Histoplasma capsulatum, an endemic mycosis in the United States, can result in a variety of clinical manifestations. When encountering histoplasmosis sequelae, such as mediastinal adenitis, granulomas, and fibrosing mediastinitis, surgical management may be an unexpected but necessary treatment. Due to the complexity of the mediastinum, it is imperative to have optimal operative planning. In this report, we present an unusual case of an inflammatory mediastinal mass in the setting of acute histoplasmosis resulting in left atrium compression and arrhythmias. Histoplasma capsulatum, an endemic mycosis in the United States, can present with a variety of clinical manifestations. Inhalation of airborne particles in the conidia state most commonly results in asymptomatic colonization of the lungs, though exposure can also trigger a robust inflammatory response manifesting with flu-like symptoms such as fever, shortness of breath, cough, and weight loss [ght loss -3. In moght loss . In the ght loss . In thisA 33-year-old male with a history significant for a thyroid nodule presented with periods of palpitations and a chronic cough following a cave diving trip. The initial workup consisted of medical management for suspected bronchitis and new-onset atrial fibrillation Figure . The patH. capsulatum. Treatment was begun with itraconazole; however, debilitating episodes of palpitations and lightheadedness requiring recurrent visits to the emergency room persisted.Nevertheless, the cough lingered, and the palpitations reoccurred with increasing severity. Pulmonary function testing was obtained indicating a fixed upper airway obstruction. Imaging was obtained, which identified a 3.4-cm subcarinal soft tissue density on computed tomography (CT). The patient underwent bronchoscopy with a biopsy of a subcarinal lymph node, which revealed necrotic debris and the presence of scant organisms identified with gram stain consistent with Cardiac magnetic resonance imaging (MRI) was obtained to further evaluate the mass. The MRI depicted a large posterior mediastinal mass located posterior to the right upper pulmonary vein, abutting and compressing the superior-posterior aspect of the left atrium. Cardiac electrophysiologists conferred the location of the mass was likely a nidus for the arrhythmias. With evidence of cardiac compression and persistence of symptoms despite medical therapy, the patient was taken to the operating room for exploration, excision of the mass, and to ensure the absence of additional pathology.The procedure began utilizing a right video-assisted thoracoscopic approach (VATS) and a large inflammatory mass was identified in the subcarinal space. A meticulous dissection of the mass was started in an attempt to visualize the extent of the space-occupying lesion. However, due to the inability to adequately visualize the posterior mediastinal space, the procedure was converted to a thoracotomy via a left posterolateral incision. With improved visualization, the mass was found adherent to the right inferior pulmonary vein, esophagus, pericardium, and right lung. Following continued meticulous dissection, the mass was successfully removed, and no additional pericardial compression was observed.Postoperatively, the patient recovered uneventfully in the cardiothoracic intensive care unit and was discharged with itraconazole on postoperative day three. Final pathology demonstrated necrotizing granulomatous inflammation, a sequela of pulmonary histoplasmosis. Subsequently, the patient returned home and remains symptom-free at one-year follow-up with no resultant complications or readmissions.H. capsulatum is an endemic mycosis in the Mississippi and Ohio river valleys with an estimated incidence of 6.1 cases per 100,000 individuals [ et al. studied complications from pulmonary histoplasmosis and found that hemoptysis and recurrent pneumonia were the main reasons for operative intervention [rvention . In our The complexity of the mediastinum makes imaging a necessity for diagnosis as well as accurate delineation of mediastinal structures and compartments. When concerned for mediastinal pathology, the cross-sectional images generated by CT are useful in detecting cysts, adipose tissue, soft tissue masses, calcification, and air, which can aid in the creation of a differential diagnosis . MRI, alUtilizing a VATS approach to mediastinal surgery offers the benefits of decreased morbidity and recovery time in comparison to traditional thoracotomy . HoweverIn conclusion, histoplasmosis can result in a variety of clinical manifestations. When encountering histoplasmosis sequelae, such as mediastinal adenitis, granulomas, and fibrosing mediastinitis, surgical treatment may be an unexpected but necessary treatment. Due to the complexity of the mediastinum, it is imperative to have optimal operative planning. When dense inflammatory tissue is encountered, especially in tight areas such as the posterior mediastinum, early conversion to an open thoracotomy should be considered to improve surgical field exposure and facilitate a safe completion of the operative procedure.


Computed tomography scans showed a posterior vertebral scalloping change in L3, L4, and L5. Meanwhile, magnetic resonance imaging revealed epidural mass posterior to the L3, L4, and L5 vertebral bodies. The solitary mass was isosignal to subcutaneous fat and asymmetrically compressed to the left side of the dural sac and L4 nerve root, as observed on axial T1- and T2-weighted images. To the best of our knowledge, there have been few reports of a solitary epidural lipoma causing lumbar radiculopathy. The patient underwent transforaminal lumbar interbody fusion at L4–L5, and his symptoms then resolved. Thus, we recommend decompression and fixation as appropriate management for lumbar radiculopathy caused by epidural lipoma located on the ventral side of the dura and intervertebral foramen.A 56-year-old obese man with a body mass index of 30.9 kg/m Spinal epidural lipomatosis (SEL), the abnormal accumulation of unencapsulated adipose tissue in the epidural space of the spinal canal, is a well-known rare condition with distinctive magnetic resonance imaging (MRI) findings , 2. MoreHere, we present the clinical, radiographic, and pathological assessment of a patient with a rare case of lumbar radiculopathy and intermittent claudication secondary to an epidural lipoma located on the ventral side of the dura and intervertebral foramen.A 56-year-old man presented with left anterior thigh pain, left sciatica, and intermittent claudication for 5 years, and his symptoms had worsened within 1 year. The patient had no history of corticosteroid use or endocrinopathy.2), the extension of the lumbar spine was limited, and the Kemp sign was positive on the left side. The patient had severe limitations in the left lower limb in performing straight leg raise test, although no motor weakness or hypoesthesia was elicited in further tests. Plain radiographs showed no abnormality, instability, or other pathologic findings. Computed tomography (CT) revealed posterior vertebral scalloping change of L3, L4, and L5 without erosion of the cortical and medullary bone and Schmorl's nodes at the endplate of the L3, L4, and L5  and Schmorl's nodes at the endplates of the L3, L4, and L5 vertebrae were demonstrated with SEL in our case. Although endplate degeneration findings (Modic type 1) in patients with chronic low back pain have been suggested to be associated with a high rate of low back pain , the patHowever, these changes may affect radiculopathy. Kim et al. reported a case of solitary epidural lipoma causing lumbar radiculopathy associated with unilateral arthritis of the posterior facet joint . They prIntraspinal epidural lipomas are very rare and may be easily overlooked because of their subtle MRI findings that are similar to those of normal anatomical variations or SEL. This case highlights the importance of considering an epidural lipoma when MRI reveals an epidural compressive and asymmetric fatty encapsulated lesion.In conclusion, although MRI can diagnose an epidural lipomatous mass, additional procedures may be required to examine the mass. We recommend transforaminal lumbar interbody fusion for the inspection of an epidural lipoma, especially when it is located on the ventral side of the dura and intervertebral foramen.


Tumoral calcinosis is a rare syndrome that affects mostly soft tissues. It is characterized by calcium salt deposition in the periarticular soft tissue surrounding bony structures forming slow-growing, seldom asymptomatic masses. This case report describes a 41-year-old male with end-stage renal disease on home hemodialysis, who presented with an unusual rapidly progressive mass overlying the manubrium and suprasternal notch, following recent cardiothoracic surgery, which was initially felt to be a hematoma. The case highlights the role of spectral detector computed tomography (SDCT) in reaching the correct diagnosis of tumoral calcinosis as well as demonstrating additional changes of ectopic parathyroid hyperplasia in the anterior mediastinum. Tumoral calcinosis (TC) is a rare, complex, and benign entity, primarily affecting the surrounding soft tissues of adjacent joints, which was first reported by Inclan et al. in 1943 .TC lesions are most notably well-demarcated, firm, painless, and lobulated masses that locate mostly near joints, and rarely in the neck and head. In this case report, we present a rare and unique case presentation of the entity where spectral detector computed tomography (SDCT) played a vital role in the diagnosis and thus avoiding patient morbidity.A 41-year-old male has a past medical history of hypertension, hyperlipidemia, type 2 diabetes mellitus, ESRD on home hemodialysis five days a week since 2014, and coronary artery disease status post-three-vessel coronary artery bypass grafting as well as simultaneous mitral and tricuspid valves repair, six months before presentation. He presented with a large palpable, painless, swelling overlying manubrium and supraclavicular notch, which was firm in consistency with no clear definition of the edges and no overlying skin changes. It was non-pulsatile, non-tender, and measured approximately 15-20 cm. The sternotomy wound was completely healed. There were no signs of sternal dehiscence. Posterior-anterior and lateral chest x-rays were obtained initially and did not show the lesion despite repeated retrospective review of the x-rays; the nonspecific soft tissue swelling could not be confidently connected to the clinically palpated lesion. Due to the abnormal physical findings, a contrast-enhanced CT scan of the chest was requested for further evaluation. Initial conventional CT demonstrated a multilobulated lesion in the soft tissues immediately superficial to the sternotomy site with hyperattenuating layering material /no iodine image Figure  from SDCThe diagnosis was also supported by the similar layering of hyperdense material in a cystic lesion with fluid calcium levels in the right pelvis on an outside non-contrast CT of the abdomen and pelvis performed one year before the current presentation Figure . AdditioLaboratory testing and subsequent Tc-99m sestamibi parathyroid nuclear medicine scan Figures , 7 confiFinally, the patient underwent subtotal parathyroidectomy with the removal of enlarged left and right superior and ectopic left inferior parathyroid glands. Normal appearing right inferior parathyroid gland was left behind. The presternal mass was also removed as part of the median sternotomy for resection of the mediastinal parathyroid gland. The mass contained thick consistency pus-like fluid, and histopathologic analysis showed calcified nodules separated by fibrovascular bands consistent with a diagnosis of TC.Post-operatively, the patient was placed on a calcium gluconate drip due to low serum calcium levels and the risk of hungry bone syndrome . On the fourth post-op day, the IV calcium infusion was stopped, and he was transitioned to oral calcium supplements. On discharge, the patient's serum ionized calcium was slightly low but stable on a regimen of 5 g calcium carbonate four times a day, along with cinacalcet and calcitriol.Our current case highlights the role of spectral CT in diagnosing and managing a rare entity, TC, in a patient with a history of ESRD and open-heart surgery, as well as detection of additional anterior mediastinal abnormality, compatible with parathyroid hyperplasia secondary to renal dysfunction. SDCT data informed the further management of this case, as establishing the diagnosis was crucial to managing the condition with parathyroidectomy.SDCT is a novel imaging technology that, unlike conventional CT, is equipped with a dual-layer detector that allows for separate registration of low-energy and high-energy photons. The projection data simultaneously obtained from both detector layers can also be utilized to generate various diagnostically useful spectral images, including, virtual monoenergetic images . The exponential dependence on the atomic number Z4) and proximity of iodine’s K-edge (approximately 33 keV) results in increased contrast in low-energy VMIs (VMIlow) on contrast-enhanced CT scans -4. and proxThe coining of the term “tumoral calcinosis” (TC) dates back to 1943 and is attributed to Inclan et al., who