Dentigerous cyst is an odontogenic developmental cyst arising from the pericoronal tissue of an impacted tooth, and that may exhibit various radiological aspects. The aim of this article is to present four cases of histologically confirmed mandibular dentigerous cysts to highlight diverse radiological presentations: one of classical appearance (well-limited unilocular radiolucent lesion surrounding the crown) and three which have shown radiological peculiarities . Such radiologic diversity may, on occasion, suggest a clinical aggressive lesion such as an odontogenic keratocyst or ameloblastoma. The diagnosis of dentigerous cyst requires a thorough evaluation of the clinical presentation and accurate radiological studies. A dentigerous cyst (DC), also known as a follicular cyst, is a cyst of non-inflammatory odontogenic origin that develops from the pericoronal tissue  of an impacted tooth, either permanent or deciduous or supernumerary ,3,4,5,6.Furthermore, 2.5 to 4% of patients with an impacted tooth develop a DC , of whicBilateral lesions are extremely rare, and when occurring, association with development anomalies and syndromes, such as mucopolysaccharidosis or cleidocranial dysplasia, should be suspected ,2,5.Clinically, DCs are often asymptomatic but may occasionally cause swelling and dental displacement ,9,14,15.Radiologically, DCs usually appear as well-defined unilocular radiotransparent homogeneous lesions with a round or ovoid shape attached to the cementoenamel junction of an impacted tooth, usually third molars, and largely in the mandible ,11,12.The borders of the lesion may appear sclerotic and are less well-defined when the cyst becomes infected. When the cyst is large, it may displace or even resorb adjacent dental roots or may induce bone remodelling. However, the bone cortex usually remains intact.In this article, we present four cases of DC to highlight the diverse radiological presentation: one of classical appearance (case #2) and three which have shown radiological peculiarities .All the cases presented refer to lower third molars.Case #1:A 30-year-old male in good general health consulted the Oral Surgery and Implantology Unit of the Geneva University Hospitals for pain experienced for two days localized in the left lower quadrant of the mandible, with no fever nor ear, nose, and throat symptoms.On extraoral examination, palpation at the angle and the horizontal branch of the mandible was painful, and so was intraoral palpation at the vestibular level from tooth #37 to the left ascending branch of the mandible.On dental examination, tooth #37 showed sensibility positive test, slightly painful percussion, and a pocket depth on probing of more than 9 mm localized distally and associated with suppuration.Panoramic radiography revealed the presence of a pericoronal radiolucent lesion around the crown of an impacted tooth #38  . The lesAn additional cone-beam computed tomography (CBCT) X-ray examination confirmed the presence of the large pericoronal cystic lesion attached to the cementoenamel junction of tooth #38 . We obseThere was also no periosteal reaction, pathological fracture, evident signs of sequestration or sclerosis of the surrounding bone, nor infiltration of the perimandibular soft tissues. Tooth #38 had two roots, and the mesial root came into contact with the lingual wall of the IAC. The radiological appearance evoked a DC. Differential diagnoses included odontogenic keratocyst and unicystic ameloblastoma. The lesion was enucleated in toto together with tooth #38 under local anesthesia. The diagnosis of DC was confirmed by histopathological examination . The patCase #2:A 38-year-old female in good general health was referred by her orthodontist for diagnosis and treatment of a lesion in the right lower quadrant of the mandible discovered incidentally on an OPG X-ray performed prior to orthodontic treatment. The oral examination was unremarkable, and the patient was asymptomatic.A new OPG X-ray revealed the presence of a pericoronal radiolucent lesion on an impacted tooth #48, which was inverted in the mesio-caudal direction . The lesOn the complementary CBCT X-ray, it was observed an impacted tooth #48 in horizontal/inverted orientation in the mesio-caudal direction . The twoTeeth #18, 28, 38 and 48 were extracted, and the pericoronal lesion in tooth #38 was enucleated in toto under local anesthesia. The diagnosis of DC was confirmed by histopathological examination. The patient was followed-up for two years. At 12 months of control, an intraoral X-ray showed good healing of the enucleation cavity of the follicular cyst . ClinicaCase #3:A 46-year-old female in good general health consulted the Oral Surgery and Implantology Unit of the Geneva University Hospitals for the management of a lesion in the left lower quadrant of the mandible discovered fortuitously on an OPG X-ray performed by her dentist. The patient had a history of episodic pain in this area over several months, which she treated intermittently with self-medicated painkillers and anti-inflammatory drugs.The oral clinical examination was unremarkable, and the patient was asymptomatic. On the OPG, a pericoronary radio-transparent lesion around impacted tooth #38 was discovered . The invThe complementary CBCT examination found that tooth #38 was directed mesially and slightly lingually  and thatTeeth #37, 38 and 48 were extracted under local anesthesia. The lesion on tooth #38 was submitted for histopathological examination, which confirmed the diagnosis of DC.Case #4:® for epilepsy, Beloc ZOC® and Atacand® for high blood pressure and Crestor® for hyperlipidemia. He was a heavy smoker (70 pack year) and consumed 60 g of alcohol a day.A 59-year-old male was referred to the Oral Surgery and Implantology Unit of the Geneva University Hospitals for a comprehensive oral examination and dental care prior to the start of radio- and chemotherapy for squamous cell carcinoma of the floor of the mouth. The patient was taking RivotrilThe extraoral clinical examination was unremarkable. Intraorally, the mucosa of the hard and soft palate as well as the lingual mucosa showed keratotic dots; on the floor of the mouth, there was a 3 cm long and 1 cm wide ulceration; the oral vestibule presented a smoker keratosis. Oral hygiene was poor with plaque and tartar deposits; the patient had severe periodontal disease with grade III furcation involvement of teeth #46, 26 and 16, polycaries of teeth #16, 14, 13, 12, 23, 25, 46, 45, 43, 42, 41, 32, 33, 34 and 35; teeth #15, 14, 11, 22, 27, 47, 36 and 37 were absent.On an OPG X-ray, teeth #38 and 48 were impacted and distally orientated . Tooth #On CBCT X-ray, the distal root of the impacted tooth #38 was in contact with the upper wall of the left IAC, generating a discreet deformation of the canal . The cysThe lesion was enucleated in toto, and the teeth extracted  under geHealing was uneventful and the patient had no complaints. Radiologically, at the 6- and 12-month follow-up , there wDC is the second most common odontogenic cyst occurring in association with an unerupted tooth. It develops from the accumulation of fluid between the reduced enamel epithelium of the dental follicle and the crown of an unerupted tooth . The micIn the case of inflamed DC, histopathologic examination reveals a fibrous-connective tissue wall with a variable infiltration of chronic inflammatory cells and, on occasion, cholesterol clefts. The cyst is lined in part or entirely by non-keratinizing squamous epithelium, which shows varying amounts of hyperplasia with the development of elongated and interconnected rete ridges. These features may lead to a misdiagnosis of radicular cyst . Mucus cAlthough the definitive diagnosis of cystic lesions requires histopathological analysis, clinical and radiological examinations are of paramount importance in establishing the differential diagnosis ,9. In thIn the cases presented here, the presumptive radiological diagnosis of DC was confirmed by histopathological examination. However, in the OPG and CBCT images, the lesions varied in size, contour appearance, relationship, and effects on the surrounding anatomical structures. Differential radiological diagnoses differed from case to case and are summarized in Radiologically differential diagnosis of DC is mainly made with hyperplastic dental follicle, odontogenic keratocyst, and unicystic ameloblastoma. The following characteristics point toward a DC: neighboring tooth infiltration, bubble-like cortex, and the pericoronal space thicker than 5 mm ,4,8,9,16In this case series, the most likely differential diagnoses were keratocyst and unicystic ameloblastoma. The radiological findings that influenced the differential diagnosis were mainly the effects of the lesion on the adjacent anatomical structures (root resorption vs. infiltration) and the multilocular contour (case #4). On the other hand, although the 3D CBCT X-ray allowed us to appreciate the lesion volume and the relationship between the lesion and the surrounding structures, the differential diagnosis remained the same as the one deduced based on the OPT.For cases #2 and 3, the presumptive diagnosis of DC was quite high because of the classical appearance and the resorption of the adjacent roots made it possible to exclude keratocyst. This was in contrast to case #1, where the teeth/roots were displaced. Case #4, particularity, was the presence of a well-defined multilocular contour and the presence of septa, both of which, however, did not exclude the possibility of a keratocyst and ameloblastoma.When the DC is of large size, it can predispose the patient to pathological infections or fractures ,9. Rare The treatment of DC is represented by enucleation followed by curettage. It has been proposed that natural polymers may favorably help bone regeneration . The use of local antibiotics after the enucleation of the cyst has been advocated , as wellWe have presented four examples of radiological presentation of DCs. Diagnosing DC lesions involved multiple aspects. Although it is most often based on OPT images where it appears as a radiolucent lesion surrounding an impacted tooth crown, other characteristics of the lesion should be taken into account since they may lead to a different differential diagnosis. Limitations of this study is the observational nature based on a small number of cases.


