Craniocerebral metastases as the initial spread of supraglottic squamous cell carcinoma (SCC) are exceptional. The presence of several months' history of dysphagia, dyspnea, cachexia, tobacco/alcohol abuse, and seizure(s) is suspicious of craniocerebral metastases from an advanced‐stage supraglottic SCC. Physicians should be aware since early diagnosis and treatment may increase patient survival. Craniocerebral metastases as the initial spread of supraglottic squamous cell carcinoma (SCC) are exceptional. The presence of several months' history of dysphagia, dyspnea, cachexia, tobacco/alcohol abuse, and seizure(s) is suspicious of craniocerebral metastases from an advanced‐stage supraglottic SCC. Physicians should be aware since early diagnosis, and treatment may increase patient survival. Tobacco and alcohol consumption are described as the main risk factors for laryngeal SCC development. Locoregional spreading through contiguous structures and lymphatic extension is the most frequent dissemination pattern for laryngeal SCC.The incidence of symptomatic distant metastases from laryngeal SCC ranges from 1 to 4%, and the lung is among the most common sites of distant spread, followed by bone and liver.Of note, after conducting a literature review, we only found nine reported cases with intra‐ and extracranial metastases resulting from the spread of a supraglottic SCC.2A 71‐year‐old man with a 50‐year history of tobacco and alcohol abuse presented to the emergency department with a focal to bilateral tonic‐clonic seizure, lasting 2‐3 minutes, followed by drowsiness and confusion. He had a 6‐month history of dysphagia, dyspnea, and 22‐kg weight loss, along with hoarseness since last month. His past medical history was otherwise normal.3/µL), probably due to the seizure.On examination, he was cachectic and had an evident inspiratory stridor and a painless forehead lump. Apart from that, chest X‐ray and laboratory results were normal, except for an elevation of creatine kinase (553 IU/L) and white blood cell count  scan was obtained, showing a frontal osteolytic mass Figure A and rin3We decided to commence the patient on levetiracetam administered intravenously. He became seizure‐free after starting at 1000 mg of levetiracetam twice daily.In light of patient's history, clinical evolution, and highlights from examination, diagnostic workup was completed with a laryngoscopy, which revealed a supraglottic exophytic lesion invading both the trachea and the esophagus. Pathological findings disclosed a poorly differentiated supraglottic SCC Figure . Whole‐bHe was diagnosed with supraglottic SCC (stage IVC) and underwent total laryngectomy, bilateral cervical lymphadenectomy, and adjuvant chemoradiotherapy. Unfortunately, he died on the fifth postoperative month due to acute respiratory failure from aspiration pneumonia.4There is a consensus that adults with an unprovoked first seizure should undergo neuroimaging to identify any process, which may be the seizure trigger. CT is usually easily available and rules out problems that deserve urgent attention in the emergency department and therefore preferred over magnetic resonance imaging (MRI).Initiating antiepileptic drug (AED) therapy is recommended after the first seizure in patients at higher recurrence risk , because high‐risk patients with early AED treatment present a slightly more favorable long‐term outcome compared with those in whom it is delayed. Levetiracetam is indicated as first‐line monotherapy, being as efficacious as carbamazepine, for new‐onset focal seizures, with or without secondary generalization, but with no clinical hepatotoxicity, something to bear in mind before a patient with history of alcohol abuse.Computed tomography scanning and MRI are helpful studies for determining the spread of supraglottic cancer.Furthermore, whole‐body multidetector computed tomography (WB‐MDCT) provides a high‐resolution imaging of cortical and trabecular bone with a short acquisition time, for approximately one minute. This technique provides a cost‐effective and patient‐friendly diagnostic tool, as well as an appropriate image quality to assess normal osseous architecture. The principal limitation of WB‐MDCT is its high radiation dose. Further studies regarding low‐radiation‐dose applications of this imaging modality are warranted.Moreover, cross‐sectional cranial imaging with CT and MRI could be useful for differentiating tumours from resembling lesions in renal osteodystrophy patients. In this scenario, we can find brown tumours presenting as focal reactive bone remodeling lesions with multiple cystic and/or mixed lesions, uremic leontiasis ossea characterized by serpiginous tunneling or channelling within the bone and poor visualization of the cortical bone, and dystrophic calcification with calcified soft‐tissue masses. It is recommended that clinical features be correlated with laboratory and radiological results to make a definitive diagnosis.Klebsiella rhinoscleromatis, specifically for evaluating the inferior extension of subglottic scleroma and its invasion into the trachea, along with distinguishing between sclerotic and granulomatous stages.In addition, MRI is essential for the differential diagnosis of a subglottic mass when suspecting laryngoscleroma, a chronic granulomatous inflammation caused by a Gram‐negative diplobacillus, On the other hand, it is worth mentioning a state‐of‐the‐art MRI technique such as arterial spin labeling (ASL), which does not require an exogenous contrast agent administration. Besides, it is noninvasive, nonionizing radiation, repeated safe, and able to supply quantitative values. It has a role in the characterization and grading of brain tumours, differentiation from mimicking lesions, pretreatment assessment, monitoring of treatment response, and discrimination of tumour recurrence from posttreatment changes. Its limitations include a low signal‐to‐noise ratio of tumour blood flow (TBF) maps and the potential for systematic measurement errors because of a prolonged transit delay between the tagging area and the imaging slice. Further research addressing parameters standardization of different ASL vendors is needed.The key clinical feature of this case is the conjunction of patient's history and neuroimaging and histopathological findings. Supraglottic cancer causes late‐onset symptoms, including dysphagia, trouble breathing, and voice changes, so is often diagnosed in evolved stages and may present with metastases in distant organs, owing to rich lymphatic supply in the supraglottic larynx.There is no standardized treatment for advanced (stages III and IV) supraglottic tumours,Ultimately, brain metastases are a very rare initial spread due to laryngeal SCC. Although this occurrence has been adequately published in scientific literature,5In short, this case illustrates the extremely uncommon presentation of a patient with a painless forehead lump and a seizure owing to extra‐ and intracranial metastases, respectively, as the initial feature of a supraglottic SCC. The conjunction of unexplained significant weight loss, chronic hoarseness or voice change, neurological symptoms ), a forehead lump, and brain metastases should raise suspicion for an advanced supraglottic SCC, in order to ameliorate the disease course.The authors have no conflict of interest to disclose.ML‐R and JB‐L: involved in substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafted the article or revised it critically for important intellectual content; and involved in final approval of the version to be published.