reported three cases of TC that involved the gluteal area, the elbows, and in one case the thigh and hip. All TC reports were described in patients of Black and Hispanic ethnicities who were under 20 years of age, and, in two cases out of three, women were affected. The histopathological examination of the tumors revealed a multicystic structure and calcium salts deposits. Treatment consisted of surgical resection of the masses with a favorable evolution of the patients ,6. In GeTC can be either primary or secondary. Primary TC can be further classified into two subtypes: hyperphosphatemic TC and normophosphatemic TC. Primary hyperphosphatemic TC is familial, and mutations in the Fibroblast Growth Factor 23 (FGF23), GalNAc Transferase 3 (GALNT3), or KLOTHO genes are critical factors in its genetic basis, resulting in reduced phosphorus elimination . Primary2/dL2. Secondary TC is a rare event in ESRD [Secondary TC develops mainly in patients with ESRD. Such subjects often develop concurrent secondary or tertiary hyperparathyroidism . ESRD/he in ESRD  and, in  in ESRD .Diagnosis of both primary and secondary TC can be made by combining the clinical scenario and typical radiological features with the serum biochemical profile. Patients present with painless periarticular masses that cause no general symptoms and involve mainly the hips, elbows, or shoulders. Plain radiographs reveal the presence of well-defined nodules with fibrous septa (chicken-wire or cobblestoned appearance). Calcium layering results in the “sedimentation sign,” which can be highlighted using a horizontal beam radiological examination, computed tomography, and even magnetic resonance imaging. If bone scintigraphy is employed, TC sites exhibit high uptake. Ultrasound examination is useful in detecting fluid collections ,10,12. ITreatment strategies differ depending on the TC subtype. Surgical resection of the tumor is the procedure of choice in primary TC, yet recurrence has been noted in many cases. In patients with elevated levels of serum phosphorus, other measures might be useful: diets with low intake of phosphorus, acetazolamide to increase urinary phosphate elimination, and oral phosphate binders such as aluminum hydroxide or sevelamer carbonate. Combined surgical and medical treatment seems to generate the best results ,10,12.2/dL2, which leads to calcium salts deposits in soft tissues. Thus, medical treatment based on diets deficient in phosphorus, dialysis, and phosphate binders  are used. When unsuccessful, it is replaced by surgery. The surgical approach consists of subtotal or total parathyroidectomy and tackles the encountered masses only in peculiar clinical settings. ESRD patients also benefit from renal transplantation [In ESRD-related TC, treatment is focused on the pathophysiological mechanisms driving this subtype: serum calcium-phosphorus product above 45 mgantation ,12.The diagnosis of TC can be made by combining the clinical scenario and typical radiological features with the serum biochemical profile. Spectral CT reconstruction can serve as a problem-solving tool, helping in better diagnostic confidence, and may reveal additional significant findings, such as enlarged ectopic parathyroid gland, as in our patient. Additionally, there is no extra radiation dose or specific imaging protocols needed for SDCT.


Giant cell granuloma of the respiratory tract or Central Giant Cell Granuloma (CGCG) is considered an intraosseous, non-neoplasm tumor, responsible for less than 7% of all the mandible expansive lesions, its most common site of involvement.3It affects more often the young people – 75% of the cases happen to patients below 30 years of age.This paper describes a CGCG case, with mandible involvement and revises characteristics inherent to CGCG, with emphasis in diagnosis, thus yielding a less mutilating treatment.A 30 year old brown woman came to our ENT outpatient ward because of a recurrence of a left mandible tumor, with a progressive, painless growth, associated with facial deformity after a surgical removal of a giant cell reparative granuloma in the previous year.She reported a prior dental removal, 11 years before in the left mandible region. She denied past diseases.The physical exam showed a hard and painless tumor, a bone notch in the left mandibular region associated with facial deformity.Routine workup, serum calcium, phosphorus and alkaline phosphatase were normal.The panoramic radiograph showed a radiolucent area in the left mandible body, a recent post-surgical area, with mild radiologic signs of bone regeneration.The mandible CT scan showed a morphostructural alteration with bone remodeling and a large irregular lithic area in the mandible body and left mandible alveolar processes which could correspond to post-surgical alteration or tumor recurrence .Figure 1The tumor was surgically excised without complications.The pathology exam confirmed central giant cell granuloma.The mechanism by which these lesions are formed is still uncertain. Local causes suggested are trauma and vascular injuries, and the systemic causes reported in the literature associate the development of CGCG with syndromes such as, Neurofibromatosis I, Noonan syndrome and hormonal disorders such as hyperparathyroidism and pregnancy.The clinical manifestation can evolve in a few weeks or take years, it is usually associated with tumor expansion and its respective compressive effects on adjacent structures, with a possibility for local discomfort; however, overt pain is less frequent. Clinically speaking, the differential diagnosis of CGCG goes from a cyst all the way to a malignant lesion, and one must investigate the level of aggressiveness, how fast it develops, inflammatory characteristics, pain and dental mobility.CGCG radiographic characteristics are not pathognomonic, they are radiolucent uni or multilocular images, well outlined and with peeled off margins.Radiographically speaking, differential diagnoses are cysts, periapical granulomas, ameloblastomas, keratocysts, myxomas and sarcomas.Histology shows giant cells distributed throughout the loose connective tissueIt is important to study levels of calcium, phosphorus, alkaline phosphatase and parathormone to rule out hyperparathyroidism.Prognostics are favorable and there are no reports of metastasis, which confirms the benign characteristic of the lesion.The treatment of choice for CGCG is surgical.Curettage is the most used treatment, because of its ease of execution and low grade of recurrence. Usually, the same recurrences respond well to a new curettage, unless the lesion is aggressive. For more aggressive lesions, or those that perforate the cortical bone and involve soft tissue, en-block resection may be indicated.Radiotherapy is contraindicated because of the potential for sarcomatous transformation that has been reported.For recurrent or extensive lesions, alternative treatments have been indicated, aiming at achieving lesion regression or termination, avoiding more invasive and mutilating surgical procedures.CGCGs are a reason for much research and discussion, since there are many theories to explain its etiologic and clinical manifestations. It is a benign lesion, therefore proper diagnosis avoids mutilating radical treatments. Curattage is still used with high success rates. For extensive or recurrent lesions, treatment with intralesional injections of steroids can be useful.


The eosinophilic vacuolated tumor (EVT) of the kidney is a newly identified and pathological emerging entity. In this case report, EVT diagnosed due to a partial nephrectomy performed for a suspicious kidney mass in a 47-year-old patient is presented. A review of the literature and this case indicates that EVT, also called high-grade oncocytoma, does not show clinically aggressive behavior. However, in case of clinical suspicion, tumors with this oncocytic morphology should be treated with nephron-sparing treatment methods, considering that they may be hybrid malignancies. Renal masses are common pathologies in the urology clinic, which can be diagnosed incidentally with the frequent use of radiological imaging methods. A pathological diagnosis is crucial for evaluating the follow-up and treatment processes of patients from a urological point of view. Therefore renal masses that can not be classified can cause clinical difficulties. Sometimes, unnecessary invasive treatments applied to these masses may cause severe morbidities .The 2016 World Health Organization (WHO)/International Society of Urological Pathology (ISUP) classification is used to classify renal masses, in which more than 50 pathologies are defined. Included under the title of the novel, emerging and provisional renal entities are recently defined in this case report and are not yet defined in the WHO/ISUP classification. in our case report, the preoperative examination and patient characteristics of our patient, who was diagnosed with eosinophilic vacuolated tumor (EVT) [A 47-year-old male patient with no known comorbidity presented with left flank pain. The patient's physical examination was considered normal, and his history included being followed up for urolithiasis in the left kidney seven years ago and spontaneous stone passage. He is a teacher with no history of risky occupational exposure. The patient, who was admitted to the physical therapy and rehabilitation clinic due to flank and back pain in the last year, was found to be normal in a complete urinalysis, while Hgb: 16.1 g/dL, creatinine: 0.9 mg/dL. During the urinary ultrasonography at the beginning of the urological evaluation, an isoechoic solid lesion measuring 40x30 mm with a lobulated contour including internal vascularity was observed in the lower pole of the patient's left kidney. Contrast-enhanced abdomen computed tomography (CT) of the patient, who was initially evaluated as renal cell carcinoma (RCC), revealed a solid character of 33x27 mm in the left kidney lower pole medial aspect with medium contrast, and a well-contoured soft tissue mass suggesting a tumoral mass Figure -1B. In aIn the operation, a soft, well-circumscribed but non-encapsulated mass of approximately 4 cm was seen in the lower pole of the kidney. While it was observed that the separation of the mass from the surrounding tissue was not clear during the resection, the resection was performed so that the surgical margin was negative. The surgery was completed with a warm ischemia time of 11 minutes and 100 cc of bleeding in a total of 80 minutes. The patient, whose general condition was good after the operation and was followed up clinically, was discharged on the second postoperative day.Macroscopically, the tumor was well-circumscribed, smooth, and mahogany brown. Microscopically, the tumor consisted of cells with a solid or occasionally nesting pattern, with extensive eosinophilic cytoplasm Figure . There wThere are insufficient data available to predict the clinical behavior of this newly identified EVT. During the evaluation of our case and the literature, it was seen that EVT exhibits clinically nonaggressive behaviors. The anatomical and radiological features of the reported masses are also consistent with the clinical non-aggressiveness of EVT. However, in case of clinical suspicion or detection in renal biopsy, it would be appropriate to treat EVT with nephron-sparing methods until high-level evidence is obtained.According to the case series by He et al. and Chen et al., it was found that EVT is more common in women, unlike in our case. All the cases in these studies were operated on at the clinical T1 stage. Moreover, recently, Farcaş et al. reported epidemiological findings similar to the first two studies in their study. Although the mean follow-up period of these studies was not very long, no recurrence or death was observed in the follow-up period of up to 198 months in a total of 40 patients in these three studies -5. AlthoRadiologic and anatomical predictors can distinguish benign from malignant such as nephrometry scores and vena cava lesion-attenuation difference; the lesion-cortex-attenuation ratio was evaluated retrospectively for our case, and no clue could be obtained. Renal mass biopsy (RMB) may be recommended for active surveillance in cases where EVT is suspected. However, the presence of renal oncocytoma in the RMB does not exclude malignancy. It should be kept in mind that there may be hybrid tumors with oncocytomas . In caseThe use of 99Tc-sestamibi single-photon emission computed tomography (SPECT/CT) is promising, in line with the studies performed on the differentiation of renal oncocytoma and RCC . It coulAnother finding that can be used in the clinical approach to EVT is the association of EVT with mTOR pathway abnormalities. In this context, nonoverlapping mutations have been observed in tuberous sclerosis complex 1, tuberous sclerosis complex 2, and the mammalian target of rapamycin (mTOR) genes ,9. AlthoEVT is a newly defined entity with insufficient information, which urologists should be aware of. In our case report and the cases reported so far, EVT did not exhibit aggressive behavior. EVT should be treated with nephron-sparing methods until a high level of evidence for the treatment scheme is available, along with regular follow-up. A multidisciplinary approach, including the pathologists, should be applied.