Gliomatosis peritonei (GP) refers to the implantation of glial tissue on the visceral and parietal peritoneal surface, often associated with immature teratoma. It is a rare condition and the pathogenesis is not fully understood. In addition, the indistinguishable radiological appearance of immature and mature teratomas, and limited pathology samples make an accurate diagnosis difficult in most cases. More importantly, patients are also at risk of recurrence after surgery. This report aims to describe the process of diagnosis and treatment of GP with immature teratoma.The patient, a 38-year-old woman presented with GP complicated with immature teratoma after laparoscopic ovarian cyst excision.α-fetoprotein and carbohydrate antigen 125. We suspected malignancy according to the comprehensive preoperative evaluation, the postoperative pathology revealed an immature teratoma of the left ovary and complicated with gliomatosis peritonei. Three months after the second surgery, possible recurrence of immature teratoma was considered and the patient underwent the third laparotomy. But the postoperative pathology indicated mature teratoma and mature glial components in the pelvic lesions.On physical examination, a 15 cm-pelvic mass, with poor mobility, was palpated. And tumor marker demonstrated a moderate increase in The patient underwent 2 more surgical resections after the initial resection and 3 cycles of bleomycin, etoposide, and cisplatin regimen chemotherapy. She was regularly followed up in the outpatient after surgery, and no recurrence has been reported in the pelvic cavity till date.The case illuminated that the primary diagnosis of GP complicated with immature teratoma is critical but highly challenging for both gynecologists and pathologists and more attention should be paid to “GP complicated with immature cystic teratoma” patients to avoid inappropriate treatment. The pathogenesis of GP is not fully understood. It may correlate to defect of primary tumor capsular or capsular rupture during operation. In addition, genetic evidence has demonstrated they have unique genetic characteristics.,8 The IMCT along with many serum tumor markers increased, for example, carbohydrate antigen 125 (CA125),9 and α-fetoprotein (AFP).,11 However, no studies have reported that an elevated level of serum human chorionic gonadotrophin (HCG) is associated with IMCT or GP so far. Here, we present a case of GP complicated with ovarian IMCT after laparoscopic ovarian cyst excision and a review of relevant literature.Gliomatosis peritonei (GP) refers to the implantation of glial tissue on the visceral and parietal peritoneal surface, often associated with immature cystic teratoma (IMCT). It is a rare condition, only around 130 cases recorded, with a favorable prognosis in most.A 38-year-old female presented to our hospital with a recurrent pelvic cyst with no abdominal discomfort or vaginal bleeding following a laparoscopic left ovarian cyst excision performed 8 months ago due to a peduncular torsion of the ovarian cyst in another institution. The patient was G3P1 with a regular menstruation cycle. Her family history is unremarkable. A 15 cm-pelvic mass, with poor mobility, was palpated during the gynecological examination. The magnetic resonance imaging suggested there were bilateral ovarian teratomas , and the analysis of tumor marker levels demonstrated a moderate increase in AFP  and CA125 . The other tumor marker levels were in the normal range.We suspected malignancy according to the comprehensive preoperative evaluation. The second laparotomy was operated on December 24, 2020. During the operation, we found that the left ovary was cystic and solid, irregularly enlarged with a diameter of about 10 cm. The left fallopian tube adhered tightly to the surface of the left ovary. Another mass of about 18 cm was observed on the surface of sigmoid colon. There was no abnormality on the right ovary and fallopian tube. The left ovarian cyst was removed and the intraoperative frozen section was suggestive of mature teratoma with extensive implantation of glial components in the pelvic and abdominal cavity. According to the National Comprehensive Cancer Network guideline, cystectomy was preferred given the benign nature of mature teratomas. However, considering the risk of recurrence with the widespread implantation of glial components, and possible postoperative histopathology indication of malignancy, we performed left salpingo-ovariectomy and pelvic lesion resection. The postoperative pathology revealed, a grade II immature teratoma of the left ovary, no lesion on the left fallopian tube, Other lesions presented with mature teratoma components and complicated with a large number of mature glial implants . Considering the rapid expansion of the lesion in the short time and possible recurrence of immature teratoma, the patient underwent the third laparotomy with a total hysterectomy, right adnexectomy, and pelvic lesion resection. The postoperative pathology indicated mature teratoma in the left paracolic sulcus lesions and abdominal wall lesions, and mature glial components in the pelvic lesions  is the most common subtype of ovarian teratomas, commonly termed “dermoid cyst”, which usually contains mature tissues of the ectoderm , mesoderm , and endoderm (sticky or ciliated epithelium). The probability of the malignant transformation of MCT usually does not exceed 1% to 2%. Similarly, the tissues of IMCT can be traced to the 3 embryonic germ cells, especially the ectoderm, with the most abundant tissue component being neurogenic in origin. In general, IMCT possesses larger tumor volume and higher malignancy potential when compared to MCT. Moreover, it has a unique characteristic called chemotherapeutic retroconversion (CR), where its malignant degree is reversed. The phenomenon of CR is considered to occur infrequently previously.,18 Nevertheless, CR seems to be more and more common according to the recent research.,19 As reported in our case, the ovarian immature teratoma also reported mature teratoma in the third laparotomy after 3 cycles of chemotherapy.Ovarian teratoma is a common ovarian lesion ,,21 Effects of an unintended rupture of IMCT are prognostically relevant because they change a possible stage 1A to stage 1C. The rupture of MCT also leads to acute peritonitis as Rubod reported. The remission rates of malignant ovarian germ cell tumor have increased dramatically with the introduction of platinum-based chemotherapy. The 5-year survival rates have increased to 99% and 69% in the stage I patients and stage IV patients with distant metastasis. No long-term adverse effects on reproductive function have been observed in the fertility-preserving patients.,27 However, approximately 20% of patients are resistant to chemotherapy or relapse after surgery.Nowadays, the laparoscopic removal of ovarian cysts is a state-of-the-art procedure. However, the cyst rupture with intraperitoneal spillage occurs in 18% to 57.8% of laparoscopy compared with laparotomy. The tumor contains a large amount of glia and secretes growth factors to stimulate peritoneal stem cells to differentiate into glial cells. Nogale also supports that peritoneal stem cell differentiation could explain the single form of astrocytes presented by GP in some cases. Another theory proposes that the glia is differentiated from tumor cells in the ovarian immature teratoma.,31 The macrophage-derived factors could allow the neural component of ovarian teratoma to implant in the peritoneal cavity and induce astroglial differentiation, which could explain why the peritoneal implants are mostly mature even when they originate from immature teratomas. The detailed information of peritoneal gliomatosis remain to be determined.Histologically, the implants of GP are similar to the benign mature glial tissue, with delicate fibrous processes and scattered supporting cells. There are 2 theories about the biogenesis of peritoneal gliomatosis. One theory suggests that glial implantation of GP comes from the differentiation of peritoneal pluripotent mullerian stem cells. Moreover, Li demonstrated that the tumor cells expressed sex determining region Y-box 2 but not octamerbinding transcription factor 4 or homeobox protein Nanog homeobox in all GP specimens in their cases.The diagnosis of GP depends chiefly on pathological sections, but the inflammatory cell infiltration, hemorrhage, and choroid plexus can also be seen in the sections, which makes it difficult to diagnose, especially the intraoperative frozen sections. In these challenging situations, immunohistochemical staining for glial fibrillary acidic protein and S100 protein may be helpful.,33 There is no difference in overall survival between IMCT with GP or without GP, though patients with GP present with more frequent recurrence and shorter recurrence-free survival (Table  Therefore, many researchers suggest we do not have to resect the tumor in asymptomatic patients.,38The mature glial cells are noninvasive, the implantation could remain stable for a long time and the malignant transformation is extremely rare.al Table . And Rob Furthermore, the GP lesions are extensive, and complete excision in 1 go is usually difficult. Therefore, it requires a careful monitoring of residual lesions using scanning imaging such as computerized tomography and magnetic resonance imaging, which are safe, reproducible, and accurate techniques for patients who are associated with GP.In our case, the GP lesions recurred 1 month after the operation and it continued to grow up after 3 cycles of chemotherapy. Although chemotherapy achieves the retroconversion of IMCT to MCT, whether it is an effective treatment for GP is questionable. Harms pointed out that when GP included immature implants, additional chemotherapy can induce maturation of the implants. In addition to the secretion from the pituitary, we propose 2 hypotheses: On the 1 hand, the elevated HCG level is derived from the glial components of GP. With the stabilization of glial components, the level of HCG decreases gradually. On the other hand, HCG is secreted by mature teratoma reversed from immature teratoma after chemotherapy. Whether HCG is a tumor marker for GP is still uncertain, but we should pay more attention to the HCG levels in these groups. Further cases and studies are required to support the role of serum HCG as a predictor of GP.We accidentally discovered that the level of HCG increased significantly to 8.14 mIU/mL and a slight decline was noted after resecting the recurrent tumor in the third laparotomy. Three months later, the HCG level decreased to the normal range. A head computerized tomography was performed on this patient to rule out abnormality in pituitary. There were no studies have reported GP with IMCT accompanied by an elevated level of HCG so far, but Downey reported a case of ectopic HCG secretion by a mature teratoma.,41 However, the volume of GP becomes large or symptoms develop in the short term, it is recommended to be resected. Finally, GP is often accompanied by numerous peritoneal implants, and complete resection is difficult to achieve. Therefore, the frequency of postoperative follow-up should increase appropriately. It is recommended every 3 months for the first 2 years after surgery, every 6 months during years 3 through 5, then once a year thereafter, with the psychological preparation to undergo multiple surgeries.In our case, GP complicated with IMCT was treated with 3 surgeries and 3 cycles of bleomycin, etoposide, and cisplatin regimen chemotherapy. We summarize some of the lessons learned from this case. First, we advocate that content spillage should be avoided during the operation, especially when the cyst is suspected to be malignant. When removing the cyst, we should place it into a surgical retrieval apparatus and appropriately extend the incision during operation. In case of inevitable content spillage, complete suction of the spilled contents and thorough rinse of the abdominal cavity with physiological saline to avoid implantation. Second, the radiological features of IMCT and MCT are indistinguishable, and the samples from intraoperative frozen sections are limited. It undoubtedly challenges the clinical diagnosis and operation scheme. Hence, multiple intraoperative and postoperative samples of the lesions must be obtained and careful analysis of tissue sections must be carried out to make accurate judgments. In addition, after exclusion of the presence of immature elements in massive peritoneal lesions, a more conservative treatment may be considered for young women who wish to preserve fertility.Conceptualization: Fei Guo.Data curation: Yukai Liu, Jiaqi Lu.Formal analysis: Jiaqi Lu.Funding acquisition: Xiaoyong Zhu.Investigation: Fei Guo.Methodology: Yukai Liu.Resources: Zhiyong Wu.Supervision: Xiaoyong Zhu.Validation: Zhiyong Wu.Writing – original draft: Fei Guo.Writing – review & editing: Xiaoyong Zhu.The funding number 2071624 in the footnote has been corrected to 82071624.


