her from sleeping. The mass was confirmed to be a schwannoma with cystic degeneration by pathology slicing after the operation. By this time, doctors were alerted to the fact that the removal of the chest wall mass had nearly disabled the left upper limb of the patient, which was a great warning to the thoracic surgeon. In this case report, we hope that all surgeons will be cautious and careful and will not trust the imaging diagnosis too much. It is also hoped that the patient understands that some procedures may lead to unexpected complications. Schwannomas are tumors arising from the embryonic neural crest cells of the nerve sheaths of peripheral and cranial nerves, and they are a rare type of soft tissue mass, accounting for approximately 8% of all tumors . It mainA 47-year-old female patient was admitted to the hospital because of the discovery of a left chest wall adjacent axillary mass six months earlier. She had two children more than 20 years ago, and all of them were breastfed. She also had a left chest wall adjacent axillary mass three years ago, which had disappeared after two weeks (according to the own recollection of the patient). She had no prior history of tumors or breast nodules. Recently, she had no fever or other discomfort, and no local skin redness or swelling. Physical examination showed a palpable left chest wall adjacent axillary mass with well-defined boundaries, poor mobility, a hard, smooth surface, no tenderness, and no abnormal movement of the left upper limb. Color ultrasound examination indicated that a 4.9 × 3.2 cm solid hypoechoic nodule was seen in the left chest wall adjacent to the axilla, with clear boundaries, uneven internal echogenicity, and multiple echogenicity areas  for the publication of any potentially identifiable images or data included in this article.P-SW, LY, and DX contributed equally to this report; therefore, they are considered co-first authors. They made a substantial contribution to the acquisition, data interpretation and draft manuscript preparation. Y-HG and LX critically studied the conception and designed and prepared and revised the manuscript for important intellectual content. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors thank the patient who agreed to be included in this report for her cooperation and support for academic communication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Folliculosebaceous cystic hamartoma (FSCH) is an uncommon hamartoma that usually presents on the central face area of adults as an asymptomatic, solitary dome-shaped or pedunculated papule. We report a case of a 35-year-old female who presented with six-months history of skin lesions on her labia majora. Histological findings included cystically dilated hair follicles with branching epithelial strands and interconnecting sebaceous gland consistent with the diagnosis of FSCH. The genital variant of FSCH was first described in 1998 and since then only six cases have been reported in the literature. We aim to increase awareness of this rare presentation due to the significant psychological implications and the risk of misdiagnosis. Folliculosebaceous cystic hamartoma (FSCH) is a hamartoma composed of follicular, sebaceous and mesenchymal elements. It usually presents as an asymptomatic, solitary dome-shaped or pedunculated papule or nodule on the head in adult patients, with predilection for the central face and nose . Here, wA 35-year-old female presented with multiple asymptomatic papules and nodules on the labia majora. The lesions were of 6 months duration and gradually increased in number and size. They were rounded, skin-colored, pedunculated, firm, had a smooth surface and ranged from 0.5–2 cm in diameter. The patient was concerned about having viral warts. Her husband did not have history of similar lesions. The clinical differential diagnosis included condyloma lata, condyloma accuminata, fibrolipomas, and adnexal tumors. Excision of 3 lesions were performed and histological examination revealed multiple cystically dilated and distorted hair follicles surrounded by thin anastomosing epithelial strands. Sebaceous glands were seen communicating with the cyst through small ductules. The surrounding stroma was composed of highly vascular, dense collagenous tissue and was separated from the surrounding adjacent uninvolved dermis by prominent clefting. A granulomatous inflammation was also noted . The feaFSCH was first described as a distinct entity by Kimura et al. in a series of five cases in 1991 . The maiBolognia and Longley described the genital variant of FSCH in 1998 . The autFSCH does not have distinguishing features clinically and can be easily mistaken for neurofibroma, lipoma, intradermal nevus, and sebaceous hyperplasia . Viral wThe main histological differential diagnosis tends to be STF, which presents as a depressed lesion clinically. It tends to show hair shafts within the dilated hair follicle, displays branching finger-like smaller follicles, and a more frequent connection to the epidermis. It also lacks the characteristic stroma of FSCH . Due to 2 laser and acitretin has been described in one patient with a giant lesion [Treatment in most cases has been surgical excision . Successt lesion .To the best of our knowledge, we report the 8th case of genital FSCH. Awareness of this rare diagnosis is important due to the associated psychological distress, cosmetic and sexual issues, and anxiety of an HPV diagnosis.


Ectopic intrathyroidal thymic tissue is a rare diagnosis, specifically in adults. Such ectopic tissue is usually misdiagnosed as benign or malignant thyroid lesions and is mainly investigated by ultrasonography and pathologic examination.We present the case of an adult 31-year-old Persian female patient with a cervical mass and no other significant medical history. The lesion had hypo- to isoechoic features on sonographic imaging, and needle aspiration examination revealed lymphoid cells suspicious of lymphoid malignancies. However, pathologic examination after resection of the lesion showed normal thymic tissue.The rare entity of ectopic thymic tissue within the thyroid gland in adult patients requires meticulous examination by clinicians, radiologists, and pathologists to diagnose the condition with high accuracy and plan appropriate management. Ectopic intrathyroidal thymic tissue is a rare condition that is frequently seen in pediatric patients but extremely rarely in adults, being found incidentally on cervical imaging or usually misdiagnosed as benign or malignant thyroid lesions such as nodules or malignancies , 2. ThisWe present the case of a 31-year-old Persian female patient with a history of a mass in the left side of the neck for more than a year before referral to the clinic. The patient was gravid 2 with two children, living in the city center and working as a high-school teacher. The patient had no history of smoking or alcohol or drug use. The patient had no history of hyperthyroidism or hypothyroidism, or constitutional symptoms. History of diabetes mellitus, hypertension, and hyperlipidemia was also negative in this case. Also, the patient had no significant past medical history nor family history of ectopic cervical masses or thyroid gland lesions. The patient was using no medications when referred to our medical center.On physical examination at admission, the vital signs were normal with blood pressure of 120/80 mmHg, pulse rate of 85 per minute, and temperature of 37 °C. The primary evaluation of all 12 cranial nerves was normal. On neck examination, a palpable firm mass without tenderness was present in the left lobe of the thyroid. On auscultation of thyroid, no bruit was detected. Thyroid function tests were normal , and the patient was euthyroid at presentation. Also, all other laboratory tests were normal .3 with internal striation and cystic areas (less than 50% of mass) was detected in the lower pole of the left lobe of the thyroid gland. The lesion had no micro- or macrocalcification in the examination. There was no evidence of cervical lymphadenopathy in the US investigation -stained sections showed an encapsulated mass with thick fibrous capsule and intersecting fibrous bands separating it into lobulated architecture with cellular lobules resembling normal thymic cortex, which were composed of scattered bland thymic epithelial cells in a dense background of small lymphocytes (immature T cells). On immunohistochemistry (IHC) evaluation, the scattered epithelial tumoral cells showed immunoreactivity for cytokeratin AE1/AE3 (CK AE1/AE3) and P63. Background lymphoid cells showed diffuse immunoreactivity for leukocyte common antigen (LCA), CD3, CD43, and CD99; however, they were negative for CD20. The Ki-67 proliferation index was very high in lymphoid cells  that first presented with enlargement of the right lobe of the thyroid with low serum thyrotropin and elevated free thyroxin in laboratory tests. Their investigation with US found a hypoechoic mass in the right lobe later, confirmed as PTC, but nothing in the left lobe. Further examination by computed tomography (CT) revealed a small hypoattenuating nodule in the left lobe in the precontrast phase and no enhancement in the postcontrast phase. The patient later underwent total thyroidectomy, and histological examination of the left lobe found mature adipose tissue, lymphoid tissue, and Hassall’s corpuscles, compatible with thymic tissue [Moon c tissue .et al. reported a 29-year-old woman with history of right thyroidectomy due to PTC 3 years before her referral and a right neck mass. The initial examination with US showed a well-defined hyperechoic nodule in the left lobe of the thyroid. The patient underwent total thyroidectomy with right neck dissection. On gross examination, a well-defined pale-yellow nodule of 0.9 cm was seen in the left thyroid lobe, which on microscopic examination, mature adipose tissue, ectopic thymic tissue with Hassall’s corpuscles, and intrathyroidal parathyroid