Chordomas are rare malignant neoplasms, accounting for 1–4% of all primary bone tumors. Most spinal chordomas occur in the sacrococcygeal region and the base of the skull; however, 6% of chordomas are observed in the cervical spine. In these cases, the lesion is mainly located in the midline. These tumors slowly grow before becoming symptomatic and encase the surrounding vascular and nerve structures. Patients with advanced chordoma have a poor prognosis due to local recurrence with infiltration and destruction of adjacent bone and tissues. Systemic chemotherapy options have not been fully effective in these tumors, especially for recurrent chordomas. Thus, new combinations of currently available targeted molecular and biological therapies with radiotherapy have been proposed as potential treatment modalities. Here, the present paper describes the case of a 41-year-old male with a C2–C4 chordoma located paravertebrally, who underwent surgical resection with a debulking procedure for a cervical chordoma. Computed tomography angiography revealed a paraspinal mass with bone remodeling and the MRI showed a paravertebral mass penetrating to the spinal canal with a widening of the intervertebral C2–C3 foramen. Initially, the tumor was diagnosed as schwannoma based on its localization and imaging features; however, the histopathology specimen confirmed the diagnosis of chordoma. This case study highlights the effectivity of radical surgical resection as a mainstay treatment for chordomas, discusses neuroimaging, diagnosis, and the use of currently available targeted therapies and forthcoming treatment strategies, as alternative treatment options for chordoma. Chordomas are rare malignant neoplasms with an estimated incidence of less than 0.1 per 100,000; this prevalence peaks in men around late middle age . They acThe current paper presents a case study of massive cervical (C2–C4) chordoma, located paravertebrally, which resulted in an initial diagnosis of schwannoma rather than chordoma. It discusses the features revealed by magnetic resonance imaging (MRI) and computed tomography angiography (CTA), the diagnosis, and currently available and upcoming treatment modalities, including targeted therapies.A 41-year-old man was admitted to our hospital with a slow-growing, retropharyngeal paravertebral mass on the right side of his neck, as revealed by an ultrasound scan. On admission, he reported a long history of sore throat, dizziness, and difficulty in swallowing, but the symptoms were transient. On clinical examination, the tumor was palpable, firm, non-pulsatile, and not moveable at the right cervical region. This finding was confirmed with an MRI. The past medical history and routine laboratory diagnostics were unremarkable and no significant neurological deficits were disclosed.CTA revealed a 70 × 47 × 36 mm, well-defined paraspinal pathological mass with bone erosion and remodeling extending to the transverse processes and part of vertebra bodies, and with a widening of their intervertebral foramina on C2 to C4 a–c. It wMRI showed the paravertebral mass penetrating to the spinal canal with a widening of the intervertebral C2–C3 foramen d–f. The Based on its localization, and neuroradiological and clinical features, the tumor was preliminarily diagnosed as a slow-growing lesion, such as peripheral nerve sheath tumor (PNST), more likely than meningioma . An immunohistochemical study revealed positive reactivity for EMA, AE1/AE3, S100, and negative for GFAP, which indicated notochordal origin and confirmed the final diagnosis of chordoma .Following consultation with a radiotherapist, oncologist, and neurosurgeon, the patient’s adjuvant radiotherapy was postponed and he was eventually placed under constant care. In the event of tumor recurrence, the consecutive follow-up MRI examinations after six and twelve months showed no tumor residue or recurrence a–c. CurrChordomas are a family of primary bone tumors, which originate from undifferentiated embryonic notochord remnants present in the midline, extending throughout the skull base and the axial skeleton. This present case merits particular attention due to the unusual location of the tumor and the difficulties associated with the preoperative clinical and neuroradiological definitive diagnosis. In the current section, we decided to provide textbook-wise review juxtaposed with case discussion. We believe that this approach will be the most appropriate for clinicians, especially neurosurgeons and oncologists.Chordomas are the cause of 1–4% of all bone malignancies; they account for 0.5% of all primary CNS tumors and as much as 17% of spinal primary tumors. Population-based studies indicate the incidence rate of chordoma to be 0.08–0.1 per 100,000 in men and 0.06 per 100,000 in women ,10. The Chordomas have the possibility of affecting all parts of the axial skeleton, with an almost equal incidence reported in the mobile spine , skull base (32%), and the sacrum (29.2%) . The medThe COVID-19 pandemic significantly impacted the possibility for conventional patient examination. Telemedicine emerged rapidly and has been an important tool in delivering virtual health—also in patients with brain and spine neoplasms. In addition, it has improved the access to specialists and supportive care remotely to centers specialized in cancer treatment for an initial diagnosis or second opinion. However, the failure to perform a conventional neurological examination, especially in cases with neurological deficits due to spine disease or tumor, in telemedicine might lead to misdiagnoses and legal implications. Additionally, telemedicine misses early signs, which are important to establish initial diagnoses and further assessment in neurological deficits, in cases which are difficult to distinguish in the variety of spinal diseases, such as myelopathy, peripheral nerve disease, and cauda equina syndrome. Moreover, adequate neuroimaging modalities are fundamental to establish a definitive diagnosis; however, it is difficult to obtain an early diagnosis in this kind of tumor. Telemedicine provides a unique opportunity for delivering convenient and safety health care to patients, but its permeant benefit in managing spine patients is still uncertain, as misdiagnosis or failure to indicate the baseline issue remotely, and lack of a standard legal framework, may create malpractice litigation and legal issues. Furthermore, several studies reported inverse correlation in the doctor–patient relationship with malpractice suits, which is hard to develop virtually. Further research is needed to overcome the barriers to implementing telemedicine into surgical care and also connecting surgical teams worldwide to provide better experience to patients ,17.The majority of spinal chordomas occur on the midline and manifest themselves as a soft tissue mass with variable biological behaviors. There are four common types of chordoma: the classic and the chondroid forms, which are usually low-grade and locally aggressive tumors, the poorly differentiated form, and the dedifferentiated forms, which are more aggressive . TypicalThe diagnosis commences with radiological imaging. An X-ray can uncover bone erosions with atypical calcium foci and lytic bone lesions. CT scans show hypodense masses with calcification and evaluate the extent of bone involvement and destructive patterns; these are accompanied by reactive sclerotic changes in 40–60% of cases ,22.An MRI surpasses other imaging modalities in diagnosing chordomas. It can delineate the extent of tumors and adjacent paravertebral structures and find where the tumors originate ,24,25,26Many spinal chordomas, as in the present case, manifest themselves as a massive paraspinal mass, with or without a lytic lesion of the vertebral bodies. These tumors can extend along with the vascular structures and nerve roots in proximity, and into the spinal canal, thus, enlarging the intervertebral foramina. Large tumors, such as schwannomas and neurofibromas, have very similar neuroradiological features, as noted in the aforementioned case, including a mass hypointense mass in T1, a hyperintense mass in T2-weighted images, and an enlarged intervertebral foramen, which cause regular vertebral scalloping ,27,28. TThe present case is unique for its atypical localization and neuroradiological features. Cervical chordomas are rare and mainly located on the midline with variable and extensive bone destructions and extension into the spinal canal. In our case, the tumor was located paravertebrally and invaded the adjusting vertebral bone, which is rare and can be misleading. Therefore, we believe that this case will be helpful in the diagnostic process and therapeutic planning for neurosurgeons and specialists involved in the management of similar cases of chordomas.Appropriate diagnosis and staging play significant roles in managing a suspected primary bone tumor in the spine. Recently, two staging systems have been used to classify spine tumors in treatment planning. The Enneking classification categorizes tumors from Stage I to Stage IIIB based on grade and extent. The Weinstein–Boriani–Biagini (WBB) classification allows some staging of spinal tumors and reveals the unique anatomical