Hip replacement is the surgery of the last century due to its impact on the quality of life. A pseudotumour is a rare complication of hip arthroplasty, and it is related to a metal-bearing surface. Pseudotumour is a challenging scenario for hip surgeons due to poor clinical outcomes. The patient consulted for hip pain and paresthesia in the left lower extremity, and analyses showed that the cause was a sizeable intrapelvic pseudotumour. A multidisciplinary team surgery was planned. At first, an infraumbilical approach was made to resect the intrapelvic-retroperitoneum portion of the pseudotumour. Then, a posterolateral hip approach was performed, to resect the remaining portion of the pseudotumour and revision arthroplasty. At five years of follow-up, there are no clinical or imaging signs of recurrence of the pseudotumour. Treatment evidence is limited to a series of cases and expert opinions; we encourage complete resection and revision arthroplasty. Hip replacement is the surgery of the last century due to its impact on the life of quality . DiffereTwo major concerns for HRA are described: a higher incidence of neck fracture because, for design, more stress is placed in the neck of the femur and the other concern is metal ion risk . All proThe most specific histological finding of a pseudotumor is a lymphocytic immune response described as an aseptic lymphocytic injury-associated vasculitis (ALVAL) . Its forThe surgical treatment of pseudotumour is a theme of discussion, and only a few clinical series have been published . TreatmeOur purpose is to report the case of a patient in which a complete resection of an intrapelvic pseudotumor that compromised the retroperitoneum, following an HRA, was performed, showing no signs of recurrence after five years of follow-up.A 46-year-old female patient underwent a left hip resurfacing arthroplasty  for severe hip osteoarthritis, secondary to developmental hip dysplasia, in 2005. She had a good initial outcome with no complications. The surgery was performed in another centre.She consulted with us for the first time six years later (2011) complaining about hip pain and paresthesia in the anterior left thigh, which progressively compromised her function. She denied fever or other signs of infection. Physical exams revealed a mild claudication gait and limited active and passive hip flexion. No palpable masses or skin lesions were observed. Laboratory analyses showed a WBC, ESR, and CRP within normal limits. No signs of osteolysis were found in the hip anteroposterior radiography; nevertheless, a vertical cup was noted . It was Computed tomography and an MRI demonstrated a biloculate hypodense mass of approximately 34 × 19 cm that extended from the retroperitoneum, compromising the left iliopsoas muscle and an intimate contact with the femoral vessels, to the left hip and the left femoral-cutaneous nerve Figures  and 3. AThus, a pseudotumour was the diagnosis, and surgery led by an orthopaedic surgeon and a coloproctology surgeon was planned. The aim was to remove the pseudotumor entirely and to perform an RHA. As the CT shows , the intFirst, the patient was positioned supine, and an infraumbilical laparotomy was performed; the left paracolic gutter was dissected to address the retroperitoneum. The iliac vessels and the left ureter were protected, and an irregular cystic mass was observed in direct contact with the psoas muscle and femoral bundle. It was punctured, and an abundant grey milky-like fluid was obtained. The membrane of the cyst was carefully removed, protecting the vessels and the femoral nerve. The lesion was completely resected, and samples were sent for biopsy and cultures .Then, the patient was repositioned in lateral decubitus, and a posterolateral hip approach was performed. The capsule was looking distend; it was punctured and then, a 30 cc fluid was obtained, similar to the liquid found in the retroperitoneum. After capsulotomy and femoral neck osteotomy, all arthroplasty components were removed, noticing an anterosuperior wall defect in the acetabulum. After complete pseudotumour resection, RHA was performed . The aceHistopathological findings confirm the pseudotumour. The analyses reported an extensive aseptic inflammatory infiltrate of macrophages with detritus inside near a necrotic tissue area . A PAS hNo early- or late-surgery complication is reported. Since post surgery, the patient progressively recovers the hip's range of motion and normal gait. In the last follow-up, 60 months postoperatively, the patient is in excellent condition with no functional limitations and a full hip range of motion. Radiological exams, which included an annual MRI, showed no pseudotumour formation and no arthroplasty loosening. The MRI at five years of follow-up is shown in Pseudotumour is a rare complication of hip arthroplasty, and it is related to a metal-bearing surface . The treIt is well known that pseudotumour goes underdiagnosed; recent studies show that the prevalence of pseudotumour could be higher than previously reported . In a coPseudotumour diagnosis is not easy as patients remain asymptomatic for a long time. As it is a well-known complication, screening with images must be performed on all prosthesis with a metal-bearing surface . MoreoveAnother issue that cannot be missed is that infection must be ruled out, as it is also a complication of THA and it transcends all prosthesis design . For thiRegarding the aetiology of pseudotumours, current evidence attributes it to an adverse reaction to metal debris. Some studies indicate that this is due to a local inflammatory response to wear of the metal surface, which develops a granulomatous-like reaction proportional to the amount of the wear debris, and it correlates with the amount of metal