tissue was found [Kim as found .et al. reported a 23-year-old female patient with Grave’s disease refractory to medical management and a history of clinical hyperthyroidism, exophthalmos, and asthma. Cervical US showed a hypervascular and enlarged thyroid, and the gland had diffuse homogeneous radioiodine uptake on nuclear imaging. The patient underwent total thyroidectomy and right inferior parathyroidectomy, which was enlarged during the surgical exploration. Surgical pathology and histopathology examination of the excised tissues showed diffuse hyperplasia of thyroid tissue with colloid involution consistent with the treated Grave’s condition and focal ectopic intrathyroidal thymic tissue and some chondroid metaplasia [O’Connor taplasia .et al. reported a 26-year-old woman with hyperthyroidism controlled with levothyroxine and a heterogeneous 1.15-cm nodule containing microcalcifications in the right thyroid lobe, suggesting the presence of malignancy on the cytology examination. The patient underwent total thyroidectomy, and postoperative histopathology examination found multifocal PTC associated with ectopic intrathyroidal thymic and parathyroid tissues in the right thyroid lobe. The patient had no complications in the 2-year follow-up period after the surgery [Velimezis  surgery .Ectopic intrathyroidal thymic tissue has been studied in more detail in pediatric patients because it is more prevalent at lower ages. Ectopic thymic tissue results from deviation in the normal migration path of the thymus, which originates from the third pharyngeal pouches and moves medially and caudally to locate at the superior mediastinum by the eighth week of embryogenesis , 4, 5. BCritical differential diagnoses of an ectopic intrathyroidal mass full of lymphocytes are acute lymphoid leukemia, thymic carcinoma, carcinoma showing thymus-like differentiation (CASTLE), spindle cell tumors with thymus-like differentiation, and thymoma . Thymic As this condition is rare, overall and exceptionally in adults, the management of the lesion is subject to great doubt and remains unknown. However, all the reviewed cases, similar to the current reported case, underwent total thyroidectomy with no need for further intervention except follow-up and close monitoring of surgical complications. A previously mentioned study proposed an algorithm for diagnosing and evaluating ectopic intrathyroidal thymic tissue through a comprehensive systematic review of available literature on pediatric patients . AccordiThe rare condition of ectopic thymic tissue within the thyroid gland, without symptoms, continuing to adult age, requires refined clinical and paraclinical awareness and attention to manage the patient with the least unnecessary interventions and surgical procedures. Also, clinicians with crucial roles in this path such as radiologists and pathologists must pay special attention to this rare manifestation of a congenital remnant in adulthood. More investigations and evidence are needed to clarify the proper management of these patients, as clinicians face a dilemma regarding conducting unnecessary surgery or accepting the risk of neoplasm formation from the heterotopic tissue of the thymus within the thyroid gland.


Traumatic neuroma mostly results from nerve injury caused by surgery or trauma. Traumatic neuroma of the gallbladder without prior abdominal surgery is extremely rare, and we termed it “idiopathic traumatic neuroma of the gallbladder.” Due to its rarity and a lack of specific clinical and radiological features, it is most commonly misdiagnosed. In our case, the patient was admitted to our hospital for cholangiocarcinoma. Repeated abdominal contrast-enhanced computed tomography scans preoperatively indicated hilar cholangiocarcinoma. Due to insufficient future liver remnant, we planned preoperative percutaneous transhepatic cholangiodrainage and percutaneous transhepatic portal vein embolization based on multidisciplinary team consultation. The patient was then admitted 1 month later for surgery. We performed a laparoscopic cholecystectomy and an extensive laparoscopic right hepatectomy as gallbladder carcinoma was strongly suspected intraoperatively. However, the final diagnosis was traumatic neuroma of the gallbladder confirmed by pathological examination. Traumatic neuroma of the gallbladder is very rare, and we hope to provide some references for diagnosis by reporting our case and reviewing the literature on this topic so that extensive treatment can be avoided, thus improving patients’ quality of life. To the best of our knowledge, this is the first reported case of traumatic neuroma without prior surgery in the English literature since 1996. Neuroma arising in the biliary system is a very rare benign lesion and can be classified into two types: primary and traumatic neuroma . PatholoDiagnosis of a gallbladder neuroma is ascertained based on pathological findings of spindle-shaped cells and immunohistochemistry findings of the S-100 protein of postoperative or biopsy samples . TraumatDue to the lack of specific clinical symptoms and imaging findings, it is most commonly misdiagnosed as malignancy. Herein, we report one case of an idiopathic traumatic neuroma of the gallbladder treated at our hospital and preoperatively misdiagnosed as cholangiocarcinoma.A 60-year-old woman presented at our hospital with abnormal liver function tests discovered 2 weeks earlier on physical examination. Enhanced abdominal computed tomography (CT) scans revealed a space-occupying lesion at the hepatic hilum that was presumably considered hilar cholangiocarcinoma. The patient was admitted to our hospital on February 21, 2019. The patient denied any prior abdominal surgery or trauma. No abnormalities were found on physical examination.Laboratory investigations included liver function enzymes and tumor markers: alanine aminotransferase (ALT) 187 U/L , aspartate aminotransferase (AST) 111 U/L , alkaline phosphatase (ALP) 737 U/L , gamma-glutamyltransferase (γ-GT) 1,074 U/L , total bilirubin (TBil) 28.5 μmol/L , direct bilirubin (DBil) 13.7 μmol/L , albumin 44.5 g/L , CA19-9 50.01 U/ml , CA125 12.18 U/ml , alpha fetoprotein 8.63 ng/ml , and CEA 1.93 ng/ml .Abdominal enhanced CT scan  revealedAfter a multidisciplinary team (MDT) discussion, the location of the tumor was considered unordinary, and, since a biopsy would have been highly risky, the pathological nature of the tumor was difficult to establish preoperatively. Thus, preoperative diagnosis was considered to be hilar cholangiocarcinoma based on enhanced CT scans. However, direct surgical intervention (right hepatectomy) would be inappropriate due to insufficient residual liver volume. The patient thus underwent preoperative percutaneous transhepatic cholangiodrainage (PTCD) on March 1, 2019, followed by percutaneous transhepatic portal vein embolization (PVE) on March 4, 2019, to improve residual liver volume.One month later, the patient was admitted again for surgery. Preoperative laboratory investigations revealed elevated liver function enzymes , while bilirubin and tumor markers were all within the normal range. A contrast-enhanced CT  of the aOn April 11, 2019, the patient underwent surgery. Intraoperatively, the gallbladder was severely attached to the liver. The gallbladder had atrophied with a hardened texture . The tumPostoperative pathological examination revealed that the mucosa of the gallbladder was grayish-white with a hard texture. Fibrous tissue hyperplasia of the gallbladder wall with hyaline degeneration was seen together with chronic interstitial inflammatory cell infiltration and focal multinucleated giant cell aggregation. A nodule, 1.4 × 1.0 cm in size, with a grayish-whitcross-sectionon , was seeBenign neoplasms of the biliary system are most commonly adenomas or papillomas and account for only 6% of all biliary tumors . HoweverTraumatic neuroma is a non-neoplastic overgrowth of tissues and disorderly proliferation of nerve fibers and most frequently arises after radical neck dissection, orthopedic or limb amputation surgeries , 10. TraEven though most patients follow an asymptomatic course, some patients present with abnormal liver function, jaundice, pruritus, abdominal pain, weight loss, abnormal urine color, or clay-colored stools , 7. Our A case report by Shimura et al.  proved tIn this case, the traumatic neuroma was located in the gallbladder. Erratically, our patient had no prior history of abdominal surgery, gallstones, or polyps. Since there are no typical causes, such as surgery and physical trauma, we delineate such a finding as “idiopathic traumatic neuroma of the gallbladder.” PubMed, Embase, CNKI, and other websites were thoroughly searched for relevant publications, and only four cases of traumatic neuroma without previous surgery have been reported in the last 60 years . All theIt is worth mentioning that long-term chronic inflammation was confirmed pathologically in our case and the above-mentioned cases. Physical trauma from surgery or gallstones or polyps may not be the only triggering factors for traumatic neuroma formation in the gallbladder; chronic inflammation may also spawn traumatic neuroma . Long-teIn patients presenting with a history of abdominal surgery such as a cholecystectomy or liver transplant, traumatic neuroma should be included in the differential diagnosis, especially if the tumor arises at the remnant stump of the bile duct. However, even without prior surgery, inflammation triggered by gallstones or polyps or idiopathic inflammation can be an etiology of traumatic neuroma. While imaging modalities are not specific, liver function enzymes and tumor markers are elevated, and an intraoperative frozen biopsy should be incorporated to avoid extensive radical surgery, thus improving patients’ quality of life. Although idiopathic traumatic neuroma of the gallbladder is very rare, it should be included in the differential diagnosis in patients diagnosed with hilar cholangiocarcinoma.