complexity of the spine .Moreover, Stacchiotti and Sommer published the first guidelines for the diagnosis and treatment of chordoma in 2015 . The ultVarious chordoma treatment regimens and approaches have been attempted, including complete surgical resection, combined radiation, surgical excision, and radiotherapy. However, complete resection and determining widely negative surgical margins can often be challenging, given the proximity of the tumor to critical neurovascular structures, its slow growth patterns, the tendency to recur, and its resistance to traditional chemo- and radiotherapeutic modalities ,35. As sen bloc resection without intraoperative capsule spillage and negative margins has been associated with a reduced recurrence rate [en bloc resection. The description of margins by the pathologist is important to distinguish between margins that contain tumorous cells or tissues and those that do not to perform en bloc resection precisely [Surgical intervention and resection remain the standard treatment for chordomas and extent of the tumor resection is an important prognostic factor for patients with these tumors ,45,46,47nce rate ,49. Thesrecisely . A multiMoreover, biopsy should be performed prior to surgery for cases in which diagnosis of chordoma is suspected, which is important in overall therapeutic planning. However, this was not initially considered in our patient due to the presumptive diagnosis of PNST, as it is associated with a high risk of complications, such as neurological deficits and damaging surrounding vascular anatomy ,8. RecomBecause cervical chordoma is a rare entity, it is difficult to give recommendations regarding radiation treatment based on existing evidence. However, better outcomes have come through adjuvant radiotherapy . The delen bloc resection is sufficient [Prospective trials have shown clear and definite evidence of local control by radiation alone or local control achieved by a combination of radiation and chemotherapy agents. Nonetheless, complete surgical resection will remain the main treatment. Most authors suggest that radical excision surgery followed by adjuvant radiotherapy should be the standard procedure performed for chordoma patients. On the other hand, Boriani et al. proposed that margin-free fficient .Due to the rarity of the occurrence of cervical chordomas, no absolute therapeutic protocols or long-term evaluations have been reported, with all articles solely on a case-by-case basis ,32. AccoConsidering the rare nature of cervical chordomas, evidence-based recommendations regarding the management of cervical chordoma are difficult to attain; however, adjuvant proton beam and radiotherapy have been shown to improve the long-term remission rate and outcome ,56. NeveIn addition to the treatment modalities mentioned above, other therapeutic options are being researched by Tamborini and Weinberger, such as targeting tyrosine kinase receptors, epidermal growth factor (EGFR), or platelet-derived growth factor receptors (PDGFR); all have been associated with chordoma development, either by activation or upregulation ,58. ReceImatinib is one of the most extensively studied receptor  inhibitors regarding the treatment of chordomas and brought about positive results in a phase II study that involved 50 patients. As such, 1 patient (2%) had a partial response, 11 patients had a lower response, 35 patients (70%) remained with stable disease, and 64% of the patients benefitted clinically . AnotherOther clinical trials are being conducted to investigate how afatinib, another EGFR inhibitor, works against chordomas. A previous comparison suggested that afatinib is a more promising agent then other EGFR inhibitors, yielding better results than the others. The cell lines that are most sensitive to afatinib activity lacked serine/threonine kinase 33 (STK 33) mRNA/protein levels; this suggests that STK 33 may be used as a potential biomarker for predicting the response to afatinib by the tumor. Of the tested inhibitors, lapatinib was found to be the least effective ,63.TSC1 or TSC2) [Other treatment options and inhibitors, which may be utilized, include: Cyclin D-dependent kinases (CDK4 and CDK6) inhibitors, Palbociclib, immune checkpoint inhibitors like Avelumab, and Nivolumab . Most chor TSC2) . Studiesor TSC2) . TBXT geor TSC2) ,67. As sor TSC2) .Immunotherapy is a promising treatment regimen for cancer since it shows promising results in managing a variety of malignancies. The efficacy of combining imatinib with everolimus is currently under investigation in adult patients who have INll-negative tumors, as is the use of oncolytic bacteria, tazemetostat, and nivolumab, with or without stereotactic radiation therapy .Another promising area of research is the use of irradiated natural killer (NK) cells with cetuximab, since exposure to radiation increases antibody-dependent cetuximab cytotoxicity through overexpression of CD16 alleles on NK cells . ChimeriOur case underlines the effectiveness of radical surgical resection as a mainstay treatment for chordoma and discusses the use of currently available biological agents as well. Disease control lasted for 12 months and a follow-up cervical MRI revealed no further progression and recurrence.As chordomas remain a rare entity, planning treatments and standardizing systemic therapy constitutes a challenge in atypical cases. Here, we presented the case of a C2–C4 chordoma located paravertebrally and resembling PNST in the preoperative examination. In addition, as a limited number of randomized trials have been carried out, chordoma has only a few systemic treatment options, most of which are of limited benefit. Targeted therapy has been found to be a potential alternative treatment for chordoma, especially in cases with several relapses. Although the treatment options for recurrent chordoma are slowly growing, the condition is still burdened by significant morbidity and mortality. Hence, there is a need for further research into new therapeutic strategies. Currently, total marginal resection with the possible addition of adjuvant radiotherapy remains an effective therapeutic option. In such cases, detailed preoperative planning, by a multidisciplinary team, is crucial to achieve the best possible patient outcome.


Gastric heterotopia (GH) is a rare, congenital condition where gastric tissue is found outside of its normal location in the gastric mucosa. It is usually benign and can be found throughout the gastrointestinal (GI) tract. In the duodenum, it is usually seen as multiple polyps, specifically in the duodenal bulb. Here, we discuss the case of a 67-year-old male patient who presented with hematemesis, melena, and abdominal pain. Esophagogastroduodenoscopy (EGD) and biopsy revealed a mass consisting of heterotopic gastric mucosa along with an esophageal ulcer. In this article, we will discuss the literature related to the clinical presentation, diagnosis, and management of GH. The word heterotopia is derived from the Greek language, which refers to tissues that are found in an unusual place . GastricA 67-year-old male patient was admitted with multiple episodes of melena and hematemesis that started three days prior to admission and was associated with nausea, abdominal pain, and diarrhea. Physical examination showed mild diffuse abdominal tenderness without guarding, rigidity, or rebound tenderness. Labs were significant for hemoglobin 7.7, hematocrit 22.5, creatinine 7.25, and blood urea nitrogen 143. A computerized tomography (CT) abdomen and pelvis showed fluid-filled distension of the stomach, cholelithiasis, colonic diverticulosis, and bilateral hydroureteronephrosis. Initial management included intravenous (IV) fluids, IV proton pump inhibitors (PPIs), placing a Foley catheter , and close hemodynamic monitoring. A subsequent esophagogastroduodenoscopy (EGD) showed an ulcer in the lower third of the esophagus along with endoscopic findings of suggestive intestinal metaplasia, an esophageal hiatal hernia, and a 1.5 cm mass in the duodenal bulb  is defined as the presence of mature gastric tissue outside the gastric mucosa . It can GH is usually discovered as an incidental finding on endoscopy. Most of the patients are asymptomatic, but symptoms such as dyspepsia, heartburn, abdominal pain, obstruction, or GI bleeding have been attributed based on the location of heterotopic tissue . Our patDiagnosis of GH is made by a combination of the clinical picture, radiologic imaging, endoscopic, and histopathological evaluation. Treatment includes endoscopic or surgical resection to prevent complications . As mostGastric heterotopia (GH) is the presence of gastric tissue outside of the stomach and can be found anywhere throughout the gastrointestinal (GI) tract, although it is very uncommon in the duodenal bulb. It is mostly congenital, but repeated exposure to gastric acid can also lead to its development. Like our patient, most cases of GH are incidentally discovered, but sometimes it can cause ulceration and massive GI bleeding, leading to significant morbidity and mortality. Due to these reasons, prompt identification of GH is significant. Further studies are also needed to assess the role of routine surveillance for GH.