ions in plasma , 24. BesPseudotumour, as it has been established in previous paragraphs, is not an exclusive complication of RHA, but of those that use metal on metal-bearing surface. Even more, few cases have been reported supporting that pseudotumour could also be triggered by metal ion release from the head-neck taper junction in cases were no metal on metal-bearing surface was used . The higThere are only case report evidences of the surgical treatment of this pathology –35. ConsRegarding RHA, a bone defect caused by the pseudotumour is an issue. In this case, fortunately, it was resolved by standard components, and it was not necessary to use complex revision arthroplasty components that add morbidity to the surgery. However, we consider that performing a RHA is not easy or risk exempt. In a study that compares the result of 53 revisions of different implants of Birmingham® hip resurfacing, the author concluded that the incidence of major complications after RHAs for pseudotumour (50%) was significantly higher than that of after RHAs for other causes (14%). The authors concluded that the outcome of revision for pseudotumour (16 cases) is poor, so consideration should be given to an early RHA before the tumour grows and a significant bone defect is present .This case represents a rare but devastating complication related to metal-bearing surface arthroplasty, particularly to HRA. Currently, the evidence shows that the incidence of pseudotumours and the rate of revision for pseudotumours are higher than initially reported. So, the indication of a metal-bearing surface is questionable given the higher rate of early RHA compared to other bearing surfaces such as polyethylene or ceramic. The most remarkable of this case is that after complete pseudotumour resection and RHA, at five years of follow up, the patient achieved a complete range of motion, no pain, no limp, and no sign of recurrence in MRI. We encourage that for such cases, MRI for diagnosis should be performed, arthrocentesis to rule out infection, and complete resection of the pseudotumour and hip revision for treatment led by a multidisciplinary team. Also, we are in favour of not using the metal-bearing surface as the first option .


Duodenal necrosis is a rare complication of acute pancreatitis but can occur given the shared blood supply to the head of the pancreas and the duodenum.A 55-year-old male presented with acute-on-chronic pancreatitis and a duodenal hematoma. The hematoma expanded to occlude the biliary tree and, shortly after, the duodenum necrosed and perforated. The patient required an emergent pancreaticoduodenectomy performed in two stages.Surgical management is complex and a difficult challenge for a general surgeon. Many advocate for wide drainage to create a controlled fistula using a malecot through the wall defect/separate duodenotomy/a retrograde jejunostomy tube. This case represents an extreme variation on this issue which was best managed by definitive resection given the extent of the necrosis.This case report demonstrates that duodenal hematoma and necrosis should be recognized as part of the spectrum of consequences of acute pancreatitis. General surgeons should have a surgical approach to this complication whether that be diversion or definitive resection. The mos2A 55-year-old male who presented with new onset of abdominal pain to a peripheral hospital. He had a past history of ulcerative colitis, alcoholic pancreatitis, non-alcoholic steatohepatitis, COPD and GERD. His blood work demonstrated pancreatitis (lipase 1440), and jaundice . A CT abdomen/pelvis was performed which showed a new duodenal mass with obstruction A. In retOn arrival, the patient was afebrile with ongoing jaundice . An MR pancreas was performed which suggested that the mass in the duodenum was likely a hematoma.He required drainage of his biliary tree and an ERCP was attempted for biliary decompression which was unsuccessful. The following morning, he was peritonitic with a rigid abdomen. A repeat CT abdomen and pelvis was performed which demonstrated free air and mild free fluid in keeping with bowel perforation presumably from the duodenum D. The duThe patient was taken to the operating room urgently as he was becoming increasingly hemodynamically unwell. He was found to have a completely necrotic duodenum from D1-D4 A with thCareful examination of the excised specimen revealed multiple defects within the serosa overlying the duodenum A, arrowsMicroscopic examination of the proximal pancreatic head revealed several prominent cystically dilated pancreatic ducts A, c contReconstruction was performed on postoperative day 2 in a standard reconstruction with a two-layer pancreatico-jejunostomy (PJ), a single-layer hepatico-jejunostomy and a handsewn double-layer gastrojejunostomy. A total pancreatectomy was not considered as the cut edge of the pancreas was healthy and, despite the higher risk of initial complications by performing a PJ, the benefit of residual pancreas in the long-term out weighted these risks in our opinion. On postoperative day 12 he experienced a fascial dehiscence and required a third operation to washout the abdomen and required placement of retention sutures. Subsequent to this last procedure, he developed an infection which grew E. coli, Raoultella, and mixed flora from the drain in his abdomen. He required IV imipenem and fluconazole. He proceeded to have a type II pancreatojejunostomy leak, which was managed medically with octreotide and TPN. He was repatriated to his home hospital on post-operative day 36 once weaned off of TPN.3nd and 3rd portions of the duodenum are involved as the 1st and 4th portions are supplied by separate arteries  [Duodenal necrosis is a rare complication of pancreatitis. The underlying