We present the case of a patient with a rare synovial sarcoma (SS) of the tibial nerve. So far, only 4 cases of patients with SS originating from the tibial nerve have been described in the literature, and our patient is only the second patient whose limb was saved during treatment. Synovial sarcomas are malignant mesenchymal tumors, i.e., tumors arising from connective tissue. Synovial sarcomas account for 5–10% of all soft tissue sarcomas. However, the name synovial sarcoma is misleading, because the tumor does not originate from synovial cells, but rather from primitive mesenchymal cells. The name most likely originated from the localization around the large joints on the limbs, more often on the lower ones, in the area of the knee joints.We point out the aspects of correct and quick diagnosis and subsequent treatment, which has very important effect on the patient’s prognosis. Primary less radical excision without prior biopsy verification leads to a higher risk of local recurrence, even if a proper reexcision was performed immediately after biopsy verification of the sarcoma.A woman born in 1949 began to suffer at the end of 2020 with escalating pain under the left inner ankle with a projection to the sole and fingers. Her personal, family work and social history were insignificant. After the initial neurological examination, the patient was sent for an ultrasound examination of the ankle, which showed a lobular mass measuring 50 × 22 × 16 mm and according magnetic resonance imaging, the finding appeared to be a suspicious neurinoma of the tibial nerve. The tumor was surgically excised, without prior biopsy verification: a 50 × 20 mm tumor was dissected in the distal part of the tarsal canal, which grew through the structure of the tibial nerve and in some places into the surrounding area and appeared intraoperatively as a neurofibroma. But histologically the tumor was classified as monophasic synovial sarcoma. The patient was indicated for a wide reexcision of the skin with the subcutaneous tissue of size 91 × 20 × 15 mm. Now the patient is being treated with external radiotherapy to the tumor bed and she is able to walk.This report draws attention to a rare type of malignant nerve tumor, which both clinically and radiologically can mimic benign peripheral nerve sheath tumors. Synovial sarcoma should be considered in very painful resistances, typically located around the joints of the lower limbs, the growth of which can be slow. Because the size of the tumor is a negative prognostic factor, it is necessary to make a timely diagnosis using MR imaging and a biopsy with histological examination and to start treatment quickly. Surgical treatment should take place only after a biopsy with histological examination of the tumor so that it is sufficiently radical and does not have to undergo an additional reoperation, as happened in the case of our patient. We present the case of a patient with a rare synovial sarcoma (SS) of the tibial nerve. So far, only 4 cases of patients with SS originating from the tibial nerve have been described in the literature, and our patient is only the second patient whose limb was saved during treatment –4.A woman born in 1949 began to suffer at the end of 2020 with escalating pain under the left inner ankle with a projection to the sole and fingers, which therefore corresponded to the sensitive innervation region of the tibial nerve. The pain was severe, she could hardly touch the area around her ankle because of the palpation sensitivity. It worsened when she stepped on it, forcing her to walk on her tiptoes. If we were to evaluate the pain using a numerical scale  with a range of 0– 10, or 0– 100, where “+” means “no perceived pain” and 10 (or 100) represents “worst imaginable pain”, the patient’s reported value was around 8.So far, the patient has been treated for arterial hypertension, bronchial asthma, and diabetes mellitus type II, gastroduodenal ulcer disease, in 1985 she underwent right nephrectomy for clear cell carcinoma and in 1999 hysterectomy with adnexectomy for myomatous uterus.The patient’s mother died of an unspecified gynecological malignancy. Otherwise, the family history was negative oncologically. Work and social history were insignificant.After the initial neurological examination, the patient was sent for an ultrasound examination of the ankle, which showed a lobular mass measuring 50 × 22 × 16 mm. After supplementing the magnetic resonance imaging, the finding appeared to be a suspicious neurinoma of the tibial nerve , angioma. Malignant mesenchymal tumors are called sarcomas.Each peripheral nerve consists of axons that wrap around Schwann cells . The first protective covering, the endoneurium, is found around the Schwann cell, made of reticular and collagen fibers. Several bundles of such fibers are then enveloped by a second envelope, a peri-neurium formed from epithelioid cells, from which, for example, perineurinomas can arise. The last sheath is the epineurium, formed by a fibrous sheath of fibrous tissue, which wraps the bundles of fibers and fills them with mesenchymal cells, and from where sarcomas can originate . SynoviaThere are generally two types of synovial sarcoma. Monophasic sarcoma, i.e., made up of only one type of cells, namely spindle or glandular cells, and biphasic sarcoma made up of both types of cells. Soft tissue sarcomas are usually fast-growing, painless tumors, but synovial sarcomas often grow more slowly, are painful, can cause joint contractures, swelling, and the average time from the onset of symptoms to the established diagnosis is 2 years . Pain waThe immunohistochemical profile of synovial sarcomas characteristically shows signs of epithelial differentiation, even in the case of the monophasic form. The detection of pancytokeratins, positive in up to 90% of cases , and theThe main treatment of synovial sarcoma is surgical treatment, which should take place only after a biopsy with histological examination of the tumor so that it is sufficiently radical and does not have to undergo an additional reoperation, as happened in the case of our patient.Primary less radical excision without prior biopsy verification leads to a higher risk of local recurrence, even if a proper reexcision was performed immediately after biopsy verification of the sarcoma , 18.Neoadjuvant radiotherapy is recommended especially for larger tumors (> 5 cm) or in cases where the resection margin has been reduced, for example due to an ongoing vessel, nerve or bone . HoweverSynovial sarcomas appear to be more chemosensitive than other soft tissue sarcomas. In general, chemotherapy is recommended for younger patients, in whom it is expected to have a greater effect or for patients with unresectable or already generalized sarcomas –25.Patient’s prognosis is uncertain. It is generally reported that the five-year survival is around 30–50% and only 10% of patients survive more than ten years. Negative prognostic factors include tumor invasion into bone or blood vessels, advanced age, larger tumor size, and less radical excision –28. And This case report draws attention to a rare type of malignant nerve tumor, which both clinically and radiologically can mimic benign peripheral nerve sheath tumors. Synovial sarcoma should be considered in very painful resistances, typically located around the joints of the lower limbs, the growth of which can be slow. Because the size of the tumor is a negative prognostic factor, it is necessary to make a timely diagnosis using MR imaging and a biopsy with histological examination and to start treatment quickly.


Bone marrow evaluation showed acute myeloid leukemia (AML) with monocytic differentiation. Genomic profiling revealed NPM1p.W288fs*12, IDH2p.R140Q, NRASp.G13D, and PTPN11p.P491L. During induction, the patient complained of abdominal pain. Computed tomography (CT) scan demonstrated long‐segment thickening of the rectosigmoid colon suggestive of nonspecific colitis. No mass lesions were identified. Flexible sigmoidoscopy showed multiple ulcers of variable sizes in the sigmoid, the largest being 6 mm (Figure NPM1‐mutant myeloid sarcoma.A 78‐year‐old woman presented with persistent nausea, weight loss, and fatigue. Laboratory studies revealed leukocytosis (87 ×10m Figure . HistopaColonic ulcers are a rare manifestation of myeloid sarcoma, particularly at presentation. This case highlights the importance of having a high index of suspicion for considering colonic involvement by AML in the differential diagnosis of nonspecific colitis with ulceration in patients with AML. It also shows that detection of aberrant NPM1 expression by immunohistochemistry can be a helpful adjunct in the right context.