Aqui, apresentamos um caso de calcificação caseosa do anel mitral diagnosticado após a análise patológica do coração explantado.A calcificação caseosa do anel mitral é uma lesão cardíaca não neoplásica, considerada uma variante da calcificação do anel mitral que deve ser suspeitada quando massas cardíacas são detectadas por ecocardiograma, radiografia de tórax ou outros estudos radiológicos.Um homem de 35 anos, com diagnóstico de insuficiência cardíaca (classe III da New York Heart Association) secundária a cardiopatia reumática foi admitido em um hospital universitário público terciário para transplante cardíaco. Ele vinha tendo internações recorrentes por insuficiência cardíaca crônica. Ao exame físico, apresentava edema de membros inferiores, deslocamento lateral do batimento apical, ritmo cardíaco irregular, presença de terceira bulha e sopro sistólico e mesodiastólico precoce no ápice do coração. A radiografia de tórax revelou lesão hiperdensa localizada no coração junto à válvula mitral  e 2. O eAos 15 anos, o paciente passou por uma troca valvar mitral por bioprótese para tratamento da doença valvar mitral reumática, necessitando de duas reoperações subsequentes (aos 21 e 23 anos). Nos últimos três anos, apesar da terapia médica otimizada, sua função cardíaca se deteriorou continuamente. Não havia outras comorbidades em sua história médica pregressa.Os achados laboratoriais mostraram redução da função renal . O eletrocardiograma revelou fibrilação atrial.A principal hipótese diagnóstica foi insuficiência cardíaca avançada causada pela disfunção valvar da bioprótese mitral. Para uma massa cardíaca visualizada na radiografia, algumas possibilidades foram consideradas: calcificação do anel mitral, mixoma calcificado, outras neoplasias ou pseudoneoplasias cardíacas, abscesso cardíaco, tuberculose, tumor amorfo calcificado ou vegetações valvares calcificadas. O diagnóstico preciso é obviamente essencial para o tratamento adequado.Dada a insuficiência cardíaca progressiva, o paciente foi submetido a transplante cardíaco. Durante os primeiros dias de pós-operatório do paciente, instabilidade hemodinâmica grave e insuficiência cardíaca aguda sugeriram rejeição primária do enxerto. Apesar da intervenção farmacológica para disfunção primária do enxerto, o paciente veio a óbito três dias após o transplante cardíaco.O coração explantado pesava 515 gramas e media 10,5 x 9,5 x 8,0 cm. Todas as quatro câmaras estavam significativamente dilatadas. Uma valva bioprotética estava presente no orifício atrioventricular esquerdo; as outras três valvas eram nativas, incluindo uma valva aórtica mista estenótica e regurgitante, mostrando fusão e encurtamento dos folhetos, altamente sugestivos de cardiopatia reumática. Na porção anterior do miocárdio, na junção atrioventricular esquerda, havia uma massa oval, amarelo-acinzentada, medindo 3,3 x 2,3 cm, com bordas bem definidas e regulares e calcificação periférica fina. Após o coração ter sido seccionado, observou-se o vazamento de uma pequena quantidade de conteúdo pastoso (semelhante ao caseum) . Microsc2 Geralmente assintomática, a CAM é comumente identificada através do ecocardiograma. A calcificação caseosa do anel mitral (CCAM) é uma variante rara da CAM, representada por uma massa intramiocárdica redonda contendo abundante material pastoso ou espesso, constituído por ácidos graxos, colesterol e cálcio;5 raramente a lesão parece surgir do folheto da valva mitral.5 Também geralmente assintomática e mais prevalente em idosos, pode-se suspeitar de CCAM pelo ecocardiograma, que mostra uma massa com bordas distintas e área ecolucente central, sugestiva de liquefação na região do anel mitral.5 No presente caso, não houve suspeita clínica de CCAM.A calcificação do anel mitral (CAM) é uma lesão crônico-degenerativa que acomete principalmente indivíduos idosos, e principalmente mulheres e pacientes com doença em estágio terminal ou anormalidades no metabolismo do cálcio.7 Sua etiopatogenia é amplamente desconhecida. Consideramos a doença reumática concomitante em nosso paciente como mera coincidência.Nos exames de ecocardiografia, a CCAM é vista em 0,04% a 0,07% da população geral e em 0,06% dos pacientes com CAM.4 No presente caso, é difícil atribuir as manifestações clínicas à CCAM, pois muitas delas poderiam ser claramente explicadas pela insuficiência cardíaca causada pela doença reumática e fibrilação atrial. Nos pacientes assintomáticos, um ecocardiograma incidental pode levantar a suspeita. Em nosso paciente, dois ecocardiogramas não foram capazes de detectar a lesão. Em alguns pacientes, o diagnóstico é feito na autópsia4 ou em um coração explantado, como observado neste caso.Na maioria dos pacientes, a lesão é clinicamente assintomática. Quando presentes, os sinais e sintomas mais comuns estão relacionados à insuficiência mitral.8 Em geral, é encontrado ao redor do anel mitral. Histologicamente,a lesão contém uma camada fibrosa de tecido conjuntivo com depósitos de cálcio, células mononucleares inflamatórias e células gigantes multinucleadas circundando um material amorfo abundante.O diagnóstico de calcificação caseosa do anel mitral é estabelecido pelo exame anatomopatológico. Macroscopicamente, a CCAM é uma lesão arredondada com bordas distintas e uma área central contendo material caseoso, variando em tamanho de 1,5 a 4,0 cm.13Os diagnósticos diferenciais mais importantes incluem mixoma cardíaco, geralmente móvel, pedunculado e localizado ao longo do septo interatrial, abscessos e pseudoaneurismas, cujo conteúdo, embora pastoso, carece de depósitos de cálcio e tumor amorfo cardíaco calcificado, uma lesão constituída por tecido fibroso colagenoso denso com nódulos de cálcio, sem constituinte pastoso.5 Além de ser uma intervenção curativa, o procedimento cirúrgico é o melhor método de obtenção de amostras para o diagnóstico morfológico. Às vezes, a lesão regride espontaneamente.4 O prognóstico, geralmente bom, depende do tamanho da lesão, sua localização e padrão de crescimento.A abordagem terapêutica, em geral conservadora, é pautada pelas implicações clínicas. Em pacientes com insuficiência mitral, a cirurgia cardíaca é indicada. 3 The majority of the patients is asymptomatic, but signs and symptoms of mitral regurgitation, systemic embolization and atrioventricular blocks have been described.³ The diagnosis is confirmed by anatomopathologic examination. The prognosis is good. Here, we present a caseous calcification of the mitral annulus case diagnosed after the pathologic analysis of explanted heart.Caseous calcified mitral annulus is a non-neoplastic cardiac lesion considered to be a variant of mitral annular calcification that should be suspected when heart masses are detected by echocardiogram, chest x-ray or other radiologic studies.A 35-year-old man with diagnosis of heart failure (stage III by New York Heart Association Classification) secondary to rheumatic heart disease was admitted at a tertiary public University Hospital for heart transplantation. He had been having recurrent hospitalizations due to chronic heart failure. Physical examination showed edema of the lower limbs, lateral dislocation of apex heartbeat, irregular heart rhythm, presence of the third heart sound, and early systolic and mid-diastolic murmur at the apex of the heart. The chest x-ray revealed a hyperdense lesion localized at the heart next to the mitral valve  and 2. TAt the age of 15, the patient went through a bioprosthetic mitral valve replacement to treat the rheumatic mitral valve disease, requiring two subsequent reoperations (age 21 and 23). For the last three years, despite optimal medical therapy, his heart function had continually deteriorated. There were no other comorbidities in his past medical history.Laboratory findings showed a reduced kidney function . Electrocardiogram was remarkable for atrial fibrillation.The main diagnostic hypothesis was advanced heart failure caused by bioprosthetic mitral valve dysfunction. For a heart mass visualized on the x-ray, some possibilities were considered: mitral annular calcification, calcified myxoma, other cardiac neoplasms or pseudoneoplasms, cardiac abscess, tuberculosis, calcified amorphous tumor or calcified valvar vegetations. The precise diagnosis is obviously essential for the appropriate treatment.Given the progressive cardiac failure, the patient went through heart transplantation. During the patient's first postoperative days, severe hemodynamic instability and acute heart failure suggested primary graft rejection. Despite pharmacological intervention for primary graft dysfunction, the patient died after three days of heart transplantation.The explanted heart weighed 515 grams and measured 10.5 x 9.5 x 8.0 cm. All for chambers were significantly dilated. A bioprosthetic valve was present on the left atrioventricular orifice; the other three valves were native, including a mixed stenotic and regurgitant aortic valve showing fusion and shortening of the leaflets, highly suggestive of rheumatic heart disease. On the anterior portion of the myocardium, at the left atrioventricular junction, there was a gray-yellow, oval mass of 3.3 x 2.3 cm, with well-demarcated and regular borders and thin peripheric calcification. After cutting, a small amount of pasty content (similar to caseum) leaked . Microsc2 Usually asymptomatic, CMA is commonly recognized by echocardiography. Caseous calcification of mitral annulus (CCMA) is a rarely CMA variant represented by a round intramyocardial mass containing abundant pasty or putty-like material composed by fatty acids, cholesterol and calcium;5 rarely, the lesion appears to arise from de mitral valve leaflet.5 Also generally asymptomatic and more prevalent in the elderly, CCMA can be suspected by echocardiography, which shows a mass with distinct borders and a central echolucent area suggestive of liquefaction in the annular mitral region.5 In the current case, CCMA was not clinically suspected.Calcification of mitral annulus (CMA) is a chronic degenerative lesion that affects mainly older people, especially women and patients with end-stage disease or abnormalities in calcium metabolism.7 Its ethiopatogenesis is largely unknown. We consider the concomitant rheumatic disease in our patient as merely coincidental.In echocardiography examinations, CCMA is seen in 0.04% to 0.07% of the general population and in 0.06% of CMA patients.4 In the current case, it is difficult to attribute the clinical manifestations to the CCMA, since many of them could be clearly explained by heart failure due to rheumatic disease and atrial fibrillation. In the asymptomatic patients, an incidental echocardiogram may arise the suspicion. In our patient, two echocardiograms were not able to detect the lesion. In some patients, the diagnosis is made at autopsy4 or in an explanted heart, as occurred in this case.In most patients, the lesion is clinically asymptomatic. When present, the most common signs and symptoms relate to mitral insufficiency.8 In general, it is found around mitral annulus. Histologically, the lesion contains a fibrous layer of connective tissue with calcium deposits, inflammatory mononuclear cells and multinucleated giant cells surrounding an abundant amorphous material.Caseous calcification of mitral annulus’ diagnosis is established by anatomopathological examination. Macroscopically, CCMA is a round lesion with distinct borders and a central area containing caseous material, ranging from 1.5 to 4.0 cm.13The most important differential diagnoses include cardiac myxoma, which is usually mobile, pedunculated and located along interatrial septum, abscess and pseudoaneurysms, whose content, although pasty, lacks calcium deposits, and cardiac calcified amorphous tumor, a lesion composed of dense collagenous fibrous tissue with calcium nodules, without pasty constituent.5 Besides being a curative intervention, surgery is the method to obtain sample for morphological diagnosis. Sometimes, the lesion regress spontaneously.4 The prognosis, usually good, depends on its size, location and growth pattern.The therapeutic approach, in general conservative, is guided by the clinical repercussions. In patients with mitral regurgitation, cardiac surgery is indicated.