pathophysiology is related to vascular compromise and resulting ischemia. Pancreatitis releases enzymes and inflammatory products which can cause thrombosis of the anterior and posterior superior and inferior pancreaticoduodenal arteries or can directly affect the adjacent duodenum. This leads to transmural infarction of the duodenal wall ,13. Mostrteries) ,13.Intramural hematoma may be part of this pathologic process and may cause rupture of the duodenal wall causing peritonitis and shock . In thisMost often, necrosis affects the medial side of the duodenum as seen in previous case reports by Takeyama and Sakorafas ,13. Our The diagnosis is currently made on axial imaging. However, if the diagnosis is made intra-operatively, bile-stained peritoneal fluid is a sign of duodenal perforation and requires complete inspection of the entire duodenum . If perfSurgical management is complex and a difficult challenge for a general surgeon. Primary repair is not recommended as the rate of failure is high due to the surrounding inflammation and tissue friability. Other repairs similarly may fail due to these issues such as a onlay-type Roux- en-Y duodenojejunostomy. Other case reports have recommended wide drainage to create a controlled fistula using a malecot through the wall defect/separate duodenotomy/ a retrograde jejunostomy tube. Pyloric exclusion with gastrojejunostomy is an additional option .In this patient’s case, the plan in advance of surgery was a more conservative surgical option. However, given the extent of necrosis and the perforation of almost the entire lateral wall of the second and third portions of the duodenum, a damage-control pancreaticoduodenectomy was performed. There are limited case reports that advocate this approach . We recoThis case report demonstrates that duodenal hematoma and duodenal necrosis should be recognized as part of the spectrum of rare consequences of pancreatitis. General surgeons should have a surgical approach to this complication whether that be diversion or resection given the high morbidity and mortality of this disease.There is no funding for our work.There is no ethical approval at our institution for case reports.Patient has consented to this case report and there is a sentence in the manuscript that states this.Jennifer Koichopolos – main author, did case review and literature review and wrote paper.Jonathan Keow – wrote pathology descriptions and created pathology figures.Jeremy Parfitt – staff pathologist that reviewed Jonathan Keow’s work.Daniele Wiseman and Cathy Yoshy – staff radiologist that reviewed the imaging in combination and selected images for the paper.Ken Leslie – PI for this case report, reviewed the paper in its entirety and suggested changes.researchregistry4803.Dr Ken Leslie is the guarantor of this study.Not commissioned, externally peer-reviewed.No authors have conflicts, financial or personal relationships with other people or organizations that could influence our work.


High grade astrocytomas such as anaplastic astrocytoma and glioblastoma multiforme are aggressive central nervous system malignancies with a poor prognosis. Due to shortened survival times, their devastating effects are usually localized intracranially and rarely metastasize outside of the central nervous system. When metastases occur, they usually present in patients with longer survival times and they typically coincide with a primary site recurrence. We present a rare case of metastases from a high-grade astrocytoma/glioblastoma to the pleura, bones and liver within six months of diagnosis, without primary site recurrence. High-grade astrocytomas or glioblastomas are aggressive primary central nervous system (CNS) tumors with overall poor prognosis. They are typically divided into three categories: anaplastic astrocytomas, anaplastic oligodendroglioma and glioblastoma multiforme and are graded from III-IV . GlioblaA 56-year-old Caucasian male with past medical history of a high-grade astrocytoma of the right temporal lobe presented to the oncology clinic with dyspnea and palpitations for several weeks. He had been diagnosed with high-grade astrocytoma six months prior, which was treated with surgical resection and was followed by concurrent chemotherapy and radiation for six weeks with temozolomide with subsequent maintenance temozolomide. Pathology from his original brain tumor noted mixed features of an anaplastic pleomorphic xanthoastrocytoma (PXA) with atypical features versus glioblastoma. The pathologist described an astrocytic neoplasm composed of cells with variable polymorphism, brisk mitotic activity including atypical forms, and necrosis were present. Immunohistochemistry (IHC) stains were positive for glial fibrillary acidic protein (GFAP), oligodendroglial lineage 2 (OLIG2) and cellular differentiation 34 marker (CD34). The tumor did not harbor isocitrate dehydrogenase 1 (IDH-1), methylguanine-DNA methyltransferase (MGMT) or B-raf proto-oncogene serine/threonine kinase (BRAF) mutations.2 on days one through five every 28 days. On physical exam, he was found to be tachycardic with a heart rate in the 150s with an irregularly irregular rhythm. On physical exam, he was noted to have decreased breath sounds to auscultation on the right and dullness to percussion in the mid to lower right hemithorax. He was admitted to the hospital for further evaluation. Computed tomography (CT) of the chest showed a pulmonary embolus in the left pulmonary artery in addition to a large pleural effusion on the right with pleural thickening and a nodular appearance. There was a new hypodense lesion in the superior part of the liver measuring 2.7 x 2.3 cm with multiple lytic bone lesions on CT of the abdomen. A bone scan confirmed the metastatic nature of bone lesions. Magnetic