A muco-submucosal elongated polyp is a non-neoplastic growth composed of mucosa and submucosa. Although muco-submucosal elongated polyps are commonly reported in the large intestine, they are rare in the small intestine, in which they are called enteric muco-submucosal elongated polyps. We herein present a case of jejunal intussusception and perforation due to an enteric muco-submucosal elongated polyp.A 46-year-old woman presented with abdominal pain and vomiting. Computed tomography revealed jejunal intussusception, which was reduced via a nasointestinal ileus tube. Oral double-balloon endoscopy showed an elongated polyp in the proximal jejunum. The patient refused surgical resection and thus, the polyp was monitored. Six months later, the patient was readmitted with the recurrence of jejunal intussusception and underwent emergency surgery. Intraoperative findings revealed an intussuscepted bowel with an elongated polyp and multiple perforations in the proximal jejunum. We resected approximately 90 cm of the bowel, including the intussuscepted segment and perforated sites. The pedunculated polyp, which was 60 mm in length, was located on the oral side of the resected specimen. Histopathologically, the polyp was covered by normal mucosa and the submucosa consisted of edematous loose connective tissue. The histopathological diagnosis confirmed an enteric muco-submucosal elongated polyp.Symptomatic patients with enteric muco-submucosal elongated polyps may be at risk of complications, as observed in the present case, and need to undergo timely resection. A muco-submucosal elongated polyp (MSEP) is a non-neoplastic growth composed of mucosa and submucosa . The chaA 46-year-old woman presented to the emergency department of our hospital with abdominal pain and vomiting. She had a history of dilated cardiomyopathy and asthma and was taking a β-blocker. Upper abdominal pain had initially developed approximately 6 months earlier. Non-contrast computed tomography (CT) revealed intussusception in the jejunum Fig. . HoweverSurgery was initially performed laparoscopically. A 12-mm port was placed in the abdominal cavity through an umbilical incision, and an additional 5-mm port was inserted in the right lower quadrant. We observed a moderate amount of cloudy fluid and an intussuscepted bowel loop just under the umbilical incision. Since intussusception was difficult to reduce laparoscopically, we moved to laparotomy. We initially reduced intussusception manually by pulling the bowel loop. There were four perforated sites in the intussuscepted segment of the proximal jejunum Fig. . We reseThe patient recovered well without any postoperative complications. She was able to take a clear liquid diet on postoperative day 4 and was discharged on postoperative day 12. Seven months later, her nutritional status had recovered, and the symptom of chronic abdominal pain disappeared postoperatively.We herein reported a rare case of jejunal intussusception and perforation due to EMSEP. MSEP is relatively rare in the small intestine, but is more common in the large intestine. Histologically, MSEP is composed of normal mucosa and a submucosal layer containing dilated lymphovascular components with edematous connective tissue . In 1998There are only seven documented case reports of EMSEP on the PUBMED database, which are shown in addition to the present case in Table In contrast to that in children, intussusception in adults is relatively rare and commonly occurs with a pathological leading point . RegardiThere is currently no established treatment strategy for asymptomatic EMSEP and a potential relationship between EMSEP and neoplasms has not been proposed. A previous study suggested a relationship between CMSEP and neoplasms : they reWe encountered a case requiring surgical resection of an extensive small bowel loop because of intussusception and perforation due to EMSEP. This rare case suggests that symptomatic patients with known EMSEP need to undergo prompt resection.


Tracheal diverticulum (TD) is a rare entity in the literature. It is the consequence of a congenital or acquired weakness of the tracheal wall. The principal difference lies in the histological characteristics of the wall. Most cases are asymptomatic, but when symptoms are found, they are usually not specific. Therefore, the diagnosis is made based on the results of CT. We report a case of a 62-year-old female presenting with a chronic cough. A diagnosis of the TD was established on the basis of a thoracic CT scan. Tracheal diverticulum (TD) is an uncommon condition, generally discovered fortuitously, and characterized by single or several tracheal wall evaginations . TD was We report a case of a 62-year-old female patient with a past medical history of hyperthyroidism on carbimazole and propranolol and type 2 diabetes on insulin. The patient complained of a chronic dry cough with no signs of hemoptysis, dyspnea, fever, or dysphagia and no signs of deterioration in general condition for one year. In addition, the physical examination revealed no abnormalities, including pulmonary auscultation.A Thoracic CT scan revealed a cystic lesion of 1 cm connected to the tracheal lumen. It was located in the right postero-lateral part of the trachea, with associated bilateral calcified micronodular and nodular apical lesions that looked like sequellar lesions (stable appearance on two scans performed six months apart) without emphysema or pneumomediastinum . Bacteriological investigations, including the search for acid-resistant and common germs, returned negative. Spirometry was done and came up with normal results; no obstructive syndrome or restrictive pattern was found.The diagnosis of TD was established given the postero-lateral location at the cervicothoracic junction. The decision was to go for conservative treatment as the patient remained asymptomatic since diagnosis with a spontaneous resolution of the cough. The duration of the follow-up was nine months.TD is a rare type of paratracheal air cyst with an estimated prevalence of 1-4% ,7. ResulAcquired tracheal diverticula are due to an intraluminal pressure increment that causes a herniation of the epithelial membrane through a weak point in the tracheal wall. Unlike congenital TDs, they are larger, with wider openings to the tracheal lumen and thinner walls made exclusively of epithelium. In addition, they occur at different localizations of the trachea and are rarely multiple ,5,10,11.Clinically, tracheal diverticula are usually asymptomatic and discovered fortuitously during a radiological investigation. Symptoms such as cough, dyspnea, dysphonia, vocal cord paralysis, and pain are explained by the local mass effect of the diverticulum , 16. AddA thin-section CT scan of the trachea coupled with a three-dimensional reconstruction illustrates best the communication between the cyst and the airway. It is considered the best diagnostic approach for the tracheal diverticulum , 18. FurThe choice of treatment is decided according to several factors such as age, physical condition, and the symptoms presented . ConservTD is a rare clinical disease. It can be either acquired or congenital. Its diagnosis is based essentially on thoracic high-resolution computed tomography (HRCT) and is most often asymptomatic. The indication of conservative or surgical treatment with resection of the diverticulum depends on several factors. However, resection of the diverticulum is the proper surgery and should be necessary for symptomatic patients or in whom conservative treatment has failed. Therefore definite classification prior to surgery is mandatory . Risks of surgery include damage to the recurrent laryngeal and esophageal nerves.


Swyer syndrome is a special form of DSD (disorders of sex development), so-called pure gonadal dysgenesis with a karyotype 46, XY and a female phenotype. One of the most important problems in patients with DSD is the risk of gonadal tumors. We present a case of a 26-year-old patient with Swyer syndrome. The patient had primary amenorrhea and no puberty characteristics. In ultrasound imaging in the vicinity of the uterus, there were two homogeneous structures. A genetic diagnosis was also performed, which showed karyotype 46, XY. The patient underwent a bilateral gonadectomy. Histopathological examination revealed the presence of dysgerminoma in both dysgenetic gonads. The follow-up of five years now did not show any changes suspected of invasion. We concluded that the primary amenorrhea, along with the absence of development of sexual characteristics, should prompt an expanded diagnosis for disorders of sex development. Gonadal dysgerminoma should be suspected even in the absence of tumor features on ultrasound and blood laboratory tests. Early prophylactic gonadectomy could protect patients from developing tumors in dysgenetic gonads. Disorders of sex development (DSD) are rare, associated with a frequency of 1:1000 births . Swyer sDiagnosis of Swyer syndrome is based on medical history and physical examination, determination of gonadotropin and sex hormone levels, imaging , analysis of cytogenetic and molecular tests and histological assessment of gonads . The intOur paper presents a case of a patient with primary amenorrhea, in whom no investigation was performed, and a late diagnosis of gonadal dysgenesis with karyotype 46XY resulted in the development of bilateral gonadal neoplasm. The aim of the study is to emphasize the importance of early implementation of diagnostic procedures in the case of primary amenorrhea in patients with Y chromosome-derived genetic material.The clinical case presented, aged 26, came to the Gynecological Endocrinology Clinic due to reproductive plans and a lack of menstruation occurring for several years. From the age of 16 to 19, she was treated with oral contraception due to primary amenorrhea. During treatment, the bleeding occurred regularly. Based on the interview at that time, no diagnostics but a gynecological examination was performed. For unspecified reasons and a lack of support in the family, the female stopped treatment. The woman was 168 cm in height and 59 kg in weight. Physical examination revealed no puberty characteristics: development of mammary glands: scanty glandular tissue, pale nipple envelopes and papillae (Thelarche 2/3); scanty pubic hair (Pubarche 2); axillary hair (Axillarche-2) in addition to a narrow, childlike pelvis. The gynecological and imaging examinations revealed the presence of a hypoplastic uterus (28.0 mm × 23.1 mm) with a linear endometrium and normal cervix. In the vicinity of the uterus, there were two homogeneous structures (27 × 18 × 12 mm and 15 × 13 × 8 mm) that may correspond to hypoplastic ovaries. No pelvic abnormalities were found .Gonadotropin concentrations were determined, which were: FSH—56.7 mIU/mL, LH—19.8 mIU/mL, sex steroid concentrations: E2 < 5 pg/mL, T—0.348 ng/mL; in addition, the concentrations: 17-OHP—1.03 ng/mL, TSH—3.7 mIU/mL, fT4—1.03 ng/dL, ACTH—28.6 pg/mL, cortisol—16.9 ug/dL, tumor markers: LDH—118 U/L, β-HCG—0.753 mIU/mL, AFP—3.88 IU/mL. Detailed hormone profiles and tumor markers are shown in On the basis of the overall clinical picture and the results of previous studies, hypergonadotropic hypogonadism was found, and the patient was referred for cytogenetic testing. Since then, the female underwent intensive psychological care both in the form of individual and group therapy.The culture of peripheral blood lymphocytes revealed the presence of the SRY gene sequence and other genes within the Y chromosome  .The final diagnosis was made: DSD with karyotype 46, XY.In view of the normal macroscopic image of the gonads, the laparoscopic salpingo-ooferectomie was performed . HistopaDue to the malignant nature of the tumor and the performance of a conservative procedure, the decision of a close further observation decision was made. It involved the determination of tumor markers, alkaline phosphatase concentration, and CT imaging of the abdominal cavity, pelvis and chest CT. Additionally, an adjuvant hormonal estrogen-progestagen therapy was started to obtain regular uterine bleeding and strengthen the sense of sex. The follow-up of five years now did not show any changes suspected of invasion. Tumor markers levels after surgery were within normal limits; LDH—135 U/L, β-HCG—0.815 mIU/mL, AFP—2.88 IU/mL, Ca-125—19.01 U/mL.The most important threats for women resulting from chronic amenorrhea depend on the period of life in which the disorder occurs and include delayed puberty, infertility and distant consequences: failure to achieve peak bone mass or its rapid loss. Primary amenorrhea is defined as a lack of menstruation in a 13-year-old girl who has underdevelopment of secondary sexual characteristics or a lack of menstruation in a properly developed 15-year-old girl . Based oIn addition to gonadectomy, which is used in high-risk patients, hormone replacement therapy (HRP) should also be implemented . For priThe Bandala-Jacques et al. study compared optimal and sub-optimal cytoreduction for ovarian dysgerminoma. They concluded that initial residual disease did not significantly affect progression, recurrence, overall survival or disease-free survival. However, it should be noted that cases in stages III and IV were analyzed . In our Based on the case we described, we drew the following conclusions: The primary amenorrhea, along with the absence of development of sexual characteristics, should prompt an expanded diagnosis for disorders of sex development. Gonadal dysgerminoma should be suspected even in the absence of tumor features on ultrasound and blood laboratory tests. Early prophylactic gonadectomy could protect patients from developing tumors in dysgenetic gonads.