Acute abdominal pain caused by torsion of the pedunculated subserosal leiomyoma is rare. Miss diagnosis can lead to ischemia, necrosis, and subsequent peritonitis which may cause significant morbidity. Torsion of the leiomyoma should be recognized as a surgical emergency and once suspected, early surgical intervention should be considered.A 28-year-old woman with a medical history of uterine leiomyoma presented to our emergency department because of acute onset right lower abdominal pain.The computed tomography was performed which demonstrated multiple leiomyomas of variable sizes and a subserosal leiomyoma located at right lower abdomen with poor contrast enhancement.The gynecologist was consulted, and myomectomy was performed. The intraoperative finding showed a pedunculated subserosal leiomyoma with torsion.She underwent myomectomy for the twisted pedunculated subserosal leiomyoma as well as other leiomyomas and was discharged with a favorable outcome.Torsion of the leiomyoma is a surgical emergency as delayed in treatment may lead to marked morbidity. Once suspected, the gynecologist must be consulted, and surgical intervention should be considered. Wide range in prevalence was reported (4.5%–68.6%) based on the study populations and the imaging modalities. It is a benign tumor arising from the smooth muscle cells of the myometrium. Intrauterine leiomyomas are generally classified as submucosal, intramural, and subserosal according to their location in the uterus. The symptoms of uterine leimyomas are often chronic and may range from asymptomatic to abnormal uterine bleeding, bulk-related symptoms, and reproductive dysfunction. Acute abdominal pain caused by torsion of the pedunculated subserosal leiomyoma is rare and is often difficult to diagnose preoperatively. Miss diagnosis can lead to ischemia, necrosis, and subsequent peritonitis which may cause significant morbidity.,6 As a result, torsion of a pedunculated subserosal leiomyoma should be recognized as a surgical emergency. Once suspected, the gynecologist must be consulted, and early surgical intervention should be considered.Uterine leiomyomas, also known as uterine fibroids, are by far the most common pelvic tumor in females of reproductive age.A 28-year-old woman with a medical history of uterine leiomyoma presented to our emergency department because of acute onset right lower abdominal pain. The vital signs were stable without fever and there were no gastrointestinal tract or urinary symptoms. On physical examination, there was marked right lower abdominal tenderness. Laboratory data revealed WBC 10830, Hb 12.6 g/dL, C reactive protein 0.75 mg/L, and negative pregnancy test. Urine analysis showed only mild hematuria. Due to intractable pain, abdominal computed tomography (CT) was performed which demonstrated multiple leiomyomas of variable sizes and a subserosal leiomyoma located at right lower abdomen with poor contrast enhancement  is the most effective modality for visualizing the size and location of the uterine leiomyomas. Identifying a necrotic leiomyoma on the MRI and specifically with the presence of a pedicle between the leiomyoma and uterus is suggestive of torsion. However, because MRI requires a more stable patient, it is time-consuming to perform the examination, and relative lack of availability, the MRI may be difficult to apply in the emergency department for the evaluation of abdominal pain in regular daily practice.It may be challenging to diagnose a pedunculated subserosal leiomyoma with torsion preoperatively. Ultrasound is the most widely used imaging modality for evaluating leiomyomas due to its availability and cost-effectiveness. Torsion of the pedunculated subserosal leiomyoma should be suspected if color Doppler demonstrated a twisted pedicle or decreased vascular supply. However, ultrasound may be a less effective method if the twisted pedicle is thin or invisible.In our patient, the contrast enhanced CT scan is performed for the evaluation of acute and intractable abdominal pain. Serious lesions were excluded except a hypo-perfused subserosal leiomyoma. Based on the clinical presentation, laboratory study, and the image finding, ischemic pain from the subserosal leiomyoma was highly suspected. She underwent myomectomy for the twisted pedunculated subserosal leiomyoma as well as other leiomyomas and was discharged with a favorable outcome.Although rare, torsion of the pedunculated subserosal leiomyoma must be considered in females presenting with an acute onset lower abdominal pain. The diagnosis should base on the clinical presentations and image findings. Torsion of the leiomyoma is a surgical emergency as delayed in treatment may lead to marked morbidity. Once suspected, the gynecologist must be consulted, and surgical intervention should be considered.Writing – original draft: Ching-Tang Chang.Writing – review & editing: Ching-Di Chang, Sieh-Yang Lee.


O exame anatomopatológico revelou sarcoma cardíaco pleomórfico primário indiferenciado.Paciente do sexo feminino, 49 anos, caucasiana, com história prévia de FA paroxística, encaminhada para ablação eletiva de FA em quem foi identificada incidentalmente uma massa em átrio esquerdo (AE) em tomografia computadorizada cardíaca pré-intervenção (TCC). Ela não tinha sintomas relacionados à massa.Na avaliação inicial, o eletrocardiograma (ECG) estava em ritmo sinusal. O exame físico e a análise laboratorial completa não revelaram achados anormais.Além da história de FA paroxística, diagnosticada dois anos antes, a paciente era saudável. As medicações à admissão eram edoxabano (nas últimas 2 semanas antes da ablação), flecainida e bisoprolol, com controle subótimo do ritmo.Uma massa séssil homogênea, hipodensa, levemente irregular, localizada na parede posterior do AE, envolvendo ambos os óstios das veias pulmonares direitas (VPD), estava presente na TCC . Após esO estudo ecocardiográfico transtorácico revelou uma massa densa, irregular e espessada no teto do AE próximo à entrada das VPD . O ecocaNa ressonância magnética cardíaca (RMC), uma massa claramente definida com um diâmetro máximo de 32 mm foi mostrada. Esta era isointensa nas sequências ponderadas em T1, brilhante nas sequências ponderadas em T2, com alguma perfusão heterogênea e realce tardio com gadolínio .Suspeitou-se inicialmente de mixoma por ser a massa incidental assintomática mais comum, além do trombo, com origem no átrio esquerdo. Neste caso, a ausência de pedículo, as características imagológicas e a sua localização específica ao longo da parede posterior e superior do AE levantaram a suspeita de outra entidade clínica, nomeadamente com possível comportamento maligno.Dada a suspeita de malignidade, um F-18 FDG PET/CT foi realizado para identificar tanto o tumor primário quanto as possíveis lesões associadas à distância. Foi identificada uma massa solitária em átrio esquerdo. Realizou-se TC de corpo inteiro para estadiamento, que foi negativa para doença extracardíaca.Diante do diagnóstico presuntivo de tumor cardíaco primário de comportamento potencialmente maligno, seja por extensão local ou risco embólico, optou-se por proceder à ressecção cirúrgica para fins diagnósticos e terapêuticos. No intraoperatório, a massa ressecada estendeu-se pela parede posterior do AE até a comissura anterior do anel mitral, sem infiltração das veias pulmonares. A infiltração posterior da massa com descolamento incompleto forçou a necessidade de reconstrução do septo atrial e interatrial usando um segmento de pericárdio. A recuperação pós-operatória transcorreu sem intercorrências.A avaliação macroscópica revelou um fragmento elástico irregular de 50x25x10 mm . O exameA paciente recebeu alta no nono dia após a cirurgia. Ela foi encaminhada para terapia adjuvante. No quinto mês de seguimento já tinha completado 2 ciclos de quimioterapia com doxorrubicina e ifosfamida e encontra-se agora fazendo radioterapia com evolução clínica sem intercorrências.2 São tumores agressivos que podem ser sintomáticos ou, se não produzirem sintomas até que estejam localmente avançados, como no caso relatado, são encontrados incidentalmente durante um estudo de imagem cardíaca.3 Costumam ocorrer em pacientes jovens com idade média de 44 anos e estão distribuídos aproximadamente igualmente entre os sexos.4 Os sarcomas cardíacos, embora extremamente raros, são as lesões malignas primárias mais comuns.6 Dependendo do subtipo, podem surgir de células mesenquimais de ventrículos, átrios ou pericárdio. Essas malignidades proliferam rapidamente e causam a morte por infiltração generalizada do miocárdio, obstrução dos principais vasos cardíacos e/ou metástases à distância.7Os tumores primários do coração são entidades extremamente raras, com incidência inferior a 0,1 por cento.9 Embora os sarcomas cardíacos são tumores altamente invasivos, margens cirúrgicas claras são difíceis de obter e, portanto, podem recorrer facilmente, destacando a necessidade de tratamentos locais e sistêmicos mais eficazes que podem ser usados em conjunto com a cirurgia para melhorar os resultados dos pacientes.10 A sobrevida média ao diagnóstico é de 6 a 12 meses, mesmo após a excisão cirúrgica completa.4A ressecção cirúrgica é o tratamento local mais eficaz para sarcomas cardíacos, principalmente em pacientes com doença não metastática.As neoplasias cardíacas primárias são entidades muito raras, sendo anedóticas como achados assintomáticos. O local de inserção e algumas características de imagem, apenas totalmente detalhadas sob avaliação multimodal, fornecem pistas para o diagnóstico diferencial, nomeadamente com lesões benignas mais comuns. O uso de ferramentas avançadas de imagem para estadiamento é fundamental na definição da estratégia de tratamento mais adequada. A ressecção cirúrgica completa é solicitada como a primeira opção. 3Primary cardiac tumors are rare, and their clinical presentation ranges from incidental discovery on imaging tests to life-threatening presentations.We report a case of a young female with a history of atrial fibrillation (AF) who was found a left atrial mass in an elective cardiac computed tomography performed before AF-ablation and was qualified for surgical resection of the mass. A pathological exam revealed a primary undifferentiated pleomorphic cardiac sarcoma.A 49 year-old Caucasian female with a previous history of paroxysmal AF, referred for elective percutaneous AF-catheter ablation, was referred to the hospital due to a left atrial (LA) mass incidentally identified at pre-interventional cardiac computed tomography (CCT). She had no symptoms related to the mass.On initial evaluation, an electrocardiogram (ECG) was in sinus rhythm. Physical examination and full laboratory analysis revealed no abnormal findings.Beyond the history of paroxysmal AF, diagnosed two years before, the patient was otherwise healthy. The medications on admission were edoxaban (in the last 2 weeks before ablation), flecainide and bisoprolol, with sub-optimal rhythm control.A homogenous, hypodense, slightly irregular sessile mass localized in the posterior wall of the LA, involving both ostia of the right pulmonary veins (RPV), was present in CCT . After tThe transthoracic echocardiographic study revealed a dense, irregular, thickened ceiling mass of the LA roof near to RPV entrance . TransesAt cardiac magnetic resonance (CMR) study, a clearly defined mass with a maximum 32 mm diameter was shown. This was isointense at T1-weighed sequences, bright at T2-weighed sequences, with some heterogeneous perfusion and late gadolinium enhancement .A myxoma was initially suspected as it represents the most common asymptomatic incidental mass, beyond thrombus, arising in the left atrium. In this case, the absence of a pedicle, several imagological features and its specific location along the posterior and superior LA wall raised the suspicion of another clinical entity, namely possible malignant behavior.Given the suspicion of malignancy, an F-18 FDG PET/CT was performed to identify both primary tumor and potential distant associated lesions. A solitary left atrial mass was identified. A complete body CT scan was performed for staging purposes, and it was negative for extra-cardiac disease.Given the presumptive diagnosis of a primary cardiac tumor of potential malignant behavior, either for local extension or embolic risk, a decision was made to proceed with surgical resection for diagnostic and treatment purposes. Intraoperatively, the resected mass extended through the posterior wall of LA until the anterior commissure of the mitral annulus, without pulmonary veins infiltration. Posterior infiltration with incomplete mass detachment forced the need for both atrial and inter-atrial septum reconstruction using a pericardial patch. Postoperative recovery was uneventful.The macroscopic evaluation revealed an irregular elastic fragment of 50x25x10 mm . HistopaThe patient was discharged on the ninth day after surgery. She was referred for adjuvant therapy. At the fifth month of follow-up, she had already completed 2 cycles of chemotherapy with doxorubicin and ifosfamide and is now performing radiotherapy with an uneventful clinical course.2 They are aggressive tumors that may be symptomatic or, if they do not produce symptoms until they are locally advanced, as in the case reported, they are found incidentally during a cardiac imaging study.3 They tend to occur in young patients with a mean age of 44 years and are approximately equally distributed between the sexes.4 Cardiac sarcomas, albeit extremely rare, are the most common primary malignant lesions.6 Depending on the subtype, they can arise from mesenchymal cells of ventricles, atria or pericardium. These malignancies proliferate quickly and cause death through widespread infiltration of the myocardium, obstruction of major cardiac vessels, and/or distant metastases.7Primary tumors of the heart are extremely rare entities, with less than 0.1 percent incidence.9 Although cardiac sarcomas are highly invasive tumors, clear surgical margins are difficult to obtain, and so they can easily recur, highlighting the need for more effective local and systemic treatments that may be used in conjunction with surgery to improve patient outcomes.10 Median survival at diagnosis is 6 to 12 months even after complete surgical excision.4Surgical resection is the most effective local treatment for cardiac sarcomas, mainly in patients with nonmetastatic disease.Primary cardiac malignancies are very rare entities, being anecdotal as asymptomatic findings. Insertion location and some imaging features, only fully detailed under multimodality assessment, provide clues toward differential diagnosis, namely with more common benign lesions. The use of advanced imaging tools for staging is key when defining the most appropriate treatment strategy. Complete surgical resection is prompted as the first option.