resonance imaging (MRI) of the brain showed abnormal enhancement in the middle cranial fossa, which was thought to be related to prior treatment. Anti-coagulation with heparin was initiated for treatment of the pulmonary embolus. Thoracentesis revealed the effusion to be exudative and cytology was significant for atypical cells. Thoracoscopy was performed for pleural biopsy and on examination, classic pleural studding was noted (Figure TM catheter and was discharged home on anticoagulation therapy. Upon discharge and finalization of pathology report, the patient was offered chemotherapy with bevacizumab, but the patient opted to be placed in hospice and subsequently died a few weeks later.Upon presentation to our clinic, the patient was still receiving maintenance therapy with temozolomide 200 mg/mMalignant gliomas are some of the most common brain tumors and generally have a poor prognosis . TreatmeThere are many hypotheses that attempt to explain why this particular type of tumor usually does not spread beyond the brain parenchyma. One hypothesis notes that the rarity of metastases may be explained both by shortened overall survival in addition to the peculiarity of the brain lymphatic system ,11. The In conclusion, extracranial metastasis of high grade astrocytomas is very rare. Lung, lymph nodes, and bone are among the most commonly affected sites. It may or may not occur with a recurrence at the primary tumor site. The radiologic and clinical findings are nonspecific and it can mimic any other metastatic disease. Time to onset of metastases usually occurs in those patients with longer survivals. A high degree of suspicion is needed for early diagnosis and management of patients with this disease in order to hasten diagnosis, management and ultimately, survival.


Teratomas and lymphatic malformations are included in the differential diagnosis of congenital neck masses. They can exhibit similar clinical findings. The authors present a case of mature teratoma that had been managed as a lymphatic malformation for years. Clinicians should be careful not to dismiss clues for the correct diagnosis. Teratomas are germ-cell tumors composed of tissues derived from multiple germ-cell layers. They occasionally develop in cervical lesions, and are included in the differential diagnosis of congenital neck masses. Lymphatic malformations (LMs) are also one of these differentials; however, their physical and imaging findings are occasionally similar and can be confused with one another.OK-432 sclerotherapy is one treatment used to shrink the cystic component of LMs. Because of their similarity, misdiagnosed teratomas may undergo sclerotherapy, which is assumed to be ineffective. We present a rare case of pharynx and parotid gland mature teratoma, which had been shrunk by multiple sclerotherapy sessions until the patient was five years of age. Due to an uncommon medical history and reaction to sclerotherapy, this teratoma was believed to be an LM until surgical resection demonstrated otherwise when the patient was six years of age. We reviewed the literature to determine the appropriate approach to clinical diagnosis.An infant boy with a congenital left neck mass was referred to pediatricians at a local university hospital. Magnetic resonance imaging (MRI) revealed a multi-cystic mass located near the pharynx and parotid gland . This paThe surgeon recommended surgical resection as an LM, and the patient was referred to the authors’ department at 5 years of age. Ultrasound (US) revealed virtually no cystic component and no fluid flow, which is consistent with LM, scar tissue, and blood clots due to previous sclerotherapy.When the patient was 6 years of age, surgical resection was planned. Intra-operatively, a smooth cystic mass was found between the parotid gland and sternocleidomastoid muscle. The mass was aspirated directly to deflate it with the aim of easier resection. The internal liquid was dull beige in color. The base of the mass was in contact with the internal carotid artery and vein. The mass was completely excised. On examination, it was composed of cystic and solid components, with bone- and tooth-like tissue, hair, and sebaceous sebum matter .Cytological examination of the internal liquid revealed squamous and inflammatory cells and necrotic material. On pathological examination, the mass contained choroid and anterior pituitary gland tissue, skin with accessory glands, and adipose tissue . No immaDifferential diagnosis of congenital neck masses include variety of diseases. They are classified in three categories: inflammatory, neoplastic and congenital. Congenital neck masses include branchial cleft cysts, thyroglossal duct cysts, laryngocele, ranula, dermoid cyst, and thymic cyst ; teratomTeratomas are a type of germ-cell tumor, and more than one-half are located in the sacrococcygeal area, followed by the ovary, testis, mediastinum, retroperitoneum, and cervical lesions. Cervical teratomas are uncommon and account for less than 3-5% ,3 of allLMs are benign, slow-flowing vascular lesions composed of dilated lymphatic channels or cysts lined with endothelial cells with a lymphatic phenotype. They are classified as macrocystic, microcystic, or mixed type according to their structure, and often develop in the cervicofacial and axillary area . OK-432 The relatively low incidence of teratomas and high incidence of LMs, and their similar clinical characteristics make it difficult to distinguish teratomas from LMs . The diaAs noted above, surgical removal should be first-line therapy if teratomas is suspicious. However, previous studies present clinical course of misdiagnosed cystic teratomas, which have been treated by OK-432 sclerotherapy as LMs.  