A 45-year-old man with stage 4 chronic kidney disease (CKD) on controlled dialysis presented with right-sided painful jaw swelling and protruding into the oral cavity for one year. Examination revealed a 3 x 2.5-cm hard, fixed, and tender swelling of the right mandible. Imaging showed expansile radiolucent lesions in bilateral retromolar regions of the mandible, local destruction of the basal bone, and diffuse osteopenia of the skull. Laboratory investigations revealed elevated parathyroid hormone (PTH), elevated serum calcium, normal serum phosphorous, and elevated alkaline phosphatase (ALP). A provisional diagnosis of tertiary hyperparathyroidism (HPT) causing brown tumors was made, which was confirmed on histopathology. Surgical removal of the lesion and subtotal parathyroidectomy were done followed by cinacalcet and controlled dialysis. This case report highlights the possibility of encountering multiple focal brown tumors in a patient and the importance of their differentiation from malignancy. Chronic kidney disease (CKD) often results in osteodystrophy due to secondary or tertiary hyperparathyroidism (HPT). Elevated parathyroid hormone (PTH) causes osteoclastic resorption of the bones that leads to various skeletal manifestations, one of which is a brown tumor. Multiple brown tumors are rare and can be easily mistaken for malignancy . We presA 45-year-old man presented with right-sided painful jaw swelling and protruding into the oral cavity for one year. It had an insidious onset and gradual progression to its present size. Chewing exacerbated the associated pain. The patient had known comorbidities of hypertension and stage 4 CKD and had been undergoing dialysis three times weekly for nine years.Examination revealed a 3 x 2.5-cm hard, fixed, tender swelling of the right mandible protruding into the oral cavity. The overlying mucosa was intact. There was an associated loss of the right third molar tooth with bleeding sites on its fragile mucosa.Laboratory investigations revealed elevated PTH levels of 2,933 pg/dl [target range for stage 4 CKD as per Kidney Disease Improving Global Outcomes (KDIGO) guidelines: 70-110 pg/dl], elevated serum calcium of 13 mg/dl , elevated alkaline phosphatase (ALP) of 1,758 IU/l , and elevated serum phosphorus of 5.5 mg/dl , indicating uncontrolled severe tertiary HPT. CT scan revealed expansile radiolucent lesions in bilateral retromolar regions of the mandible, local destruction of the basal bone, and diffuse osteopenia of the skull , hyperplasia (15% of cases), or carcinoma (<1% of cases) and is characterized by hypercalcemia and hypophosphatemia. Secondary HPT can be caused by CKD, malnutrition, or vitamin D deficiency and, contrary to primary HPT, is characterized by decreased serum calcium and normal or increased serum phosphorous, whereas tertiary HPT is characterized by hypercalcemia and hyperphosphatemia .CKD results in skeletal manifestations such as osteomalacia in adults and rickets in children due to secondary HPT. These are collectively referred to as renal osteodystrophy. Radiographs can also show a diffuse increase in bone radiodensity, seen more often in the axial skeleton. The etiopathogenesis of this diffuse osteosclerosis is not well understood, although it can reflect the anabolic effect of PTH. Despite the increased radiodensity, the bone is structurally weak with increased chances of stress fracture . The spiOne of the late manifestations of the condition is a brown tumor (osteitis fibrosa cystica). It gets its name from the brown color on histology due to hemosiderin deposition. Brown tumor formation occurs in CKD due to secondary HPT, which has a multifactorial etiopathogenesis. A decrease in renal function causes phosphate retention, which triggers the release of fibroblast growth factor 23 (FGF 23) from the osteocytes. FGF 23 decreases the renal production of 1,25 dihydroxy calcitriol, thereby stimulating the release of PTH. Diminution in the expression of vitamin D receptor (VDR) and calcium-sensing receptor (CaSR) in parathyroid cells and skeletal resistance against PTH in patients with CKD further contributes to the hypocalcemia-secondary HPT cascade [Brown tumor is commonly found in the pelvis, ribs, femur, and facial bones . ClinicaThe best method for diagnosing brown tumors is a parathyroid immunoassay. Further workup with bone scintigraphy (using technetium 99m-methylene diphosphonate) can be done, which shows intense uptake by brown tumor and helps in localizing other areas of similar activity .The treatment of brown tumors is mainly pharmacological and is done by correcting the underlying HPT. In cases of tertiary HPT, it is treated by correcting HPT with calcimimetics, and controlled dialysis, renal transplant, or subtotal parathyroidectomy may also be needed. Surgical excision of the tumor is sometimes necessary, like in our case as it was protruding into the oral cavity and causing symptoms . Some adMultiple brown tumors can be seen in the mandible in patients with CKD as a result of secondary or tertiary HPT. Although they can mimic malignancy on imaging, reaching the correct diagnosis is possible with appropriate clinical history and biochemical tests. Early diagnosis and treatment lead to an overall improvement of the prognosis. Surgical removal of the lesion may be required in case of symptoms.


A prospective trial evaluating the utility of second window indocyanine green (SWIG) in predicting postoperative MRI gadolinium enhancement was performed on high-grade gliomas (HGGs) and brain metastases. Compared to white light alone, SWIG demonstrated a higher sensitivity, negative predictive value, and accuracy in predicting residual neoplasm on MRI. The specificity of SWIG for predicting MRI enhancement was higher in HGGs than brain metastases. Clinically, near-infrared (NIR) imaging was better able to predict tumor recurrence than postoperative MRI. These results illustrate how SWIG is able to take advantage of gadolinium-like distribution properties to extravasate into the tumor microenvironment, enabling guidance in surgical resection.https://stream.cadmore.media/r10.3171/2021.10.FOCVID21204The video can be found here:  What makes indocyanine green (ICG) unique in the context of intraoperative visualization is that it is a near-infrared (NIR) fluorophore, which confers ICG with some unique benefits in the surgical setting. ICG is excited around 805 nm, and its emission is detected around 835 nm. ICG is thought to accumulate due to the enhanced permeability and retention effect in the tumor microenvironment, due to angiogenesis and the disruption of blood-brain barrier integrity, and it may be endocytosed directly by the tumor cells.Our study took place between 2014 and 2019 and included over 350 patients, with a variety of CNS tumors. The technique we used is named “second window ICG” because we administered the dye in high doses (up to 5 mg/kg) up to 24 hours before surgery. Intraoperative NIR imaging was performed using an exoscope, and the residual fluorescence postresection was compared to Gd enhancement on postoperative MRI. Importantly, NIR imaging did not guide the extent of surgical resection actually performed by the surgeon.ICG is more traditionally used in the context of video angiography in typical doses between 0.2 and 0.5 mg/kg, with imaging performed within minutes of administration. Our technique and application of ICG is termed “second window ICG” because we administer high doses of ICG (between 2.5 and 5 mg/kg) 24 hours before surgery. We are able to take advantage of the enhanced permeability and retention effect in the tumor microenvironment to detect the fluorescence of ICG in this second window, as seen on the diagram.For the high-grade glioma group, we had 34 patients with NIR imaging of the final surgical cavity view postresection. Of the 25 patients who had positive NIR signal in the final view, 23 of these patients had correlating residual neoplasm on postoperative MRI. Of the 9 patients with no residual NIR fluorescence in the final view, 8 had a complete resection of enhancing tumor on postoperative MRI. When compared to white light alone, SWIG ICG NIR imaging had a higher sensitivity (96%), negative predictive value (89%), and accuracy (91%) in predicting residual neoplasm on MRI.Here we have a case highlighting the utility of SWIG in predicting postoperative MRI. This patient was a 71-year-old-man presenting with progressive confusion over a 3-week period, having specific difficulties with speech. His primary care provider thought he had a stroke and referred the patient for an MRI.Preoperative imaging reveals a 38-mm necrotic left parietal mass in the left parietal lobe, presumably glioblastoma. Here’s a still of the contrast-enhanced MRI further showing the tumor. The patient was started on dexamethasone for three times per day.6 