Colorectal cancer may masquerade as acute diverticulitis. Our case is a 71-year-old man who presented to the emergency department with abdominal pain and was diagnosed with acute diverticulitis. He was ultimately found to have metastatic hepatocellular carcinoma to the colon without any evidence of diverticular disease on colonoscopy. Although the most common malignancy to masquerade as diverticulitis is colorectal cancer, metastatic deposits should also be considered, especially in patients with a history of extracolonic malignancy. A review in 2013 found underlying colorectal cancer in 1.6% of patients with acute diverticulitis.4 When compared with an age and sex-adjusted reference population, the risk of colorectal cancer after acute diverticulitis was found to be 44-fold higher.5Diverticulosis is a common condition, present in over 50% of Americans aged 60 years and older.Guidelines recommend performing a colonoscopy 6–8 weeks after resolution of symptoms to rule out an underlying colonic malignancy. In this case report, we present a unique case of metastatic hepatocellular carcinoma (HCC) mimicking acute diverticulitis in a patient with a history of HCC that had been in remission.A 71-year-old man presented to the emergency department with a 1-week history of generalized abdominal pain and fatigue. Medical history included orthotopic liver transplantation performed 7 years earlier, for hepatitis C-related cirrhosis complicated by HCC. He was on tacrolimus for immunosuppression. Two years before, he had recurrence with metastasis to the left adrenal gland, which was resected. Notably, his HCC had been in remission on surveillance computed tomography and magnetic resonance imaging of his abdomen and pelvis, with his most recent examinations performed just 10 days before presentation.In the emergency department, he was afebrile with normal vital signs. A complete blood count and comprehensive metabolic panel were within normal limits. Abdominal computed tomography with intravenous contrast revealed acute complicated diverticulitis of the descending colon with a 1.4 cm intramural abscess and 1.1 cm abscess adjacent to the colon. These findings were new compared with abdominal cross-sectional imaging obtained 10 days before. There were no liver lesions. He was hospitalized and managed conservatively with bowel rest, intravenous fluids, and antibiotics. After a few days, his symptoms improved and he was discharged home with oral antibiotics. Two months later, he underwent a colonoscopy showing a small area of subtle irregularity in the descending colon that was concerning for a possible infiltrative lesion Figure . The pat6 Metastasis to other parts of the gastrointestinal (GI) tract is less common and previously estimated to affect ∼2% of patients with HCC.7 A recent review by Yu et al regarding metastasis in patients with HCC surmised that upper GI sites  are more likely locations of metastasis because these are subject to direct invasion by the primary tumor.8 Lower GI tract sites  otherwise are unlikely targets for metastasis because of their location far from direct invasion and downstream from portal venous flow.8 The most frequent sites of colonic involvement include the ascending and transverse colon, with only one case reported of distal colonic involvement. A case series of HCC with colonic metastasis by Yu et al found that the most common presenting finding was GI bleeding.9 None of the patients in this review manifested with findings of acute diverticulitis.Extrahepatic metastases in patients with HCC are not rare and the most common locations include the lungs, lymph nodes, bones, and adrenal glands.10 Multiple reviews have found the risk of occult malignancy to be significantly higher in patients with complicated as opposed to uncomplicated diverticulitis. The American Gastroenterological Association recommends all patients with an episode of complicated diverticulitis (and those after a first episode of acute uncomplicated diverticulitis) to undergo colonoscopy 6–8 weeks after the resolution of symptoms.11 This recommendation is also supported by guidelines from the American Society of Colon and Rectal Surgeons.12Most cases of acute diverticulitis are uncomplicated, with only an estimated 10% of patients presenting with complicated disease.13These guidelines exist primarily to exclude colorectal cancer. However, it is important to remember that other malignancies may also metastasize to the colon and masquerade as acute diverticulitis. Such lesions may appear as ill-defined and possibly subepithelial in origin, as in the case of our patient, contrary to the classical findings of primary colorectal cancer which the endoscopist may be looking for. Moreover, patients with a history of liver transplant are at increased risk of solid organ cancers, a component of which may be due to adverse effects of immunosuppressive drugs .In summary, we present a case of recurrent HCC with metastasis to the descending colon masquerading as a case of acute complicated diverticulitis. In patients with a history of extracolonic malignancies, metastatic deposits should be considered in the differential diagnosis of acute diverticulitis and colonoscopy should be performed after symptom resolution. This case also emphasizes the importance of adherence to established guidelines regarding follow-up colonoscopy for patients with acute diverticulitis.Author contributions: T. Brotherton and AM Al-Taee wrote the initial draft of the report. D. Carpenter provided images and descriptions of pathology slides. AR Cheesman served as supervising physician on the case who reviewed and edited the manuscript before submission. T. Brotherton is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.


Actinomyces species, which are anaerobic Gram-positive bacteria that normally colonize the human oral cavity and digestive and urogenital tracts. Although this lesion often occurs on soft tissue around the mandible, cases localized in the lip are very uncommon. We encountered a patient with actinomycosis in the lower lip. A 76-year-old woman with a 5-mm submucosal nodule of the lower lip was referred to our hospital from a dental clinic. The clinical diagnosis was a benign submucosal tumor. Total excision and histological examination were conducted. No oral antibiotic therapy was prescribed. The histological diagnosis was actinomycosis. The postoperative course was uneventful with no signs of recurrence during the 6 months after surgery.Actinomycosis is usually a chronic infectious disease caused by  Actinomyces israelii is known as the most common causative organism [Actinomycosis is a chronic disease caused by the anaerobic Gram-positive bacterium Actinomyces, and organism , 2. Althorganism . Actinomorganism –8. In thA 76-year-old woman with a 2-month history of a submucosal mass on her lower lip was referred to our hospital. She had not received any treatment for the lesion as she had no history of fever, pain, or trauma. An intraoral clinical examination revealed a nonmovable asymptomatic submucosal nodule ~5 mm in diameter on the right side of the lower lip . A whitiThe clinical diagnosis of a possible benign submucosal tumor was based on the clinical examination findings and the lesion's appearance. A complete excision was performed with the patient under local anesthesia to obtain the histological diagnosis. The surgeon decided not to prescribe antibiotics because the excision was not complex.Low-power microscopy revealed the bacterial colony within a dilated salivary gland duct in a submucosal area which was covered by non-atypical squamous epithelium . An abscSeveral clinical types of actinomycosis have been described, including actinomycosis at a cervicofacial, thoracic, abdominal, or female genitalia site; ~50% of the reported cases occurred in the cervicofacial region , 10. TheFirst, an excisional biopsy is practical for the final diagnosis of actinomycosis involving the lip. A histological examination plus bacterial culture has been considered the gold standard for diagnosing cervicofacial actinomycosis . HoweverSecond, no considerable advantage in prescribing antibiotics may be obtained by treating actinomycosis with a small and limited lesion. Although it is known that actinomycosis can be treated with penicillin , 13, ourThird, we suspect that the lesion in our patient's case was due mainly to the bacterial infection via a duct of a minor salivary gland. Dental manipulation, soft tissue injury, odontogenic infection, poor oral hygiene, diabetes, immunosuppression, malnutrition, irradiation, and neoplasm have each been associated with cervicofacial actinomycosis . Dental In conclusion, a microscopic examination is essential to achieve an accurate diagnosis of actinomycosis involving the lip. Although oral antibiotic therapy may not be necessary for small and localized lesions, further studies are required to clarify this. Our patient's actinomycosis of the lower lip might have been caused by the bacterial infection via a duct of a minor salivary gland.