Table 2Table 2. Sclerotherapy is not a radical treatment for teratoma. Moreover, it can make surgical resection difficult due to the scar tissue left behind. Because early removal is advised for teratoma, it is preferred to make a definitive diagnosis to clearly distinguish teratoma from LM before intervention. We reviewed the literature to determine the characteristics of provisional examinations.US is a convenient and popular method for initial assessment, while CT and MRI are both useful to evaluate the mass, in whole or in part, in different ways.Teratomas can be cystic, solid, or a combination of both, with proportions of each being variable. A mixed cystic/solid lesion highly suggests teratoma . On US, LMs usually present as a cystic lesion filled with lymphatic fluid. They are classified as macrocystic or microcystic according to structure. US reveals cystic lesions with a cyst wall of variable thickness. On CT, they appear as hypo-attenuated polycystic masses. On MRI, cystic components are hypo- to iso-intense on T1-weighted imaging, and hyper-intense on T2-weighted imaging. MRI imaging is the most reliable modality for characterizing the extent of the mass . HoweverIn the case presented, multiple sclerotherapy sessions had modified the structure of the teratoma. Even though mixed cystic/solid lesion suggests teratoma , the solIn summary, there can be virtually no differences between LMs and teratoma, especially when majority of the mass is composed of cystic lesion and no calcification. Small specific findings may exist; thus, careful examination is essential. We believe MRI is an appropriate option as initial clinical imaging for congenital neck mass, in order to avoid radiation exposure. However, in this case we presented, we should have taken a closer look at MRI and should have noticed small low intensity area that suggests calcification which indicates teratoma.Cytology is an assistive tool for diagnosis. Cells derived from multiple germ-cell layers usually indicate teratoma. However, puncture fluid consistent with lymph fluid is non-specific. A previous report described a case of teratoma in which repeated puncture fluid cytologies were consistent with lymph, and appropriate intervention was delayed until the patient was 3 years of age .To our knowledge, the specificity and sensitivity of cytology for teratoma and LM remain unclear. However, it makes sense that cells from more than 2 germ-cell layers are highly sensitive for teratoma. Because clinicians cannot diagnose LMs definitively without biopsy or surgical resection, it makes sense to conduct cytology and sclerotherapy at the same time and to confirm the diagnosis of LMs or to obtain clues for correct diagnosis. Cytology can be repeated to increase sensitivity for teratoma; however, its cost effectiveness is unknown. In our case, cytological results of the internal liquid, which contained squamous cells, should have raised the possibility of teratoma if the internal liquid was obtained by skin puncture.As noted above, teratomas tend to be misdiagnosed as other congenital neck masses, including LMs. To our knowledge, OK-432 sclerotherapy was performed for five cases of neck teratoma in the past due to initial misdiagnosis. In four of these cases, OK-432 did not affect the volume of the mass . HoweverOK-432 sclerotherapy provokes a strong local immunological reaction by many kinds of cytokines , which lOhtas et al attempted OK-432 sclerotherapy in 148 cases of otolaryngological cystic disease , and reported that it was effective in 76% of all cases . The autHowever, past systematic review shows only 83% of LMs decrease in size after sclerotherapy . To put Congenital neck teratomas can be similar to lymphatic malformations in clinical history, physical examination and diagnostic imaging findings, which lack high-specificity or high-sensitivity clues in most cases. Occasionally, they are ‘treated’ by OK-432 sclerotherapy, and even shrink as a result, which makes diagnosis even more difficult.Pathological evaluation is essential for definitive diagnosis of teratoma or most of the congenital neck mass; thus, careful attention is required in clinical history, examination, radiological findings. Biopsy or resection should be considered when diagnosis is suspicious.


A 74-year-old male patient was presented with scrotal swelling and a pulsatile mass of the left femoro-inguinal region. His medical history included hypertension, coronary artery disease, respiratory failure, and an aortobifemoral bypass surgery performed 7 years ago. Ultrasound evaluation revealed a massive scrotal hematoma. Computed tomography angiography (CTA) was conducted, confirming the aortobifemoral graft existence and revealing bilateral anastomotic pseudoaneurysms with the left one being ruptured, resulting in extension of the hematoma to the left femoro-inguinal region and the scrotum. An emergency surgery was performed, where proximal control of the left limb of the synthetic graft as well as distal control of the iliac vessels were accomplished. After the control of the hemorrhage, an iliofemoral bypass with a Polytetrafluoroethylene (PTFE) 6 mm synthetic graft was placed. Unfortunately, the patient passed away during the first postoperative day due to myocardial infarction. Taking into account the large number of reconstructive vascular procedures being performed in latest clinical practice, there is an expected increase in the number of post-procedural complications, including anastomotic pseudoaneurysm formation. If those anastomotic pseudoaneurysms are left untreated, they may lead to peripheral embolism or rupture, conditions that are limb or life-threatening respectively and in great need for immediate intervention . In thisA 74-year-old male patient came to our hospital's ER with a progressively enlarging