Leiomyosarcoma (LMS) is a smooth muscle-derived malignant mesenchymal tumour. Primary LMS arising from the ovarian vein is uncommon. A 51-year-old female presented with left loin pain and was diagnosed with a LMS arising from the gonadal vein. The patient refused any treatment. Early detection and timely diagnosis of retroperitoneal masses will improve the prognosis and survival rate in these patients. CT imaging plays an important role in diagnosis.Retroperitoneal leiomyosarcoma of vascular origin is a rare entity. CT plays crucial role in diagnosing them by demonstrating the extent of the tumor along the gonadal vein. Early detection and timely diagnosis of retroperitoneal masses will improve the prognosis and survival rate in these patients. It is a malignant mesenchymal tumour that may have a vascular or non-vascular origin. Primary LMS of vascular origin is uncommon, representing less than 1 in 100 000 of all malignant tumours.2 They can also arise from the renal, mesenteric, hepatic, saphenous or gonadal veins.3 The ovarian veins are an uncommon site of LMS - there have been 15 cases described in the literature to date.4 Leiomyosarcoma from other origins have a relatively better prognosis than LMS of vascular origin.1Venous LMSs account for 5% – 7% of soft tissue sarcomas. About 50% of cases arise from the inferior vena cava (IVC) and at least 200 cases have been reported to date.This report describes a biopsy confirmed case of LMS arising from the left ovarian vein and discusses the imaging findings on ultrasonography and multidetector CT.A 51-year-old female presented with left sided loin pain for 6 months. There was no history of urinary complaints, haematuria, weight loss, loss of appetite or cough. Ultrasonography of the abdomen and pelvis demonstrated a well-defined solid mass in the left retroperitoneum with a lobulated outline, anterolateral to the adjoining left psoas muscle, causing compression of the left upper ureter with resultant moderate proximal hydronephrosis and hydroureter .CT of the abdomen and pelvis revealed multiple well-defined lesions in the right hepatic lobe, with enhancement in the arterial phase, appearing hypodense in the portal phase and becoming isodense on venous and delayed phases – suggestive of hypervascular metastases. The largest lesion measured 16 mm × 12 mm in segment VI .A large solid mass with a lobulated outline, measuring approximately 82 mm × 52 mm × 64 mm , was identified in the retroperitoneum along the anterior surface of the left psoas muscle from the L3 to the L5 levels, demonstrating heterogeneous post-contrast enhancement with central non-enhancing hypodense areas of necrosis. No calcification was observed. The fat plane between the mass and the left psoas muscle was obscured. The adjacent left ureter was markedly compressed and involved by the mass with resultant proximal obstructive uropathy .The left gonadal vein revealed a filling defect at the L3 level. The mass appeared elongated and oblong-shaped along the course of the left gonadal vein, which was indistinctly visible from the L3 to the L5 levels. Mass effect was noted on the adjacent descending colon and small bowel loops with maintained intervening fat planes. The left kidney showed marked hydronephrosis with thinning of the renal parenchyma and a dilated renal pelvis with an AP diameter of 3 cm. The left ureter was dilated in its upper portion and could be traced up to the inferior endplate of the L3 vertebral body, where it appeared compressed and involved by the retroperitoneal mass. There was no excretion of contrast by the left kidney on the delayed phase .Mild ascites and small bilateral pleural effusions were noted. The rest of the abdomen was unremarkable. A diagnosis of a neoplastic retroperitoneal mass within the left gonadal vein was considered.A needle aspirate sample taken from the retroperitoneal lesion revealed a tumour composed of interlacing bundles of spindle cells with mild atypia. Mitosis was observed at 3 to 4 per 10 high power field. A histological diagnosis of LMS was ascertained. The patient refused biopsy of the hepatic lesions.The patient was advised to have surgery with radiotherapy and chemotherapy as adjuvant therapy but refused any treatment and demised two months later.1 The ovarian vein is the eighth most usually afflicted vessel among vascular LMS. Until now, there are six known cases of LMS (40%) from the left ovarian vein and nine cases of known LMS (60%) from the right ovarian vein that have been published.4Leiomyosarcoma is the second most common retroperitoneal sarcoma in adults. Smooth muscles present in the walls of retroperitoneal veins or embryonic remnants are the sites of origin.1Retroperitoneal LMS has three major growth patterns: completely extravascular or extra luminal (62%), completely intravascular or intraluminal (5%) and a combination of extra luminal and intraluminal patterns (mixed – 33% of cases). Extra luminal LMS is usually detected late, while those with intraluminal and mixed patterns usually show early symptoms depending on the affected vein.5Retroperitoneal LMS is typically solid with cystic areas related to necrosis. The characteristic imaging features of LMS arising from the gonadal vein are the presence of a solid or necrotic extra- or intra-luminal retroperitoneal mass, not arising from a retroperitoneal organ and its continuity with the enhancing gonadal vein along its course. Rarely, there may be extensive vascular proliferation and dilatation within the mass. In such cases, the differential would include haemangioma, haemangiopericytoma and angiolipoma.6 A large lobulated, retroperitoneal mass with heterogeneous enhancement, extending in a longitudinal direction along the course of gonadal vein, which may have internal necrotic components, is suggestive of the diagnosis. CT depicts the exact origin of mass from the vessel and excludes masses arising from the other retroperitoneal structures. With multidetector CT, multi-planar reconstruction is extremely useful in demonstrating the relationship of the mass to the vessel, the tumour extent, the relationship with adjacent structures and the presence of necrotic/cystic components and hypertrophied vessels within the mass. Demonstration of the claw sign indicates a vascular origin of the mass.6 Imaging with Fluorodeoxyglucose positron emission tomography (FDG-PET) will show increased uptake within the mass. Haematological metastases occur more commonly than lymphatic metastases, and may occur in the liver, lung, peritoneum and brain.7Contrast enhanced CT is superior to ultrasound and is the diagnostic test of choice for gonadal vein LMS. It is extremely useful in the preoperative diagnosis, assessing the boundaries and extent of the LMS.3 Up to 60% of adjacent organs are microscopically invaded by the tumour at pathology.8En bloc resection with histopathological free margins is the surgical gold standard with good prognosis.9 Retroperitoneal sarcomas have a more than 50% recurrence rate and a 5-year-survival of 52% – 60%, despite complete resection.10 Consequently, adjuvant chemotherapy and radiotherapy is recommended.Histopathological examination shows bundles of spindle-shaped cells, perinuclear vacuoles, eosinophilic cytoplasm and mitotic figures. Immunohistochemistry is positive for smooth cell actin, vimentin, desmin and negative for S-100 protein or neuron specific enolase.3Diagnosis can be incidental in a third of cases and is often delayed, resulting in a worse prognosis. Cases seldom present with symptoms unless they have progressed to a large size as with other retroperitoneal tumours.None of the previously published ovarian vein LMS cases reported hepatic metastases. Although the hepatic lesion in the current case was not biopsied, metastases were highly probable and portended a worse prognosis for the patient.Leiomyosarcoma arising from the gonadal vein is a rare retroperitoneal tumour and diagnosis is often delayed because of non-specific symptoms. It should be suspected when tumour is seen along the course of the gonadal vein and extends in a longitudinal manner. Both ultrasound and CT are useful in demonstrating the relationship of the mass with the gonadal vein along with its extent. Multidetector CT is useful in preoperative evaluation of the mass with respect to location, extent, growth patterns and the relationship of the tumour and vessel.