This transdural fluorescence allows us to center over the tumor prior to incising the dura. Once the dura has been opened, we can see the dye permeating the hypervascular tumor environment, allowing the surgeon to identify the neoplastic tissue.Here we are performing the craniotomy for this patient. The fluorescence seen in this video is a pseudocolor overlay on top of white light. One of the unique advantages of ICG is its ability to penetrate through the dura mater, given that it has a longer wavelength than visible light dyes.Once the majority of the tumor has been removed, we can see some residual fluorescence in this final view. As previously mentioned, fluorescence was not used to guide the extent of resection in the study. Here, the surgeon removes a sample, which is clearly visualized by ICG, from the margin of the cavity to send to pathology for further evaluation.Postoperative MRI shows some residual enhancement around the resection cavity, deep and close to the lateral ventricle. These enhancements are highlighted by the white arrows.This is a comparison highlighting the correlation between SWIG fluorescence and Gd enhancement. Prior to the resection, on the left, we can see the fluorescence in the bulk of the tumor correlating to the enhancement on MRI. Postresection, on the right, we can see the location of residual fluorescence  correlating to the rim of enhancement also seen on postoperative MRI. Ultimately, this patient underwent combined chemoradiation following surgery due to this residual tumor.For the brain metastases group, we had 44 patients with NIR imaging of the final surgical cavity postresection. This group highlights that a lack of NIR fluorescence in the final view correlates with a lack of Gd enhancement on postoperative MRI, emphasizing the sensitivity and negative predictive value seen with SWIG. Of the 16 patients in our study with no residual ICG fluorescence upon resection, all 16 had a complete resection of enhancing tumor on postoperative MRI. Though compared to the HGG groups, SWIG has a lower specificity for predicting MRI enhancement in brain metastases, NIR imaging clinically predicted the tumor recurrence better than postoperative MRI. Of the patients with recurrent tumors, a greater number had positive findings on final view NIR imaging compared to postoperative MRI.8 The top row depicts a metastasis in the right temporal lobe. Upon resection, there is no visible NIR fluorescence in the surgical cavity (seen in box E on the top right). This correlates with the lack of significant enhancement seen in the postoperative MRI (box B).8 In contrast, the bottom row shows a non-GTR for a right occipital mass. Box J (on the bottom right) highlights residual enhancement seen anteriorly in the resection cavity in the final view, which correlates to the anteriorly located enhancement seen in the postoperative MRI.8This figure shows the correlation between final view ICG and postoperative Gd enhancement in a gross-total resection (GTR) and non–gross-total resection (non-GTR).6 In this context, SWIG serves as a valuable tool to improve overall sensitivity and achieve a greater extent of resection, which may have positive implications related to survival and adjuvant therapy.9In conclusion, SWIG extravasates into the tumor microenvironment of HGGs and brain metastases via the enhanced permeability and retention effect, with gadolinium-like distribution properties. SWIG provides an intraoperatively useful means of predicting postoperative Gd enhancement with a high sensitivity and NPV.Dr. Lee reported other from VisionSense/Medtronic during the conduct of the study.Primary surgeon: Lee. Editing and drafting the video and abstract: Karsalia, Cheng, Cho, Harmsen. Critically revising the work: Karsalia, Cheng, Cho, Harmsen. Reviewed submitted version of the work: Karsalia, Cheng, Teng, Harmsen. Supervision: Karsalia, Teng.


Trigeminal neuralgia (TN) presents with symptoms of intense recurrent shock-like brief pain localized to specific areas of the face innervated by the fifth cranial nerve. The pathology of trigeminal neuralgia is attributed to the fifth cranial nerve compression or demyelination. Most cases of this diagnosis are not due to bony structures, making this case an uncommon presentation of trigeminal neuralgia. Herein, we present a case of trigeminal neuralgia due to an intraosseous meningioma that formed along the left petrous bone, resulting in trigeminal nerve compression. On head computed tomography (CT), osteomatous growths along the left petrous bone were noticed compressing the trigeminal nerve. After trigeminal nerve decompression and drilling out the protruding part of the petrous bone through middle cranial fossa craniotomy, the patient’s symptoms were completely improved postoperatively and at the two-month follow-up. To our knowledge, there are only four reported cases of trigeminal neuralgia caused by petrous bone compression in the literature. We emphasize the significance of considering petrous bone lesions as a cause of trigeminal neuralgia. Trigeminal neuralgia (TN) is characterized by recurrent shock-like brief pain restricted to unilateral trigeminal divisions ,2. TN ocA 32-year-old female arrived at our hospital due to increasing facial pain over the left back of her jaw that extended halfway down the mandible with recurrent episodes of shock-like pain, which was grade 4 on the Barrow Neurological Institute (BNI) pain scale. At the time, the patient stated that there had been more facial pain, increasing in severity with each passing day. Most of the pain was left-sided, with occasional right-sided pain. She also experienced temporal pain. Her past medical history includes difficulties with muscle pain along her jaw and cramps in the masseteric region. She also received multiple Botox injections to the masseters, temporalis, and lateral pterygoids. For a while, headaches and pain significantly improved temporarily. However, her symptoms were not fully resolved. Other forms of treatment did not provide long-term relief and included methods of dry needling, physical therapy, medication, and chiropractic adjustment. The patient has a past medical history of fibromyalgia and postural orthostatic tachycardia syndrome.Her physical examination was unremarkable except for left facial numbness. The patient was given a diagnosis of TN, and various pain medications, such as Tegretol, were tried for pain management. The results from medication were unsatisfactory, and after attempting other ways of treatment, she eventually opted for surgical intervention. Head computed tomography (CT) and magnetic resonance imaging (MRI) showed osteomatous growths along the left petrous bone that compressed the trigeminal nerve Figures -2.A retrosigmoid approach was discussed among other surgical options with the risks explained to the patient. A left retrosigmoid craniotomy was initially attempted but aborted due to intraoperative cerebral swelling. After a couple of days, a left middle fossa craniotomy was performed. The protruding petrous bone was drilled out to relieve trigeminal nerve compression. Postoperatively, head CT results showed no compression on the trigeminal nerve Figure . The patThe microscopic examination of the resected bone lesion shows an intraosseous meningioma, WHO grade 1. The specimen showed fragments of reactive bone with nests of meningothelial cells in intertrabecular spaces with whorl formation and collagen deposition. Round to oval nuclei were observed with frequent intranuclear pseudoinclusions and syncytial arrangement of the cytoplasm. There were no definitive meningiomas observed outside bony fragments. There were no high-grade morphologic variants, high-grade features, necrosis, or mitotic figures Figures -5. A twoTrigeminal nerve compression by mass lesions or blood vessels causes focal demyelination in the compressed region of the TN axon ,2,8. DemThe medical treatment of TN includes antiepileptics and tricyclic antidepressant medications. Carbamazepine is the first-line treatment for TN ,15,16. SMechanical compression on the trigeminal nerve by petrous bony mass lesions is rare -11. Our TN may arise from a series of different nerve and vascular concerns, and the compression of the fifth cranial nerve is known as a common cause of TN. To our knowledge, this is the fifth reported case of TN resulting from petrous bony structure abnormalities in the current literature. Our patient presents with TN caused by the growth of an intraosseous meningioma along the left petrous bone, resulting in trigeminal nerve compression. The patient underwent petrous bone decompression through a middle cranial craniotomy. Postoperatively and at two-month follow-up, the patient’s pain was completely resolved. This case calls attention to trigeminal neuralgia as a consequence of petrous bone lesions.