Epithelioid hemangioma (EH) is an uncommon benign vascular tumor of mesenchymal origin. It mainly presents as expanding nodules around the ear, the forehead, and long bones. Only a handful of cases have been found in cervical, thoracic, lumbar, and sacral vertebrae as lytic lesions with pain and neurological impairment. We present the case of a 36-year-old female with an incidental finding of a sacral mass along with inguinal lymphadenopathy on imaging. Initially, there were no symptoms. The mass gradually progressed and later showed an extraosseous extension with involvement of sacral neural foramina and nerve roots causing severe low back pain and weakness of the left lower extremity. Differential diagnoses initially included secondary metastases and chordoma. However, the biopsy of the mass revealed findings consistent with an EH. To our knowledge, this is the first case of EH presenting as an isolated mass in the sacrum and the third case of EH involving the sacrum in continuation with other vertebrae. EH should be in our differential diagnoses when there is a sacral mass. Epithelioid hemangioma (EH) is a benign vascular tumor. It commonly affects people aged 20-50 years, with no gender predilection overall ; howeverHere, we report a rare case of a 36-year-old female who was incidentally found to have a sacral mass on imaging which was later consistent with an EH on biopsy. To our knowledge, this is the first case of sacral EH without the involvement of other vertebrae and the third case of vertebral EH in continuation with other vertebrae.A 36-year-old female with a medical history of diabetes, asthma, and hypertension presented with generalized swelling of the body and shortness of breath for three days.Vital signs were stable except for blood pressure of 220/110 mmHg. Physical examination was significant for pitting edema of bilateral lower extremities. Laboratory tests were unremarkable. Chest X-ray was suggestive of pulmonary vascular congestion. The patient was admitted for a hypertensive emergency.In the inpatient unit, the patient had diffuse abdominal pain. To determine the cause, a CT scan of the abdomen and pelvis without contrast was done which showed a sacral mass Figure .MRI of the lumbar spine also showed a sacral mass primarily centrally located extending between the right S1-2 and S2-3 sacral foramina , carbohydrate antigen (CA)-19-9, and alfa fetoprotein (AFP) were within the normal range. Pheochromocytoma was ruled out. Before the workup could be completed, the patient left against medical advice and did not follow up for further management.Five months later, the patient presented to the emergency department with severe low back pain radiating to the left flank for two days. There was decreased power (3/5) in the left lower extremity. A repeat MRI of the lumbosacral spine redemonstrated the sacrum mass which now had a more expansile appearance with an extraosseous extension in S2-4 vertebrae.The main differential diagnoses considered were chordoma, giant cell tumor, and metastatic disease. Multiple myeloma was also considered, but clinical and laboratory findings were not suggestive of multiple myeloma. A sacral bone biopsy was performed. While waiting for the results of the biopsy, a CT of the chest, abdomen, and pelvis with intravenous contrast was done which showed progression of osteolytic and destructive lesions in the sacrum associated with large soft-tissue components and stable bilateral inguinal adenopathy Figure .A preliminary pathology report showed concern for metastatic adenocarcinoma. Slides were sent to another referral center for a second opinion. Immunohistochemical stains were negative for AE1/AE3, cytokeratin (CK)7, CK20, paired-box gene 8 (PAX8), GATA binding protein 3 (GATA3), Mammaglobin, gross cystic disease fluid protein 15 (GCDFP-15), S100, thyroid transcription factor-1 (TTF-1), Napsin A, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (Her2) but positive for CD31 and ETS-related gene (ERG), confirming the endothelial differentiation. Ki-67 stain showed a low proliferative rate of 5% Figures -6.Overall, the findings were consistent with an EH. The patient was referred to a higher center for a sacrectomy.When a patient presents with a vertebral mass, metastatic cancer versus primary tumor is the main concern. Metastatic tumors are the most common tumors of the spine 97%) [7% [9]. TIn our case, apart from a metastatic tumor, chordoma and GCT, being the two most common primary sacral tumors, were our top differential diagnoses. In chordoma, an X-ray shows osteolytic lesions of the sacrum with mass and calcifications in soft tissue. On CT scans, bone destruction with an associated lobulated midline soft-tissue mass is typically seen . MRI shoEH is a mesenchymal tumor of vascular origin. The presence of osseous EH involving the spine is less common. As in our case, the EH of the spine may have locally aggressive features with progressive expansile nature. It may present with pain and/or neurological impairment due to the destruction of the bone causing instability or pathologic fractures . Plain rHistologically, the proliferation of blood vessels with epithelial endothelial cells is observed. Endothelial cells are so dense that vascular spaces are sometimes difficult to assess and aggregates can look like granulomas. A collection of lymphocytes and numerous eosinophils accompany vascular proliferation . ImmunohVarious treatment options such as en bloc resection, curettage, pre/postoperative embolization, radiation, and microwave ablation have been used either alone or in combination with success. Local recurrence was reported in 11% of patients in a series of 36 patients with EH of bone treated with curettage, local resection, and radiotherapy . In suchWhenever there is a radiological finding of a sacral mass, either with or without neurological involvement and/or low back pain, EH, although very rare, should be in our differential diagnoses. EH initially can be an incidental finding. However, patients should undergo a prompt evaluation as EH may become symptomatic gradually with pain and weakness from neurological impairment due to extraosseous extension of the tumor.


Giant bladder stones, weighing more than 100 g, are a rare entity in western practice, usually associated with bladder outlet obstruction, urinary tract infections, or the presence of intravesical foreign bodies. We present a case of a 53-year-old man with a giant bladder stone weighing 600 g. He underwent suprapubic cystolithotomy, had no major surgical complications, and was discharged with a significantly improved urine flow stream. Prevalence of urolithiasis in developed countries is between 4% and 20% . BladderA 53-year-old man presented to the emergency department complaining of dysuria and intermittent gross hematuria. From his medical history, he had an open ureterolithotomy surgery on his right ureter 15 years ago. He reported having a pigtail end left in his right ureter from this surgery due to an unsuccessful attempt to remove it and negligence of his own to find a solution. An x-ray showed a bladder stone measuring 9 x 8.7 cm and a stone in his right kidney measuring 4.7 x 3.7 cm (Figure The patient received intravenous ciprofloxacin and underwent open cystolithotomy, which revealed a giant stone weighting 600 g Figure . Both suBladder stones comprise approximately 5% of all cases of urolithiasis . As for Conservative management includes medical treatment with oral urine alkalization for uric acid stones with urine pH > 6.5. Extracorporeal shock wave lithotripsy is another option for the treatment of bladder stones. It is a safe and effective method for patients with high anesthetic risk, patients fearing anesthesia or endoscopic procedures, and patients who have difficulty in positioning. The treatment of choice for bladder stones is usually transurethral cystolithotripsy as it has high stone free rate, shorter hospital stay than other procedures and less pain . HoweverGiant bladder stones are not common today. They can present with symptoms that do not predispose them to such a rare entity. Treatment modality for each patient differs with respect to the size of the stone and feasibility of the surgery. Usually, open cystolithotomy is the most effective treatment. In the current era of endourology and minimal invasive surgery, open cystolithotomy still has a place in the urological armamentarium.


Helicobacter pylori infection. However, some examples show that lymphoma regressed when H. pylori were removed.The body contains mucosa-associated lymphoid tissue (MALT), with the greatest amount located in the gastrointestinal (Gl) tract. Lymphoma may form when the cell growth in this tissue is aberrant. The small intestine is a common extranodular site of lymphoma, a systemic illness. Additionally, it has been proposed that MALT lymphomas (MALTomas) arise as a result of chronic and persistent immunological activation, either of an autoimmune or infectious type. The MALToma that develops in the duodenum is typically thought to be unrelated to  Mucosa-associated lymphoid tissue (MALT) lymphoma was described first by Isaacson (&) Wright in 1983. They found that the peripheral lymph nodes and MALT shared more histological characteristics with primary low-grade gastric B cell lymphomas and immunoproliferative intestinal illness. The MALTomas can develop at a variety of extranodal sites, such as the stomach (70%), the lung 14%), the ocular adnexa 12%), the thyroid (4%), and the small intestine [%, the th%, the ocA 38-year-old male patient developed sudden onset of pain in the abdomen, which was colicky in nature, non-radiating, moderate to severe, gradually progressive in intensity, and associated with one episode of non-bilious non-projectile vomiting with food and water content. He had not passed stools for the past two days. There was no history of fever, cough, or burning micturition. There was no significant past medical or surgical history. He occasionally drank about 60ml of alcohol once a month. The general physical and systemic examinations were normal except for tenderness in the right iliac fossa. Contrast-enhanced computed tomography (CECT) abdomen and pelvis was done which was suggestive of telescopic appearance in the ileal segment intussusception. The patient underwent resection and anastomosis of the ileal segment Figures , 2.Postoperatively the specimen was examined and the gross appearance of the resected ileal segment was suggestive of a growth over which intussusception was present Figure . The specimen was sent for histopathological examination and was suggestive of non-Hodgkin's lymphoma Figures , 5.The patient's postoperative period was uneventful, and he was discharged with a follow-up date six months post-surgery.Helicobacter pylori infection and gastric MALTomas. This is the most prevalent infectious agent connected to worldwide cancers during an H. pylori infection. Three chromosomal translocations, namely t , t, and t, help turn healthy B cells into cancerous clones. Nuclear factor kappa B (NF-B), which is implicated in immunity, inflammatory processes, and apoptosis, is stimulated as a result of these translocations [H. pylori infection. However, some examples show that lymphoma regressed when H. pylori were removed.The most amount of MALT is located in the GI tract. Lymphoma may form when the cell growth in this tissue is aberrant. A MALToma of the GI tract makes up 50% of cases that are present. The small intestine, the stomach, and the colon are the next most frequent sites where a MALToma can occur. Small intestine lymphomas specifically account for up to 40% of primary GI lymphomas and 25% of primary malignancies at this level. The small intestine is a common extra-nodular site of lymphoma, which is a systemic illness . The ileely t11;1 (q21;921ocations . The invH. pylori infection, leaving the cause of this condition unexplained. Nearly half of the patients present with a single tumor that resembles a carcinoma in physical appearance; multiple masses or lymphomatoid polyposis are less common [An unusual discovery in our case is the MALToma in the ileum. According to early descriptions, the endoscopic pattern consists of many reddish or white masses with a polished and smooth mucosa look. Five patterns were distinguished in the first classification of ileal lymphoma endoscopic features: mucosal fold thickening alone, nodular pattern, infiltrating pattern, ulcerative pattern, and mosaic pattern . Even ths common . By perfs common . For thes common .The most sensitive procedures are endoscopic submucosal resection or ultrasound-guided endoscopic fine-needle aspiration biopsy . NongastH. pylori, which is a major factor in the formation of MALToma, should be the first line of treatment. It is difficult to make a quick clinical diagnosis because the diagnosis is only made intraoperatively for intestinal blockage. The incorporation of both chemotherapy and surgery is thought to be superior to other approaches. In the case described above, the ileal segment was resected and anastomosis was done. The incidence rate as well as the proper diagnostic and treatment procedure for intestinal MALToma is not standardized in previous studies and literature, which proves to be a major problem. The third most prevalent non-lymphoma Hodgkin's subtype is MALToma. Since MALToma of the ileum is uncommon, treating