Methotrexate (MTX) is increasingly used in the treatment of rheumatoid arthritis. Many recent reports have identified MTX-related lymphoproliferative disorder (MTX-LPD) as lymphoma that develops during MTX therapy. However, spinal lesions, which are extremely rare, can be misdiagnosed as spinal metastases or pyogenic spondylitis. Here, we describe a 69-year-old man with rheumatoid arthritis who had MTX-LPD of the thoracic spine. He complained of back pain and weakness in the bilateral iliopsoas muscle. A radiographical assessment by his previous physician revealed the cause to be a spinal tumor. They performed posterior spinal decompression and fixation, and a pathological examination revealed only inflammatory changes, necrosis, and increased collagen fiber growth, with no evidence of malignancy. Nevertheless, magnetic resonance imaging two weeks after the surgery showed an increase in the size of the spinal tumor. When the lesion paralyzed the patient soon afterward, the physician considered that a total en bloc spondylectomy was necessary and referred the patient to our hospital. MTX-LPD was suspected because of a history of MTX administration, and a biopsy, posterior spinal decompression, and fixation were performed again. Following the histopathological diagnosis of the tumor as MTX-LPD, MTX administration was terminated. Three months following surgery, the tumors' removal was confirmed. Because MTX-LPD can be treated with MTX withdrawal, correct diagnoses should be made, and unnecessary treatments avoided. Rheumatoid arthritis (RA) is treated with the immunosuppressive drug methotrexate (MTX), an antimetabolite. However, MTX therapy is widely known to cause serious adverse effects, including liver disorders, interstitial pneumonia, and myelosuppression, among others.The first instance of MTX-related lymphoproliferative disorder (MTX-LPD) was described by Ellman et al. in 1991 as lymphoma developing in RA patients receiving MTX [Spinal lesions associated with MTX-LPD, which are extremely rare, can be misdiagnosed as spinal metastases or pyogenic spondylitis. Here, we report a case of MTX-LPD in the thoracic spine of a patient with RA who was being treated with MTX.A 69-year-old rheumatoid arthritis (RA) patient reported bilateral iliopsoas muscle weakening  grade 3) and back pain. He had been on MTX (10 mg/week) for approximately 10 years (approximate cumulative dose of MTX: 2000 mg).His prior medical professional discovered a spinal tumor after a radiographic examination Figures -1B. A coOn admission to the previous hospital, the patient's bilateral iliopsoas weakness progressively worsened, making it impossible for him to walk. He underwent posterior spinal decompression with a laminectomy and posterolateral fixation of the Th5-9 vertebrae as a result, along with a biopsy Figure .However, the biopsy only detected inflammatory changes, necrosis, and increased collagen fiber growth, with an absence of malignancy. Nevertheless, magnetic resonance imaging (MRI) two weeks after the surgery showed an increase in the size of the spinal tumor. His physician judged that total en bloc spondylectomy (TES) was necessary, and the patient was referred to our hospital for further treatment.On admission to our hospital, initial testing showed bilaterally enhanced patellar and Achilles reflexes, bilaterally weak iliopsoas muscles, an MMT score of 3, and bilaterally impaired sensory function in the posterior lower legs.Laboratory tests showed normal lactate dehydrogenase levels (134 IU/L), elevated C-reactive protein level (9.4 mg/ml), a slight elevation in the soluble interleukin-2 receptor value (1370 U/ml), and an increased Epstein-Barr virus (EBV) immunoglobulin G antibody titer. The range of tumor markers was normal.A soft-tissue mass that spread to the epidural space, mediastinal region, and paravertebral lesion in the T7 vertebral body was discovered by CT and MRI scans Figures -2C.A case of MTX-LPD was suspected based on physical examination, blood tests, and MRI findings; however, other differential diagnoses suggested spinal metastases as well as myeloma and inflammatory changes. We, therefore, planned a re-biopsy, which, due to a walking disability, was performed along with another posterior spinal decompression and posterolateral fixation of the Th5-9 vertebrae. A dark brown malignant lesion was found on the dorsal side of the dura mater at the Th7 vertebral level, according to the intraoperative results. We removed as many epidural lesions as we could without harming the dura since they were securely adherent to the dura, and we were unable to remove all of them. Pathological specimens were also collected. An intraoperative rapid pathological examination suggested the presence of lymphoma.Final pathological findings revealed the formation of an extensive necrotic layer, the margins of which contained areas of aggregates of lymphocytes, eosinophils, and macrophages, among which were large atypical cells. The nuclei of the large atypical cells were enlarged Figure . The EpsConsidering these pathological findings, the history of MTX treatment and EBV positivity, the patient was diagnosed with MTX-LPD. His MTX therapy was discontinued based on a working diagnosis of MTX-LPD. After the discontinuation of MTX, we observed an improvement in his symptoms and shrinkage of the tumor, therefore leading to a definitive diagnosis of MTX-LPD. The patient's postoperative bladder rectal dysfunction and bilateral iliopsoas muscle weakness both showed recovery, and he was able to walk again. Soluble interleukin-2 receptor levels decreased to 565 U/ml one month after MTX discontinuation. An anti-EBV capsid antigen immunoglobulin G (IgG) level that was 5.7 times higher than normal (less than 0.5) during a postoperative test indicated a history of infection. The symptoms of RA did not worsen. A contrast-enhanced CT scan performed two weeks following MTX discontinuation showed that a residual tumor on the lateral side of the vertebral body had begun to shrink. The results of the MRI showed a decompressed spinal cord and a partially resected epidural tumor mass. Within three months of the procedure, it was determined that both tumors had vanished Figures -4B. By tPatients with suspected spinal metastases should have a thorough diagnostic work-up, including a history assessment, physical examination, and imaging studies. Although advances in imaging technology have improved the detection of cancerous lesions, tissue samples from spinal masses are often still required for definitive diagnoses. For cases of spinal tumors with advancing symptoms, a proper diagnosis is essential for determining the best course of treatment since chemo- or radio-sensitive tumors can be treated without spinal surgery, which has a complication risk of 21-26% . Up to 6The initial case of MTX-LPD very recently came to light and was based on the genesis of a malignant lymphoma during MTX treatment, which, along with the associated clinical symptoms, spontaneously remits when MTX administration is stopped. Although the exact mechanism of MTX-caused pathogenesis is unknown, the number of reports is steadily growing. This disorder has been reported more frequently in Japan than in other nations, but it is unclear if this is due to a local perception or racial differences .MTX-LPD is a general phrase that refers to all LPDs that arise in patients receiving MTX therapy. It could encompass both typical LPD and LPD associated with RA, both of which are difficult to distinguish. The most prevalent extra-lymphatic lesions associated with MTX-LPD are ones in the gastrointestinal system, skin, liver, and lungs . The musThe clinical features of MTX-LPD include a history of MTX treatment for at least 30 months, a history of EBV infection, and the potential for remission following the cessation of MTX . The preThe most common treatment option is the discontinuation of MTX. Although no strict guidelines for the treatment of MTX-LPD have been established, the withdrawal of MTX under observation has usually been considered to be beneficial. According to previous studies, over half of the MTX-LPD cases respond to MTX withdrawal alone -8. In otHere, we report a rare case of an MTX-LPD originating in the thoracic spine. The patient, who had been receiving treatment for RA for 10 years, was initially misdiagnosed with a spinal tumor. A correct diagnosis, obtained through careful evaluation of his medical history and biopsy findings, allowed for prompt treatment in the form of simple discontinuation of MTX. Although spontaneous regression was achieved by MTX discontinuation alone, the patient will require continuous and rigorous follow-up in six-month intervals. MTX-LPD should be considered one of the differential diagnoses of spinal tumors in patients receiving MTX therapy and thus be screened properly to assure diagnosis in relevant cases.


Lingual leiomyomatous hamartomas are rare lesions of the tongue with largely unknown mechanisms of formation. These lesions are often asymptomatic, though they may present with symptoms, particularly relating to swallow function. Workup should include imaging of the head and neck, and diagnosis should be made histologically. Treatment is surgical excision. This case is a report of a 4-week-old female who presented for evaluation of an asymptomatic 1 × 1 cm dorsal midline tongue mass discovered at birth. The patient was monitored until the age of 9 months, at which time the mass was surgically excised. The patient had an uncomplicated postoperative course. Pathological analysis yielded a diagnosis of leiomyomatous hamartoma. Lingual leiomyomatous hamartomas are rare, often asymptomatic lesions that are defined by the predominance of smooth muscle on histological examination . In the An otherwise healthy 4-week-old female born at 34 weeks without complications presented to our otolaryngology clinic with an asymptomatic, stable tongue mass originally discovered at birth. On exam, a firm, nonfriable, 1 × 1 cm lesion was appreciated at the level of the dorsal midtongue, anterior to the foramen cecum. No further abnormalities were noted. It was recommended that the lesion be excised between the ages of 6–12 months. After multiple surveillance visits, the decision was made to surgically excise the lesion when the patient was 9 months old. Prior to the operation, an ultrasound of the neck was obtained to confirm the presence of a thyroid gland, given the known tongue lesion. The thyroid was present; however, the ultrasound demonstrated a 3.7 × 2.0 × 3.1 mm nodule in the right lobe, which was interpreted as likely intrathyroidal ectopic thymic tissue . A folloA 3.0 silk suture was placed down the midline of the tongue for retraction, and the lesion was completely excised with 1 mm margins using a guarded needle tip Bovie. The mucosa was then reapproximated with a 4.0 vicryl suture. The mass was sent for pathological analysis as a fresh specimen. Blood loss was minimal and the patient had no postoperative complications.Gross examination of the specimen demonstrated a tan-white, semi-firm, glistening nodule, measuring 0.9 × 0.7 × 0.5 cm. Histological analysis revealed a raised, broad-based polypoid lesion covered with stratified keratinizing epithelium with a central core of smooth muscle . Smooth Hamartomas are heterogeneous lesions made of disorganized native tissue that may occur in a variety of locations throughout the body, and these lesions are defined by their predominant tissue type . LingualMany patients with lingual hamartomas will present asymptomatically. In symptomatic children, feeding difficulties seem to predominate, including recurrent emesis, swallowing dysfunction, and failure to thrive and less commonly, signs of airway obstruction  , 26. CliThere does not appear to be a standardized approach to the workup of these lesions. A review of the literature indicates that providers have utilized both CT and MRI for further evaluation; however, the diagnosis is ultimately made histologically –27. MicrAs with any midline tongue lesion, it is important to evaluate for the presence of a lingual and native thyroid gland, as premature excision of the lingual mass could induce a hypothyroid state if there is inadequate native thyroidal tissue . The preHamartomatous lesions, defined by their predominant tissue type, may be present throughout the body and rarely occur in the tongue and tongue base. Our case is one of only 30 total cases reported in the literature since 1945 of lingual leiomyomatous hamartomas. When presented with a midline tongue lesion, hamartomas should be included in the differential with lingual thyroid, various cystic lesions, polyps, macroglossia, and neoplasia. Workup of these lesions should include imaging, preferably with higher resolution  and histological examination. A diagnosis of lingual leiomyomatous hamartoma is made histologically. Treatment is excision with wide margins and is curative.