Metastasis to the orbit, which is uncommon due to the character of the orbital volume with relative stenosis, is estimated to account for 1–13% of all orbital tumors.A 52-year-old male with abrupt-onset hoarseness visited the authors’ clinic. His medical history was otherwise unremarkable. A 1 × 1 cm hard, fixed lymph node was palpable in the right level II area. Flexible fiberoptic laryngoscopy revealed right vocal cord paralysis. An ulcerative nasopharyngeal mass was observed by nasal endoscopy. Computed tomography (CT) of the neck revealed an enormous nasopharyngeal mass extending into the right oropharyngeal, masticator, carotid, prevertebral, and paravertebral space, with multiple bilateral cervical lymph nodes metastases. Transnasal endoscopic biopsy under local anesthesia and fine needle aspiration on the right level II lymph node were performed. Histopathologic examination revealed keratinizing squamous cell carcinoma (SCC) in both the nasopharyngeal mass and right cervical lymph node A.Figure The patient received docetaxel and cisplatin chemotherapy. However, chemotherapy was stopped after the first cycle due to neutropenic septic shock. Therefore, early radiotherapy of the nasopharynx and cervical lymph nodes  was completed. After one month, mild swelling in the right medial canthal area was noted. Visual acuity, intraocular pressure, and ocular motility were within normal limits and there was no exophthalmos. Orbit CT revealed a newly developed 1.0 × 0.9 cm soft tissue mass with indistinct margins on the inferomedial side of the right orbit A and B. A 67-year-old male presented with abrupt-onset ocular pain and blurred vision, which he had first noticed one month prior to presentation. He was seen by a neuro-ophthalmologist, who observed visual loss to no light perception on the right. The patient's medical history was otherwise unremarkable. Nasal endoscopy revealed a mild contour protrusion without mucosal ulceration or necrosis in the nasopharynx. Neck CT revealed a soft tissue mass in the extraconal and intraconal space of the right orbit. Moreover, asymmetry of the left nasopharynx and metastatic lymph nodes were present in the left level II, III, IV, and retropharyngeal areas . On PET/The patient received two cycles of chemotherapy with docetaxel and cisplatin. However, he refused further treatment for economic reasons and died six months after orbital metastasis diagnosis.NPC is a tumor that arises from epithelial cells covering the surface and lining of the nasopharynx.Orbital metastatic tumors are characterized by rather abrupt onset of diplopia, blurred vision, and pain. A visible lump may also be present beneath the eyelid and progress is relatively rapid. Examination may disclose proptosis, displacement of the globe, blepharoptosis, and a visible or palpable mass.The diagnosis of orbital metastasis should be suspected when a patient with a history of cancer exhibits the aforementioned symptoms. If the patient has no history of cancer, such findings should prompt a systemic survey to detect a primary neoplasm and other sites of metastasis. Although the ultimate diagnosis of orbital metastasis is rendered by biopsy or fine-needle aspiration, CT or MRI orbital imaging studies should also be preformed. CT is typically employed first because it provides better evaluation of bone. However, MRI usually provides the best resolution for orbital metastasis evaluation because the majority of orbital metastases principally affect orbital soft tissues. MRI typically reveals an inhomogeneous low signal mass on T1 images, increased signal intensity on T2 images, and a degree of enhancement with contrast agents.The main aim during treatment of orbital metastasis is to alleviate suffering and maintain visual function. Radiotherapy is the mainstay treatment for orbital metastasis from NPC, due to its sensitivity, but chemotherapy is also used in certain patients.Although NPC with orbital metastasis is rare, NPC can develop metastases in orbital and ocular regions. If NPC patients complain of ophthalmological symptoms such as local pain, impaired vision, eyelid swelling, or diplopia, it is important to consider orbital or ocular metastatic disease.The authors declare no conflicts of interest.


Bile duct hamartoma in the liver (LBDH) is relatively rare among the hepatic space-occupying lesions that occur in adults, and the malignant transformation of LBDH is even rarer. In the present case report, a 63-year-old male was found to have two space-occupying lesions in the right lobe of the liver upon ultrasound examination. Enhanced computed tomography (CT) suggested benign hepatic haemangioma, and contrast-enhanced ultrasonography (CEUS) suggested well-differentiated hepatocellular carcinoma. The final pathology results revealed the malignant transformation of LBDH into well-differentiated intrahepatic cholangiocarcinoma. Improved recognition of this type of rare disease can be obtained by radiographic analysis of this case. These findings contribute to a better understanding of the enhanced development pattern of this disease on contrast-enhanced CT, as well as on CEUS. Bile duct hamartoma in the liver (LBDH), also known as von Mayenburg complex (VMC) and polycystic bile duct hamartoma, is a benign malformation of the intrahepatic bile duct associated with bile duct plate defects ,2. The cAn elderly male, aged 63 years, was found to have space-occupying lesions ~2 cm in size in the liver during a routine physical examination at an external hospital. Therefore, the patient was admitted to The Second Hospital of Wuxi Affiliated to Nanjing Medical University  in January 2021. The patient was generally in good condition without obvious symptoms of discomfort and no yellow staining of the skin or sclera. The patient had a flat and soft abdomen, and no abnormal masses could be palpated. Laboratory examination revealed that the tumour marker levels, including that of AFP, CEA, carbohydrate antigen (CA)-125 and CA-199, were within the normal ranges (data not shown). The results for hepatitis virus markers were negative.The patient was subjected to a routine liver ultrasound examination. Entire liver sections were scanned with a conventional US. When a target lesion was found, the maximum cross section of the tumour diameter and blood supply were examined and recorded. The ultrasound examination showed diffuse chronic liver disease and cirrhosis. Two space-occupying lesions were found in the right lobe of the liver: One close to the liver capsule and located in segment six (S6), and the other 1.5 cm away from the liver capsule and located in segment five (S5). Both masses were hyperechoic and had uneven internal echoes, unclear boundaries and no obvious capsules. If benign, these masses could be hepatic haemangiomas, while if malignant, they may be hepatocellular carcinoma (HCC). Therefore, the ultrasonographer suggested further examinations to determine the nature of the masses.The abdomen was scanned by a Toshiba Aquilion ONE64 slice spiral CT scanner. The scanning parameters were 200 mAsec, 120 kV and a slice thickness of 0.5 mm. The contrast agent injected for enhanced scanning was ioversol (320 mg I/ml). The injection flow rate was 3.0 ml/sec and the dose applied was 1.5 ml/kg of body weight. Arterial phase scanning was performed 25 sec after injection, venous phase scanning was performed 60 sec later and delayed phase scanning was performed 120 sec after this.Enhanced CT showed local enhancement in the arterial phase  and contAt the suggestion of the ultrasound doctor, the patient underwent CEUS. CEUS was initiated using a Resona 7  ultrasound instrument. After a bolus injection of 1.6 ml SonoVue (Bracco Group) through a peripheral venous cannula, a 5-ml saline flush was used and the timer on the sonography was started. Observations were made until the microbubbles cleared from circulation . All video clips were recorded and then transferred to a hard disk.The examination showed a mass in S5 . At 13 sNext, the patient now presented with liver cirrhosis, which led to the consideration of HCC; however, due to the late and slow regression, a highly differentiated HCC was considered.Therefore, from the imaging examinations, CEUS had revealed a highly differentiated HCC, enhanced CT showed benign lesions and CEUS showed malignant lesions.Finally, the patient chose to undergo surgery, and during the operation, the liver exhibited small nodular cirrhosis. The two masses were located by B-ultrasound during the operation and were found to be located at the junction of S5 and S6. The nodular masses were grey in pathological appearance. One was close to the liver capsule (3.0x2.5x2.0 cm in size), and the other was 1.5 cm away from the liver capsule (3.0x2.0x2.0 cm in size). The boundary remained clear.The hepatobiliary surgeon removed two lesions and sent them to the Department of Pathology for examination. Pathologists sectioned and stained the samples, and performed histological and immunohistochemical examinations. First, the specimen was placed in fixative  overnight at a normal atmospheric temperature. The samples were taken on the second day (the sample size was 1.5x1.5x0.2 cm). The samples were then dehydrated overnight in a dehydrator. On the third day, the sample was placed in an embedding box for embedding (65˚C in paraffin). After embedding, they were placed in a paraffin slicer for tissue sectioning at a thickness of 3-4 µm. The cut sample slices were placed on the slides, and the slides were baked on an electric heating plate at 60-70˚C for 1-1.5 h. H&E staining was then performed. The whole H&E staining process consisted of dewaxing, dyeing, dehydration, making the section transparent and sealing. First, wax was removed from slices using xylene three times for 5-10 min each. The xylene was then washed away with alcohol . Next, the slices were rinsed with water for 2 min. The slices were then stained with haematoxylin for 5 min. The cells were rinsed with water again for 1-3 min after staining. After the sections were rinsed with water, they were rinsed with acidic alcohol (1%) for 20 sec. The sections were rinsed in water for >15 min until the nuclei turned blue. Eosin solution was used for dyeing for 30 sec to 1 min, and each alcohol concentration  was used for 1-2 min/wash. The tissue sections were made transparent three times (2 min/wash) with xylene to ensure