scrotal edema of non-traumatic nature, noticed during the last few hours. Clinical examination at the Urology Department revealed hemodynamic stability and a painful pulsatile mass of the left femoro- inguinal region without any existing signs of local or systemic infection, causing however extreme discomfort to the patient. His past medical history included hypertension, coronary artery disease and respiratory failure, whereas his surgical history of interest included an aortobifemoral bypass surgery using a synthetic graft due to severe peripheral arterial disease, conducted 7 years ago. Ultrasound evaluation of the scrotum revealed scrotal hematoma existence. A triple phase computed tomography angiography (CTA) examination of the abdomen and pelvis was then performed using our Department's 64-detector row CT scanner  on an emergency basis, including unenhanced, arterial and portal phase post-IV contrast media administration. CT Angiography (CTA) protocol included supine patient positioning with hands above head and thin CT slices of 1.5 mm from the supraceliac aorta to proximal thighs. A total of 150 mL of non-ionic iodinated contrast material with iodine concentration of 370 mg/mL was used with a flow rate of 4 mL/sec, followed by saline flush. Both arterial and portal phase imaging were obtained using the fixed time-delay technique. Specifically, arterial phase CT angiographic images were obtained 25 sec after the onset of peripheral intravenous injection, whereas portal phase CT angiographic images were obtained 70 sec post contrast media injection. Maximum intensity projections (MIPs), oblique or curved multiplanar reformats and 3D volume-rendered (VR) images were also evaluated in addition to cross-sectional axial images. CTA showed the aortobifemoral graft and confirmed the clinical suspicion of a ruptured pseudoaneurysm at the distal end of the left limb of the graft , pseudoaneurysms represent by definition an arterial wall defect that allows luminal arterial blood communication with the adjacent soft tissue –4. They Although theoretically anastomotic pseudoaneurysms can develop at any anastomotic site, 80% of them appear at the femoro-inguinal region possibly because of acting forces from motion of the adjacent joint , 9. AnasIt is quite common for femoral pseudoaneurysms to measure up to 4 cm in diameter before being clinically identified and sometimes, they may exceed 15 cm before rupture . IndicatAccording to the current guidelines, CTA represents the reference non invasive imaging modality for the diagnosis of anastomotic pseudoaneurysms and their associated complications. It can also reveal signs of impending pseudoaneurysm rupture (fissure existence or lack of thrombus homogeneity), and help at therapeutic approach planning , 15. In Anastomotic pseudoaneurysm rupture constitutes a vascular emergency condition in great need for immediate surgical treatment, since there is always the risk of death due to excessive hemorrhage. Whenever a patient with a pulsatile mass and a medical history of vascular bypass surgery comes to the ER, clinical suspicion of the above complication should exist and a CTA must always take place on an emergency basis, as it highlights the pathology and it also helps decide the appropriate therapeutic approach.


The zone phenomenon is the most important diagnostic feature in differentiating myositis ossificans from malignancies such as osteosarcomas, which calcify from the center to the periphery and its presence in our late‐stage lesion was the key to diagnosis. The zone phenomenon is the most important diagnostic feature in differentiating myositis ossificans from malignancies such as osteosarcomas, which calcify from the center to the periphery and its presence in our late‐stage lesion was the key to diagnosis. A 53‐year‐old man presented with a 1‐year history of persistent, durable right shoulder pain. No trauma history was admitted. Initial workup consisted of a magnetic resonance imaging (MRI) of the right shoulder. Both T1‐ and T2‐weighted images revealed a round, well‐defined, inhomogeneous mass with signal intensity similar to fat, localized in the infraspinatus muscle. A mild, low‐signal, peripheral rim was evident Figure . MyositiMyositis ossificans typically has three stages of progression: the early stage, the intermediate stage, and the mature stage. Each of these stages is characterized by its own radiographical findings. In early stage, plain radiographs are usually normal or faint calcifications may be seen. During the intermediate stage, a peripheral calcification may be demonstrated whereas a mature lesion may appear with diffuse calcification, as the osteoid becomes mineralized. T1‐weighted images will demonstrate iso‐ to hyperintense‐signal, and T2‐weighted images will demonstrate a hyperintense inhomogeneous mass usually with diffuse surrounding edema. As the lesion progresses, it matures and calcifies from the periphery to the center, the so‐called “zone phenomenon. This centripetal pattern is the most important diagnostic feature in differentiating MO from malignancies such as osteosarcomas, which calcify from the center to the periphery, and its presence in our late‐stage lesion was the key to diagnosis. Additional imaging characteristics to this direction is the lack of invasion of adjacent tissues and the absence of muscle fibers within the lesion, often seen in tumors.None declared.Eliza Stavride: reviewed the literature, wrote the manuscript, and edited the images. Antonia Bintoudi: established the diagnosis, made a contribution to drafting, and reviewed the manuscript. Sofia – Chrysovalantou Zagalioti: contributed to review of the literature and drafting. Nikiforos Galanis: contributed to patient care and revised the manuscript.