The patient denied melena or hematemesis, and she had no significant medical history. Colonoscopy revealed a large polyp of over 5 cm located 40 cm from the anal margin. She underwent endoscopic resection without complications. The histological examination confirmed the lipomatous nature.Lipomas of the colon are benign tumors of the digestive tract. They are usually asymptomatic, and often discovered incidentally during a colonoscopy. However, lipomas larger than 2 cm may present with abdominal pain, bowel changes, and rectal bleeding. They may mimic cancer, depending on multiple factors including tumor size, location, and complications, which often makes preoperative diagnosis difficult. In this report, we discuss the case of a 34-year-old woman who presented with paroxysmal abdominal pain in the left iliac fossa withmoderate hematochezia that had beennecessary.It can often be difficult to choose between endoscopic and surgical treatment. The choice of treatment depends on the size and location of the tumor and complications. Endoscopic resection may obviate the need for surgery and can potentially reduce surgical morbidity. We aimed to report and discuss the management of this patient who underwent endoscopic resection for a large mass with a definitive pathology of colonic lipoma.An accurate preoperative diagnosis of lipomas is  Lipomas of the colon are benign tumors of the digestive tract. Although most of them are asymptomatic, colon lipomas can present with symptoms such as pain, diarrhea, obstruction, and bleeding. Although it is a benign, nonepithelial tumor, the complication of bowel obstruction can be life-threatening . ColonicEndoscopic resection of large colorectal polyps has become the treatment of choice. However, surgery may still be performed frequently for large colorectal polyps that can be resected endoscopically. We report a case of large colonic lipoma with the endoscopic appearance of neoplastic polyp on colonoscopy that was removed with endoscopic resection. Through our observations and a review of the literature, we highlight the benefits of endoscopic resection for large polyps to avoid the cost and complications of surgical resections.A 34-year-old female patient with no specific medical or surgical history presented with paroxysmal abdominal pain with moderate hematochezia six months ago. The pain commonly radiated to the left iliac fossa. The patient reported no melena, hematemesis, or other extra-intestinal symptoms. She did not have anorexia, weight loss, or asthenia. The physical examination at admission found tachycardia with a heart rate of 80 beats per minute, a normal blood pressure, oxygen saturation of 94%, and discolored conjunctiva. An abdominal examination revealed no abdominal mass, and the digital rectal examination was normal.The results of the laboratory investigation were normal. Colonoscopy revealed a large mass (>5 cm in diameter) located 40 cm from the anal margin. It was round, polylobed, and mobile. Its base of implantation was difficult to visualize. The overlying mucosa was not ulcerated. The lesion was found to be a mass of hard consistency, which may lead to an impression of malignancy. It did not have the “classic” endoscopic features of colonic lipomas, such as the “tent sign” Figure .The patient was informed about the increased risk of perforation and bleeding during endoscopic resection. The polyp was resected endoscopically by hot-loop diathermy after the injection of serum and adrenaline Figure . The patThe polyp was then retrieved. The tumor was of hard consistency with submucosal location and did not show mucosal ulceration Figure . The hisThe evolution was marked by the disappearance of digestive symptomatology.Lipomas of the gastrointestinal tract are rare entities and were first recognized by Bauer in 1757. They are more common in women than in men . The oveThe symptomatology is non-specific, essentially consisting of abdominal pain, constipation, and/or rectal discharge . This syColonoscopy is commonly used to diagnose lipomatous lesions. It is manifested by a swelling of the mucosa overlying the lipoma (tent sign), or by a soft mass under the biopsy forceps (pillow sign) . Lipoma Large colonic lipomas continue to present challenges in the preoperative differential diagnosis between malignant and benign colonic neoplasms. This is one of the biggest clinical problems associated with large colonic lipomas. They can become symptomatic and may mimic clinical and endoscopic features of malignant colon tumors. This may cause symptoms similar to malignant colon tumors, such as constipation, diarrhea, abdominal pain, or rectal bleeding . Benign It is important to properly diagnose these lesions before choosing the treatment method. In cases where the diagnosis is uncertain or difficult, and a colonoscopic biopsy is noncontributory, further evaluation can be done using CT or endorectal ultrasonography (ERUS).In the literature, the decision to resect lipomas and whether to choose the endoscopic or surgical technique remains a subject of controversy . With adDifferent views regarding the endoscopic removal of large lipomas have been reported. Surgical treatment has been another option employed for large colonic lipomas due to the fear of complications (such as bleeding or perforation after endoscopic snare resection) . RecentlThe positive diagnosis of colonic lipoma is often made after a pathological study of the resected mass. Histologically, colonic lipomas are usually located in the submucosa. They may show prominent fibrosis or vasculature .Colonic lipomas are benign and usually diagnosed incidentally during colonoscopy. The diagnosis of a typical colonic lipoma is not very difficult. However, in cases of large lipomas, it would be important to distinguish between the lipoma and the malignant tumor. Proper radiological and colonoscopic evaluation is essential to avoid unnecessary wide surgical resection. Based on our findings in this report, we believe that large colonic lipomas can be safely removed by endoscopic resection, even though this can be technically challenging due to their vascular nature, large pedicle, and size. It is imperative to establish a proper preoperative diagnosis in order to choose the appropriate procedure.


Continuous urinary leakage, along with normal deliberate voiding, must suggest diagnosis of ectopic ureter, specifically in girls. Combination of a duplicated collecting system with distal, infra-sphincteric, vaginal insertion of ureter is an uncommon congenital anomaly and rare cause of urinary incontinence. We present a case report of a 7-year-old girl who presented to the urology department with urinary incontinence despite successful toilet training and history of recurrent urinary tract infections. Right duplex collecting system was seen on ultrasound. Magnetic resonance urography revealed a near complete right duplex collecting system with ectopic insertion of ureter into vagina, and aplastic uterus with bilateral normal ovaries suggestive of Mayer-Rokitansky-Kuster-Hauser syndrome. Surgical treatment consisted of "common sheath" reimplantation of ectopic ureters into bladder, with complete resolution of symptoms. This case suggests to us that congenital abnormalities of the genitourinary tract should be considered in case of urinary incontinence and recurrent urinary tract infections. There was no history of urge or stress incontinence. Despite having incontinence, she had normal bladder habits. On examination, the patient's vitals were stable, general condition was fair and without pallor, icterus, cyanosis, dehydration or edema. Systemic examination findings were satisfactory. Also, there was normal external genitalia with no vaginal pooling or any visible ectopic ureteral orifice with intermittent incontinence on increased abdominal pressure.Her parents gave a past history of recurrent febrile urinary tract infections since her infancy. She was under prophylactic antibiotics for urinary tract infection and was prescribed anticholinergics suspecting overactive bladder but the symptoms didn't subside. Here at our hospital, we first advised abdominal ultrasound which revealed the right duplex collecting system. CT urogram was planned which revealed a partial duplex system of the right kidney with ectopic insertion of ureter in the cervix .To confirm origin, course and insertion of ureters, magnetic resonance urography was done which suggested near complete right duplex collecting system with ectopic insertion of the ureters into lower vaginal canal and aplastic uterus with bilateral normal ovaries suggestive of Mayer-Rokitansky-Kuster-Hauser syndrome .th postoperative week.The child was admitted in a surgical ward and planned for common sheath right ureteral reimplantation in the bladder. Under general anesthesia, Rutherford Morison incision was given, abdomen opened in layers, with intraoperative findings of double ureter  and open7 A duplex collecting system with ectopic ureter opening in the vagina is an extremely rare congenital genitourinary tract abnormality and this is the first such case reported from the country.Duplication of the ureters is a relatively common congenital anomaly but an ectopic ureter, however, is a rare ureteral entity with an estimated incidence of 0.05-0.025%.8 In our case as well, double ureters originating from a near complete right duplex system inserted into the lower vaginal canal. In their case "en bloc" ureteral reimplantation using the open "Cohen ureteroneocystostomy" was performed. However in our case "common sheath" reimplantation of the ectopic ureters into the bladder using the open "Lich Gregoir ureteroneocystostomy" was performed.In a case report by Duici C, et al. duplex left kidney with double ureters, both inserting together into the vagina was reported.2The sites of insertion of ectopic ureters are the bladder neck/urethra (35%), vestibule (30%), vagina (25%) or uterus (5%) in females, and the bladder neck and prostatic urethra (48%), ejaculatory ducts (8%), and vas deferens (3%) in males. Urinary incontinence is the main symptom of an ectopic ureter, especially in females, while in both sexes, an ectopic ureter may present as a prenatal diagnosis because of a urinary tract infection (UTI), or congenital obstructive uropathy which can lead to chronic kidney failure.9Occasionally, although the ureter opens into infra-sphincteric region, incontinence does not manifest itself if it drains an excessively atrophic renal segment or in the presence of compression of lower third of the ureteral segment between muscles of the external sphincter till advanced age. However, they become symptomatic at a later stage in conditions like childbirth which weakens the external sphincter.10 Usually males do not present with urinary incontinence because of the ureter's insertion above the external urethral sphincter. Similar to our patient, most girls present with urinary dribbling, as the insertion of the ectopic ureter is distal to the urethral sphincter. Mostly the affected girls accompany normal voiding patterns with small volume or spotting incontinence.The patient's presenting symptoms depend on the insertion site of the ectopic ureter, and this differs between girls and boys.5Imaging studies are mandatory to confirm the diagnosis. Renal ultrasound represents the initial diagnostic investigation but because of its limitation, it is not helpful. So, contrast-enhanced computed tomography (CT) or magnetic resonance urography should be the method of choice for depicting or ruling out an ectopic ureter.8The best treatment in children and symptomatic patients is surgery, and it tries to resolve the incontinence, prevent further complications, preserve renal function and eliminate recurrent UTIs. The surgical management of ectopic ureter depends on surgeon experience and preference, laparoscopic experience, pediatric material investments.8 Thus, proper medical history and complete clinical evaluation is mandatory.Normally, the duplex system is associated with Weigert Meyer Principle, in which the upper moiety ureter inserts inferomedially and is ectopic while the lower moiety ureter is inserted superolaterally in orthotopic location. In our case, there is near complete duplication of ureters and the common ureter is inserted into the vagina, which does not follow the usual Weigert Meyer Law of Duplex Systems. Our case is not the first case report that does not follow the Weigert-Meyer law. Rarely reported in literature, "ectopic pathway" of Stephens postulates that an ectopic ureter may drain not only distal to the normal ureteric orifice (Weigert - Meyer law) but may also drain medially and superiorly to it (violating Weigert-Meyer law).