the transparency of the sections. Finally, the tablet was sealed with neutral gum and labelled accordingly. Images were then taken under a light microscope (Nikon Corporation) at x200 magnification.Under a light microscope, obvious hyperplasia of the interlobular bile ducts was observed, along with lobulated and partial cystic dilatation, suggesting LBDH . In addi™ Super system (MXB Biotechnologies) was applied according to the manufacturer's instructions. The system used a two-step method in which the primary antibodies were mouse anti-human IgG monoclonal antibodies . Then a large amount of secondary antibody (anti-mouse/anti-rabbit) IgG polymer  was indirectly linked to the antigen-bound primary antibody in the sample by linking with reaction amplifiers.Following tissue preparation as aforementioned, the EliVision2O2) was dripped onto the sections, and the sections were incubated at normal atmospheric temperature for 10 min and rinsed with PBS (cat. no. PBS-0060) three times (3 min/wash). After rinsing, the primary antibody was added to the sections and incubated at normal atmospheric temperature for 60 min. After incubation, the sections were rinsed with PBS again three times (3 min/wash). Reaction magnifying agent was then added to the slices, which were incubated for 15 min at normal atmospheric temperature. After incubation, the sections were rinsed with PBS again three times (3 min/wash). After rinsing, high-sensitivity enzyme-conjugated anti-mouse/anti-rabbit IgG polymer was added to the sections, which were incubated at room temperature for 15 min. After incubation, the sections were rinsed with PBS again. A total of 120 µl DAB chromogenic reagent (Titan Super) was added to the slices after washing. Finally, the sealing piece was redyed with haematoxylin. Images were then taken under a light microscope (Nikon) (image magnification is 200 times).After dewaxing and hydration, the paraffin sections were washed with water. Pre-treated tissue sections were used (depending on the specific instructions of primary antibody). Peroxidase blocking reagent  , CD34(-)https://pubmed.ncbi.nlm.nih.gov/), EMBASE (https://www.embase.com/) and Web of Science (http://webofscience.com) databases were systematically searched up to June 2021. The following key words were used:  AND . Only studies published in English or Chinese and full-text journal articles of original studies were included. All other studies were excluded. Furthermore, the references cited in the relevant studies were reviewed for additional eligible publications. In the process of the literature review, >30 case reports and literature reviews were searched. The majority of studies were for individual cases, and most of the diagnostic methods focused on imaging examinations. Imaging examinations mainly included ultrasound, enhanced CT, MR and CEUS. Among them, the use of CEUS was relatively rare, and mostly reports were on multiple benign lesions. No case report on CEUS manifestations of the malignant transformation of LBDH was found.The PubMed  or HCC. The risk factors for malignant transformation include chemical or mechanical stimulation, cholestasis or chronic inflammation caused by calculi . TherefoIn a number of cases of LBDH reported in the past, ultrasound, CT, magnetic resonance imaging (MRI), digital subtraction angiography (DSA) and magnetic resonance cholangiography (MRC) have been used to help diagnose the disease ,25. TherIn the imaging analysis of this case, enhanced CT showed a strong-equal-equal enhancement mode, suggesting a benign hepatic haemangioma. However, CEUS showed a strong-equal-low development mode, so malignant lesions were first considered. Next, the patient presented with liver cirrhosis, which led to the consideration of HCC first, but due to the late and slow regression, a less well-differentiated HCC was then considered. Therefore, enhanced CT and CEUS were performed, but one suggested a benign lesion, and the other suggested a malignant lesion. The question thus becomes why such discrepant findings were observed. Ultrasound contrast agent is a blood pool contrast agent that is injected into the human body through a peripheral vein and enters the hepatic mass through the pulmonary circulation to achieve enhancement and development . Due to In addition, enhanced CT has time constraints. For some masses with late regression, imaging technicians are likely to fail to capture the point of regression during the delay period, resulting in the illusion that the mass does not fade during the delay period and thus causing the mass to be misdiagnosed as benign. Moreover, enhanced CT exposes patients to a certain level of radiation, so it cannot be applied for a long time. CEUS, by contrast, is full-course, real-time and dynamic, and can be applied for as long as desired, providing a clearer indication of whether the delay has subsided. In conclusion, enhanced CT and CEUS both have their advantages. CEUS is more advantageous in differentiating benign from malignant masses, while enhanced CT is more intuitive and accurate in differentiating malignant tumours of different pathological types. In the present case, when a benign haemangioma was indicated by enhanced CT due to the strong-equal-equal enhancement mode, CEUS assisted in the diagnosis of malignancy due to the strong-equal-low enhancement mode, both of which provided different diagnostic ideas and surgical bases for the clinic, helped clinicians remove the lesion early, and greatly improved the prognosis of the patient. The advantages of CEUS in differentiating benign from malignant lesions should be emphasized.The time it takes for the contrast agent to regress in the delayed stage of HCC can reflect the blood supply ratio of arteries and portal veins, which can be used to judge the level of differentiation of HCC. As the degree of malignancy of HCC increases, the contrast agent regression time decreases ,33. The There are few reports in the existing literature on CEUS manifestations of isolated or sporadic LBDH, and all of these reports are of benign disease. Meanwhile, CEUS manifestations of malignant LBDH are almost completely absent from the literature . In the The differences between enhanced CT and CEUS in the current rare case were analysed, and the imaging principles and pathophysiological basis of the two examinations in the diagnosis of LBDH malignant transformation were analysed, providing new diagnostic ideas and examination methods for subsequent clinical work.The present study reveals that the use of a combination of multiple imaging methods in the diagnosis of this disease can greatly improve the rate of clinical diagnosis and reduce the rate of misdiagnosis, and reveal any malignant trend in the lesions in a timely manner, thus helping clinicians remove the lesions as early as possible and greatly improving the prognosis of the patient.In conclusion, LBDH is a rare lesion with malignant potential that lacks specific clinical and imaging manifestations. By analysing the characteristic imaging features of intrahepatic bile duct hamartomas that correspond to its pathological features, combined with the imaging rules of enhanced CT and CEUS, the diagnostic accuracy of imaging can be improved to a great extent. Malignant lesions can be found early, the lesion can be removed in a timely manner and the prognosis of these patients can be greatly improved.


Epidermal cysts are derived from the follicular infundibulum and are exceptionally found over glabrous skin, including the lips and oral mucosa. To date, only approximately 10 cases of acquired epidermal cysts of the buccal mucosa have been reported in the literature without a clear etiology. A 53-year-old white man presented to our dermatology department for an infiltrated asymptomatic nodule of the left side of the upper lip. His medical history included HIV infection, kidney transplantation, cardiovascular disease, and an autologous fat transfer (AFT) done for cosmetic upper lip augmentation 4 years ago. The nodule appeared a few months following the AFT and has been growing progressively since then. He did not recall any other inciting trauma. Details about the lipofilling procedure were not available.Physical examination revealed an indurated ill-defined nodule of the left side of the upper lip, resulting in labial asymmetry . DiffereA punch incision was performed under local anesthesia through the upper labial mucosa for tissue sampling .Fig 2PunInterestingly, an amorphous lipomatous yellowish material was extracted, along with an underlying cystic lesion of approximately 1 cm in diameter. A partial rupture of the cystic wall accidentally occurred, with drainage of a cheesy-like white keratin content. The entire specimen was sent for histopathologic evaluation. Microscopically, the specimen was composed of mature adipocytes surrounding an epidermal keratin cyst .Fig 3HisAfter 30 days of follow-up, the patient was satisfied with the result . At 1-yeAFT, also known as lipofilling, is increasingly being used in cosmetic and reconstructive procedures of the face, essentially for facial rejuvenation, and to correct atrophic conditions.Pseudocysts formation or “oil cysts” have been reported with AFT, mainly with breast surgery and exceptionally following AFT of the face.On the other hand, epidermal cysts are extremely rare on hairless skin, especially on the lips and oral mucosa. Yet, few cases have been reported in the literature without any clear etiology.A lip cyst developed in our patient a few months after having undergone an AFT. This striking occurrence may be by mere coincidence but could also straightforwardly reinforce the theory of implantation of keratinizing epidermis that may develop during the AFT procedure. The grafted fat tissue itself may also potentially play a role in the induction or progression of this cyst, depending on its quality and its stem cell content, but further similar cases are needed to confirm this theory.In conclusion, we report a rare case of an acquired epidermal cyst of the lip as a possible complication of AFT. This finding may confirm the hypothesis of a posttraumatic origin of epidermal inclusion of keratin cysts over the buccal mucosa. In this case, a less traumatic technique of AFT might be considered. Treatment of these cysts is surgical and best done with a punch excision and enucleation via an intraoral approach.None disclosed.