Uterine leiomyomas, also known as uterine fibroids, are smooth muscle tumors in the uterus, mostly benign in nature. They occur in the reproductive age group i.e. between 15 and 49 years. Asymptomatic in nature; rarely, they may be associated with symptoms like abnormal uterine bleeding, pelvic pain, and compression symptoms or secondary changes. Patients of the reproductive age group may be associated with infertility and recurrent pregnancy loss. Fibroids run in families and are associated with both estrogen and progesterone levels. Myomas produce symptoms depending on their site, size, position, number, or any secondary changes. The submucosal type of fibroid is associated with symptoms more commonly. Based on presenting symptoms, uterine leiomyoma can be managed medically or surgically. Here we present a case of a 32-year-old multigravida who had a spontaneous vaginal expulsion of a pedunculated intramural fibroid. Very rarely as in this case, complete expulsion of leiomyoma is seen. When it occurs in the reproductive age group, it may mimic many clinical conditions like incomplete or inevitable abortion. Such a case may also be associated with excess hemorrhage and can cause significant morbidity to the patient; hence it is essential to make an early diagnosis and necessary timely intervention. Myoma is the most common uterine solid smooth muscle pelvic tumor with a multifactoral etiology . DespiteA 32-year-old woman with two live issues presented to casualty with complaints of excessive bleeding per vaginum associated with the passage of clots and abdominal pain which was severe in intensity, intermittent, and colicky in nature over a period of 12 hours. She also had a history of dysuria and foul smelly, itchy vaginal discharge. This patient had a 15-day history of continuous bleeding with three to four pads soaked/day along with the passage of clots and dysmenorrhoea. The patient had a history of menorrhagia in her previous cycles. She has operated on for tubal ligation seven years ago. On general physical examination, she was fairly built, fairly nourished, and appeared pale. Her temperature was 97°F, her pulse was 90 beats per minute, regular, normovolemic, and her blood pressure was 100/60 mm Hg. Cardiovascular and respiratory examinations were found to be within normal limits.Upon examination of the abdomen, the uterus was palpable and firm. Speculum examination revealed a mass approximately 4 x 4 cm in the vagina, red in color with irregular borders and a smooth surface covered with clots and blood mixed with foul-smelling discharge. On vaginal examination a pedunculated mass was felt coming out of the internal os. Cervix was 3 cm dilated due to a thick peduncle. On sound test, the peduncle had origin in the uterine cavity and not cervical. Diagnosis of a pedunculated intramyometrial fibroid polyp with secondary infection was made clinically.The patient was admitted and all routine investigations were sent. She received ultrasonography, showing a bulky uterus 13.6 x 7 x 5.2 cm in size with evidence of a well-defined circumscribed heterogeneously hypoechoic lesion of size 33 x 22 mm in the fundal region , and emergency hysterectomy were explained. A blood transfusion was started. While examining the operating table (OT) table, the fibroid was found expelled out of the vaginal cavity; hanging onto the pedicle Figure . DiagnosThe patient was kept for observation in the surgical intensive care unit (ICU) and one more unit of blood transfusion was given. The uterine pack was removed 24 hours postoperatively. The postoperative period showed no complications, the bleeding had stopped, and her postoperative vitals were within normal limits. The patient was shifted to the ward and was counseled about secondary hemorrhage due to bleeding from the pedicle and the need for UAE or possible hysterectomy only as a necessary emergency intervention. Follow up ultrasound was done with no sign of any uterine mass. The patient was followed up for seven days with an uneventful recovery. She was discharged on iron and vitamin supplements. She was later called on an outdoor basis with no complaints.Uterine myomas in females are the most common smooth muscle benign solid tumors ,4. The iSpontaneous expulsion of uterine fibroid is a rare gynecologic event, especially in young females. This study is similar to the study done by Rios . The cauIn cases where expulsion has been complete, a thorough examination of the fibroid and the pedicle, if any, should be made. A bleeding pedicle may warrant a pedunculectomy, as in this case. In cases where expulsion is incomplete, muscle constrictors may be used. Coverage of higher antibiotics and postoperative care may suffice in such cases. Post evacuation, monitoring of patients in an ICU facility should be considered. Monitoring of body temperature, vitals, bleeding PV, inflammatory indicators, and Hb levels should be monitored for early diagnosis and prevention of further complications. Requirement for further interventions like UAE or hysterectomy, if need be, can be considered. In cases of partial or incomplete elimination, surgeries like vaginal myomectomy can be considered as it has a good success rate.The presence of uterine fibroid among reproductive-age females is very common. Asymptomatic fibroids do not require any intervention. The management in cases of symptomatic fibroids is individualized based on age, fertility, size, and site of myoma and its presenting symptom. Very rarely, as discussed in this case, a pedunculated fibroid may undergo spontaneous expulsion. The expulsion process is usually non-characteristic, however, symptoms can mimic an abortion. Usually, abdominal pain and bleeding PV are most commonly present as in the case here. A prolapsed pedunculated fibroid usually warrants a surgical intervention - either a vaginal or abdominal myomectomy. However, in cases where the self-expulsion of fibroid occurs, the process can be long as the tissue pieces might be excreted in small fragments due to necrosis and decomposition. Such spontaneous expulsion may result in potential morbidity as it can cause diagnostic delay and further delay in management. Furthermore, the necrotic fragments can get infected resulting in pus formation. Sometimes, to aid expulsion surgical evacuation of necrotic fragments may be required. As in this case, a prolapsed pedunculated fibroid was diagnosed intra-operatively and a pediculectomy was warranted.Thus, a case of complete expulsion of fibroid may sometimes cause significant morbidity and may prolong hospital stay. Clinical suspicion, elimination of pregnancy, and ultrasonography can warrant diagnosis in such cases. A complete and spontaneous expulsion, being an unusual situation, especially in a young female can lead to a delayed diagnosis and can cause significant risk to the patient. Hence, a practitioner should always consider the possibility of myoma degeneration and spontaneous removal in a non-pregnant patient presenting with pain and bleeding PV.


A middle-aged female patient who presented with back pain was found incidentally to have a renal mass by magnetic resonance imaging (MRI). Further imaging, including computerized tomography (CT) with contrast, suggested a high likelihood of malignancy. Following surgical resection, the tumor was found to be a rare benign lesion on subsequent pathological examination. The patient had conservative treatment for her presenting spine issues and is doing very well. Prompt work-up and treatment of incidental findings by the team of primary care, physical medicine and rehabilitation physicians, radiologists, pathologists, and surgeons helped to ensure a good outcome. Residents had a learning opportunity about the disease and on timely management of incidental findings. Physicians often encounter unanticipated findings unrelated to the original diagnostic inquiries . Increased use of advanced diagnostic modalities has increased the incidental diagnosis of asymptomatic entities.The metanephric adenoma is a rare, benign, embryonal-epithelial neoplasm of the kidney. It is usually discovered incidentally with no presenting symptoms. Presenting symptoms such as hematuria, pyrexia, flank pain, abdominal mass, or weight loss indicate advanced disease. A metanephric adenoma is more common in females. Most of the tumors present as unilateral and unifocal, circumscribed but not encapsulated lesions .A renal tumor with radiological features of malignancy was found on imaging for a patient with chronic back pain. After tumor removal, histological examination confirmed that it was a rare benign tumor. Proper management of these findings often requires teamwork and is key to ensuring good outcomes for patients and limiting malpractice liabilities for physicians.A 55-year-old woman with a past medical history of type II diabetes, obesity, tobacco use disorder, bilateral knee pain, and low back pain presented to the acupuncture clinic for pain management. She described a history of constant, aching pain in the low back with radiation into the left buttock and posterior thigh for 10 years, associated with numbness of both thighs. The pain was aggravated by flexion of the lumbar spine and alleviated by extension. Prior imaging indicated three herniated intervertebral discs and facet arthropathy throughout the lumbar spine. Interventions included physical therapy, lumbar selective nerve root blocks, and facet joint injections. Medications included gabapentin, cyclobenzaprine, nabumetone, and methylprednisolone. She was referred to a board-certified physiatrist who performs acupuncture.Physical examination showed the strength of bilateral legs 5/5. The patellar tendon and heel tendon reflexes were 1+ and 1, respectively, with intact sensation to light touch. Straight leg raising test caused radiating pain to the buttock and posterior thigh bilaterally. Given her persistent back pain with radicular symptoms, repeat X-ray and MRI of the lumbar spine were ordered. X-ray showed grade I spondylolisthesis at lumbar (L) 4/5 with evidence for instability with flexion. MRI showed severe bilateral facet joint degeneration at L4/5 and L5/S1 and an L5/S1 herniated disc with superimposed right lateral disc extrusion. MRI of the lumbar spine also showed an incidental finding - a lesion approximately 3 cm in diameter in the lower pole of the left kidney Figure , consistThe patient was referred to surgery and underwent a robotic-assisted minimally invasive left partial nephrectomy. After surgery, the patient continued to take medication for her low back pain. Her spondylolisthesis, not her renal tumor, was considered the generator of her pain. The patient had physical therapy, and mild to moderate aerobic exercises were encouraged.Post-resection gross examination of the specimen revealed a tan-grey, soft to firm homogeneous, relatively well-circumscribed mass in the lower pole of the left kidney measuring 3.8x3.2x2.6 cm. The tissue was embedded in paraffin and prepared for histological examination. Hematoxylin and eosin (H&E) staining showed a cellular blue tumor in closely packed tubular structures with cytologically benign-looking tumor cells Figure . ImmunohMetanephric adenoma, which derives from the embryonic tissue of the nephritic medulla, is a very rare benign tumor accounting for about 0.2% of adult renal epithelial neoplasms and can mimic malignancy clinically and radiologically. The differential diagnosis in this age group includes a solid variant of papillary renal cell carcinoma, metastatic thyroid papillary carcinoma, and metanephric adenoma, and a number of other types -7. DistiMost grade I spondylolisthesis can be treated conservatively, without surgery ,10. ThisA patient who presented with back pain was found incidentally to have a renal mass by imaging, which suggested a high likelihood of malignancy. Following surgical resection, the tumor was found to be a rare benign lesion. The patient had conservative treatment for her presenting spine issues and is doing very well. Prompt work-up and treatment of incidental findings by the team of physicians contributed to a good outcome.