Respiratory complications are among the most common problems addressed in neonatology in the first hours after birth, whereas the risk of any cancer in the neonatal period is 28 per million. Sarcomas, malignant mesenchymal neoplasms, account for about 8% of all neoplasms in the neonatal period. We report on a male neonate born at 36 + 4/7 weeks of gestation, diagnosed with retropharyngeal synovial carcinoma. Ineffective respiratory movements and generalized cyanosis were the first symptoms to be noted. On the ultrasound examination of the neck, a tumor of the retropharyngeal space was exposed, then visualized by an MRI of the head and neck. The biopsy analysis revealed the diagnosis of an extremely rare tumor in a neonate. The location of its growth was atypical, contributing to a diagnostic challenge. The neoplasm was treated solely with chemotherapy concordantly with the CWS protocol, individually customized for our patient. Preterm birth, as in our case, 36 + 4/7 weeks of gestation, may imply a possible need for resuscitation or support in the transition period. Aggressive high-grade tumors of the head and neck region are locally invasive and prone to metastasize. However, prognosis in infants is hard to estimate, therefore both individualized treatment and multidisciplinary care should be tailored to the needs of the patient. Pediatric head and neck tumors account for 3% to 5% of all tumors. Identification of such malignancies is highly important, as each requires a different management approach, further affecting its outcome. Neonatal soft-tissue tumors constitute 25% of all neoplasia occurring in infants, with 15% being malignant. Sarcomatoid carcinoma is a subtype of squamous cell carcinoma (SCC) and mainly hosts the upper aero-digestive tract. SCC accounts for almost 4% of all squamous cell carcinomas of the head and neck region in patients younger than 40 years old [Concurrently, the most common problems addressed in neonatology are respiratory complications in the first hours after birth. In near-term neonates, the main cause includes transient tachypnea of the newborn, respiratory distress syndrome, or pneumonia. However, other rare origins may also appear directly after birth, significantly, respiratory insufficiency may be caused by the mechanical obstruction of the respiratory tract, potentially a cancerous mass. Tumors arising from retropharyngeal location tend to be asymptomatic, which impedes prenatal diagnosis. Polyhydramnosis is one of the potential findings seen in the ultrasound examination, yet it is not pathognomonic.What used to define a good neonatologist decades ago, was an ability to intubate any baby and now, after thirty years of my career, what defines a good neonatologist is the knowledge and experience to know when not to intubate”“Neil Finer—® was started , however, chest movements were not observed, and the heart rate decreased to 90/min with blood saturation at a level of 50%. We checked for the position of the mask, its size, and head alignment. With no effect following these interventions, oral cavity inspection with the use of a laryngoscope was performed which allowed for visualization of the posterior wall of the pharynx. Primarily, the anatomy looked disturbed, the palate was lowered, and the pharynx seemed to be shallow. However, after the introduction of the laryngoscope, the baby took his first breath on his own. We, therefore. planned to keep the airway open with the introduction of the oropharyngeal tube. The size was measured from the angle of the mouth to the tip of the ear and introduced without twisting . This procedure however impaired again the patency of the airway. With the deteriorating state of the neonate, a decision to intubate with a 3.5 mm neonatal tube was made. As it was a life-threatening situation and the baby commenced losing consciousness, there was no premedication before the procedure. Despite the fact that in direct laryngoscopy, the pharynx seemed to have a different axis and to be shallower than usual, there were no difficulties regarding the insertion of the tracheal tube. The depth of intubation was calculated according to the rule “6+weight in kilograms”. In our case, the estimated weight was 3 kg (the exact measurement was made after having stabilized the baby) and the depth of intubation was 9 cm measured at the mouth. The tube was then fixed with a medical patch. Equipment used for intubation consisted of a laryngoscope with Miller’s blade size “0” and a cuffless endotracheal tube. Intubation has been performed by a neonatal specialist who had a shift on that day. On the first attempt, the procedure was successful, and the baby got then transferred to the NICU to continue intensive care and to expand the diagnostic measures. The airway-control process is presented in We present a male neonate delivered at 36 + 4/7 weeks of gestation with a birth weight of 2990 g by cesarean section due to the risk of asphyxia (episodes of bradycardia of the fetus after labor induction). The pregnancy was complicated by polyhydramniosis, hypothyroidism of the mother, and nine days of preterm premature rupture of membranes. The boy presented with good heart rate (140/min) and normal muscle tone. However, breathing was not effective and reaction to stimuli with generalized cyanosis and effort to breathe seen as abdominal muscle contractions were noted. In accordance with the European Resuscitation Guidelines, after umbilical cord clamping, tactile stimulation and drying were performed with no effect [2 40.2 mmHg, pO2 47.6, BE–2.6 mmol/L. Following the admission, a chest X-ray was performed. The lungs were hyperinflated, otherwise, the image was normal . After having been discharged, he did not require any further interventions within the oral cavity.The tumor was identified as biphasic synovial sarcoma. After having the incisional biopsy, further laboratory tests were conducted. Cytogenetic test by polymerase chain reaction detected the presence of the X;18 translocation, characteristic of the synovial sarcoma subtype. This chromosome mutation has been detected in samples of more than 90% os SSs and it has been suspected to impact the behavior of the neoplasm and its long-term prognosis. In our patient, the location site was not as it is typically expected. Synovial sarcomas tend to arise from the soft tissues of the para-articular regions and less commonly affect the head and neck area. After having successful partial removal of the tumor following the Cooperative Weichteilsarkom Studiengruppe protocol (CWS) the adjuvant chemotherapy was implied. On the 15th day of life, chemotherapy with vincrystyne, actinomycin D, and cyclophosphamide (VAC) adapted to the neonate’s weight and age was introduced off-label . The maiThe most common immediate complications in near-term newborns are hypothermia, sepsis, hypoglycemia, respiratory distress, and hyperbilirubinemia . PretermThe risk of any cancer in the neonatal period is 28 per million. Sarcomas account for about 8% of all neoplasms in the neonatal period, which makes them an extremely rare condition in that group . TherefoMost babies diagnosed with pediatric tumors require prolonged hospital stay due to the need for treatment administration, proper monitoring, and diagnostic procedures. In this case, because of respiratory insufficiency due to a large mass in the oral cavity, the first period of treatment required admission to the Neonatal Intensive Care Unit. On the other hand, the oncologic treatment itself must always be carried out by a pediatric oncologist. In our case, there were more than ten members of hospital staff involved in the treatment, namely a neonatologist, a pediatric oncologist, a pediatrician, an anesthesiologist, a radiologist, a pathologist, an ENT specialist, a nurse, a midwife, a psychologist, a physiotherapist, and a speech therapist. As soft tissue sarcomas can be difficult to diagnose, an experienced pathologist should always be involved in the analysis of the samples. However, the doctors leading direct care over the patient during the daily shifts must be acquainted with alarming symptoms in the course of oncologic treatment and cultivate close cooperation between the members of staff. The care must be individually tailored to meet the needs of the infant. Due to the rare prevalence of neonatal biphasic synovial sarcoma, there were no protocols available and a CWS protocol treatment had to be adapted for individual use. Similar challenges have been described earlier .The patient presented in our case report did not require surgical treatment due to effective chemotherapy which resulted in tumor necrosis and its extruding. However, provided the patient needed surgery, due to small size of airways, access to operate through the mouth can be challenging. There have been very limited publications on transoral robotic access for head and neck cancers, however with the use of this method, the rate of complications is low, and the procedure seems to be safe .Until now the patient is relapse-free, however, the prognosis is difficult to estimate due to the low number of studied cases. According to the literature, prognosis depends mainly on the tumor size, depth, invasion, and primary location in the pediatric population .In this report, we presented a rare case of a head tumor in a neonate. This is to raise awareness of the fact that thorough following of the resuscitation guidelines in airway management is needed and in rare cases, tracheal intubation may be needed even in late preterm infants.We emphasize the fact that neonatal neoplasms are extremely sparse, therefore an individualized treatment must be tailored to assure survival without long-term consequences. Prognosis in neoplastic treatment in infants is hard to estimate, therefore multidisciplinary care and parental counseling should be offered.