Intestinal epithelioid angiosarcoma is an uncommon type of vascular tumor with unusually varied clinical presentations, including non-explained severe gastrointestinal bleeding, anemia, and abdominal pain. A 77-year-old man presented with recurrent severe anemia caused by gastrointestinal bleeding. The diagnosis was jejunal angiosarcoma. The patient had three intestinal resections assisted by explorative intraoperative enteroscopy, which detected multifocal intestinal lesions. Intraoperative enteroscopy is a helpful diagnostic and prognostic approach that detects small intestinal tumors. Intraoperative enteroscopy could improve the outcome of intestinal angiosarcomas. Angiosarcomas are a group of proliferative and aggressive vascular tumors. They can affect any organ but commonly occur in the skin and subcutaneous tissues .Intestinal epithelioid angiosarcoma is an extremely uncommon type of vascular tumor with an unusual, varied clinical presentation, including non-explained severe gastrointestinal bleeding, anemia, and abdominal pain . It is aWe reported a case of a 77-year-old male who presented with several episodes of severe iron deficiency anemia requiring multiple blood transfusions due to two occasions of recurrent intestinal angiosarcoma after two intestinal surgical resections. We now performed IOE-guided objective intestinal resection. The patient underwent complete recovery.The patient was a 77-year-old gentleman with a significant cardiac past medical history, including myocardial infarction, atrial fibrillation, and left-side heart failure. He had been hospitalized several times with recurrent acute symptomatic (dyspnea with exertion) microcytic iron deficiency anemia and required several blood transfusions. He denied any history of abdominal pain or gastrointestinal bleeding. He also denied previous radiotherapy, industrial chemicals, smoking, or alcohol exposure. He was allergic to penicillin. Clinical examination including digital rectal exam was unremarkable. Laboratory examination showed microcytic anemia with hemoglobin at 66 g/L and MCV at 66 FL. CT chest, abdomen, and pelvis revealed no abnormalities.Esophagogastroduodenoscopy and colonoscopy did not explain the cause of this presentation. A complementary study with video capsule endoscopy showed the presence of an atypical, suspected nonbleeding ulcerated lesion of the proximal jejunum and other vascular jejunal lesions Figures , 2. EnteTwo months later, the patient presented with shortness of breath, melena, and anemia. We performed an urgent video capsule endoscopy that discovered multiple suspected jejunal ulcers actively bleeding Figures , 6.Emergent surgical laparotomy assisted by gastroenterologist, who performed IOE, revealed two bleeding ulcers 10-15 cm downstream from the site of anastomosis). We resected 20 cm of the small intestine with later-lateral anastomosis and jejunostomy of discharge. Histological and immunohistochemistry examinations revealed epithelioid angiosarcoma of the submucosa of the proximal jejunum, the presence of CD 31 expression, and the absence of CK AE1/3 expression.After one month, the patient was re-presented with the same symptoms. We performed an urgent laparotomy with intraoperative upstream and downstream enteroscopy from the point of jejunostomy. The upstream enteroscopy detected four scattered ulcers in the proximal jejunum that were biopsied and identified by four metallic clips and indigo carmine injections. Downstream, an enteroscopy was carried into the right colon; no lesions were found. A 30-cm section of the small intestine was resected with extensive lymph-node dissection. Histopathological examination confirmed epithelioid angiosarcoma without lymph node metastases (0/9). The immunohistochemical test was positive for CD 31 and ERG.Follow-up with laboratory examination one month after the last surgery showed stable hemoglobin. The positron emission tomography scan (upon the tumor board's recommendation) did not show any metabolic activity of the small intestine, and there were no metastatic lesions.Sarcomas are a group of soft-tissue tumors that vary in prognosis according to subtypes. The most common types are gastrointestinal stromal tumors (GISTs), liposarcoma, leiomyosarcoma, and pleomorphic sarcoma . AngiosaIntestinal epithelioid angiosarcoma is a rare, aggressive, and locally invasive vascular tumor. It mainly affects the proximal jejunum and the ileum. The most common clinical presentation is abdominal pain, obscure or occult gastrointestinal bleeding, anemia, and other nonspecific manifestations such as nausea, vomiting, and weight loss . Acute pMany factors make the diagnosis of intestinal epithelioid angiosarcoma challenging; the similarities of clinical presentations, histopathological similarities with other tumors, and immunohistochemical overlapping with other vascular tumors. However, accurate diagnosis requires histopathological and immunohistochemical examination of the tumor cells. The immunohistochemistry test is positive for CD31, CD34, vimentin, and factor VIII. Molecular studies help detect mutations in the vascular endothelial growth factor receptor-2  .Endoscopic interventions have significant diagnostic and prognostic roles in intestinal epithelioid angiosarcomas. Wireless video capsule endoscopy detects and localizes the lesions and gastrointestinal bleeding . The entIntraoperative enteroscopy IOE is a safe and promising intervention that allows endoscopists to explore the small intestine using the endoscope during surgery. This integrated procedure needs a surgeon and a gastroenterologist . TherapeThe treatment modalities include Intestinal resection with or without chemotherapy, depending on the cancer stage. However, the risk of cancer recurrence is very high . The risThe IOE could help detect subtle lesions that decrease the risk of recurrence and improve the outcome. In our case, the patient had two occasions of cancer recurrence caused by multifocal intestinal lesions that were not visualized by conventional endoscopy. IOE helped detect subtle lesions and was used for objective intestinal resection, and a normal PET scan proved one-year cancer-free.Improving survival in such aggressive tumors supports that IOE is a practical approach that could be implicated in various other SB pathologies that require surgical intervention. In a retrospective study, IOE allows recurrence-free management of persistent OGIB in 76% of cases . The advAlthough there are no recommendations for using IOE in patients with SB lesions, our findings suggest utilizing IOE in selected cases, including patients who failed conventional therapy or who are undergoing SB surgery; Bonnet S et al. described similar implications: when a preoperative work-up has diagnosed SB lesions that cannot be definitively managed by conventional treatment or whenever surgery is indicated. Given that it is a high-grade and proliferative tumor, we suggest a very close follow-up every two to three months  .We concluded that using IOE during surgery is a valuable approach for reducing the recurrence rate of intestinal angiosarcoma and improving survival. This finding supports that IOE is a practical technique for cancerous and non-cancerous small bowel lesions that require surgical intervention. Further diagnostic and therapeutic clinical trials and case series are required to learn more about more therapeutic approach.


Teaching Point: Radiologists need to be familiar with that ovarian vein thrombosis can occur as a complication of urinary tract infection.Ovarian vein thrombosis is a rare disease in which a majority of cases occur during the postpartum period. There are few case reports for ovarian vein thrombosis associated with urinary tract infection in non-postpartum women. We report a case of ovarian vein thrombosis incidentally diagnosed on computed tomography in a patient with symptoms of urinary tract infection. Ovarian vein thrombosis (OVT) is a rare condition in which a majority of cases occur during the postpartum period; this is called postpartum OVT (POVT). Although it is known to be rare, OVT also occurs in non-postpartum circumstances, such as pelvic inflammatory diseases (PID), pelvic tumors, pelvic surgery, and sepsis, and can occur occasionally without an underlying cause . In the Figure 1A), suggesting acute pyelonephritis. Additionally, CT findings demonstrated diffuse enhancing wall thickening of the left ureter and urinary bladder, which were considered ureteritis and cystitis. A round, hypoattenuated filling defect with peripheral enhancing wall of the left ovarian vein and perivenous inflammatory fat infiltration were also observed . Based on the CT findings, it was presumed to be thrombophlebitis of the left ovarian vein. There was no evidence of PID, such as pelvic fat stranding, ascites, and uterosacral ligament thickening. Upon gynecologic exam, there was no evidence of PID. As a result, she was diagnosed with UTI and complicated septic thrombophlebitis of the left ovarian vein. Fortunately, pulmonary septic embolism was not observed. She was treated with antibiotics and conservative management for 11 days and then discharged. Follow-up CT was taken after 30 days and recanalization of the left ovarian vein was noted .A 46-year-old female patient visited the emergency department with dysuria and fever. She had a medical history of cystitis. In laboratory tests, pyuria, leukocytosis, and elevated serum C-reactive protein were noted. Urine culture revealed E. coli colonization, but there was no growth of bacteria from the blood culture. CT scan showed multifocal striated nephrogram of the left kidney .CT is the most reliable technique for diagnosing OVT. The image findings include filling defects in a tubular structure with a central round hypoattenuated area and peripheral enhancing rim . In patiThere is only one case report for OVT caused by UTI. However, OVT caused by UTI is not an extraordinary phenomenon. It is a phenomenon that is likely to occur naturally and may have been reported rarely compared to the actual incidence. Therefore, radiologists need to be familiar with that OVT can occur as a complication of UTI.


Intraventricular glioblastoma multiforme (GBM) is extremely rare, especially in the trigone region. This report presents a case of trigone ventricular GBM with trapped temporal horn (TTH).A 59-year-old woman was admitted to our department with a 1-month history of rapidly progressive headache, nausea, and weakness in the right lower extremity. Head non-contrast computed tomography and enhanced magnetic resonance imaging (MRI) revealed a trigone ventricular mass lesion with TTH and heterogeneous enhancement. The lesion was found 18 months ago as a small asymptomatic tumor mimicking ependymoma. This neoplasm was removed subtotally through the right parieto-occipital approach guided by neuroendoscopy. A ventriculoperitoneal shunt was subsequently performed to relieve TTH. The final pathological diagnosis was GBM. Unfortunately, 36 days after the first surgery, the patient died due to her family’s decision to refuse therapy.This rare case shows that GBM should be considered in the differential diagnosis of trigonal tumors. In this case, the tumor possibly originated from the neural stem cells in the subventricular zone. Patients with intraventricular GBM have a worse prognosis, and careful follow-up and early surgery for small intraventricular tumors are necessary, even for those with ependymoma-like radiological findings. Glioblastoma multiforme (GBM) is a common primary intracranial malignancy that accounts for approximately 25% of all brain tumors in adults , 2 but rA 59-year-old woman was admitted to our department with 1-month history of rapidly progressive headache, nausea, and weakness in the right lower extremity. Physical examination revealed slight hemiparesis in the right lower limb (muscle power grade IV). A non-contrast computed tomography (CT) revealed a right lateral ventricular mass lesion and TTH, as well as diffuse brain edema Figure 1In fact, the tumor had been detected incidentally by CT and MRI when the patient visited our hospital 18 months ago. CT revealed a 1-cm round high-density lesion in the body of the right lateral ventricle and punctate calcification in the center. Minimal enhancement was observed on enhanced MRI Figure 3A right parieto-occipital surgical approach was used, and surgery was guided by neuroendoscopy. The tumor appeared grayish and predominantly soft and was so infiltrative that no obvious interface between the ependymal layer and lesion was differentiated. Due to the large tumor volume and deep location, subtotal resection was achieved. Histopathological examination of the tumor revealed endothelial proliferation, atypical nuclei, and necrosis. Immunohistochemistry demonstrated strong positivity for glial fibrillary acidic protein (GFAP), negativity for IDH1, and Ki67 index of 20% Figure 4GBM is a common primary intracranial malignancy that accounts for approximately 25% of all brain tumors , 2. AlthTumors that arise from the ventricular wall or structures within the ventricle are regarded as primary ventricular tumors, such as choroid plexus papilloma, choroid plexus carcinoma, ependymoma, and meningioma. Neoplasms that originate from the surrounding brain parenchyma and grow into the ventricle are regarded as secondary ventricular tumor. Astrocytoma, subependymal giant cell astrocytoma, GBM, and mixed glial neuronal tumors consist the group , 15. In Lee et al. illustrated that neuroglial cells of the septum pellucidum or fornix may be the origin of intraventricular GBM. Particularly, the fornix and limbic systems are closely connected to the ventricular system . Kim et Radiologically, ependymomas, central neurocytomas, choroid plexus tumors, and some metastases can be found in calcifications . Hence, The majority of lateral ventricular neoplasms usually grows slowly and does not cause symptoms until they are large enough to induce compression of adjacent eloquent structures or obstructive hydrocephalus . In our in situ or distant recurrence is nearly inevitable, despite the utilization of standard therapeutic strategies, including gross total resection and concurrent chemoradiotherapy  for English language editing.The authors thank the members of their research group for useful discussions and hard work. We would like to thank Editage (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.