A 59-year-old male with a medical history of abdominal aortic dissection underwent a follow-up computed tomography (CT) scan abdomen, which showed an incidental pleural-based mass in the left lung base. The patient underwent an ultrasound (US)-guided biopsy and the histology was consistent with spindle cell carcinoma (SpCC). Staging workup was concerning for a metastatic lesion on the adrenal gland. The patient refused surgery and was subsequently started on chemotherapy. SpCC is a rare histological variant of sarcomatoid carcinoma. The prognosis is generally poor and treatment is the same as for other non-small cell lung cancers (NSCLC). The literature on disease progression and treatment is limited. Sarcomatoid carcinoma (SC) of the lung are rare, comprising of a small subset of non–small cell lung cancer (NSCLC). According to the Surveillance, Epidemiology, and End Results (SEER) Database 1973-2013), SC was present in only 0.52% of all diagnosed cases of NSCLC 973-2013,. There iA 59-year-old African American male with a medical history of hypertension and abdominal aortic dissection presented to our medical clinic complaining of back pain for one month. He described it as dull, non-radiating, and with no associated motor or sensory weakness. The patient denied shortness of breath, chest pain, productive cough, weight loss, night sweats, or loss of appetite. Physical examination was unremarkable. The patient reported a 10-year pack smoking history. One year prior to the current presentation, he was admitted to our hospital with severe stabbing abdominal pain radiating to the back. Computed tomographic (CT) angiography was done which showed an abdominal aortic dissection extending from thoracic aorta to left common iliac artery that was managed conservatively with tight blood pressure control. The patient admitted to not having any follow-up imaging since discharge from the hospital.A CT scan of the abdomen and pelvis was ordered to evaluate the abdominal aortic dissection as the cause of his back pain. The results showed a stable long segment type B dissection of the descending thoracic aorta extending into the left common iliac artery. An incidental finding of a large lobulated pleural-based mass was also seen in the lower lobe of the left lung. A CT scan of the chest with contrast was ordered for better visualization of the mass, which again identified a large lobulated pleural-based mass in the posterior mediastinum measuring 21.5 x 9 x 10.2 cm  analysis was performed, which was positive for programmed death-ligand 1 (PD-L1) with a tumor proportion score (TPS) of 85 - 90% Figure .2. He was also started on Pembrolizumab, 200 mg intravenously (IV) to be given every third week, given the high-grade PD-L1 expression. The patient is scheduled for follow-up with a positron emission tomography (PET)-CT scan after completing his third cycle of chemotherapy.A bone scan and magnetic resonance imaging (MRI) of the abdomen and pelvis were done to determine the staging. A bone scan did not reveal any abnormal activity suggestive of osteoblastic metastatic disease. The MRI of the abdomen revealed a 2 cm x 2 cm left adrenal lesion suspicious for metastatic disease. The patient refused to undergo surgical evaluation for resection of the mass, so he was started on chemotherapy. So far, he has received one cycle of Carboplatin with a target area under the curve (AUC) of five, and Pemetrexed, 500 mg/mLittle is known about the clinical presentation of spindle cell carcinoma (SpCC). Our patient was incidentally diagnosed from a CT scan of the abdomen and did not have any symptoms pertinent to his diagnosis of SpCC. SpCC of the lung is more commonly seen as a peripheral lesion, which was consistent with the pleural-based lesion on the left lower lobe in our patient. Radiographically, SpCC lesions have been reported to have low-density regions in the center on CT scan, which was the case in our patient as well, having a low radiodensity of 5 Hounsfield units (HU) in the central region . SeventyPrognosis of SpCC is dismal. In the case series of 11 patients by Qi et al., only three patients out of 11 had a survival of more than two years . For patSpindle cell carcinoma (SpCC) is a very rare tumor with a poor prognosis. The literature on the treatment and disease progression is still very limited, and there is a need for publishing long-term follow-up of such patients.


To report a case of type III dens invaginatus associated with peri-invagination periodontitis in an immature permanent mandibular central incisor with open apex, in which only the invagination area was treated and vitality was preserved.A 9-year-old boy was referred complaining of pain in the mandibular left central incisor. After radiographic examination, an invagination into the pulp chamber of the tooth associated with periapical radiolucency was detected. Endodontic access was performed and the orifice was identified under a dental operating microscope. The invagination area was chemo-mechanically cleaned. After 1 week, the invagination was obturated with mineral trioxide aggregate. During the 2-year follow up period, the tooth was asymptomatic. Radiographic examination revealed significant progression of periapical healing and root development in the main root canal of the tooth.Non-surgical root canal treatment of the invagination may preserve pulp vitality, and continuous root development of the tooth. Dens invaginatus (DI) is a developmental anomaly, which results in the deepening or invagination of the enamel organ into the dental papilla before the calcification of dental tissues –3. It isWhile the tooth that is most frequently affected by DI is the permanent maxillary lateral incisor, the occurrence of DI in the mandibular central incisor is rare –8. The gA partial invagination limited to the crown of tooth in which the lesion does not extend pass the cementoenamel junction (CEJ) or the pulp was classified to Oehler Type I. In Oehler Type II, the partial invagination extends beyond the crown and CEJ. In type II, pulp may be involved but remain within the root anatomy and there is no communication of the lesion with periodontal ligament. Type III of this classification, in which the invagination continues apically through the root and shows a second foramen into the periodontal tissue, is of particular interest . Oehler Endodontic treatment of the invagination alone is advisable for maintaining the vitality of the main root canal pulp, particularly, if the affected tooth is an immature permanent tooth, with an open apex and vital pulp, while the invagination has a separate apical or lateral foramen. Although there are various management options for these cases, the aim of the treatment should be to maintain pulp vitality of the tooth for further root development.The present case report presents a case of type III DI associated with peri-invagination periodontitis in an immature permanent mandibular central incisor with open apex, in which only the invagination area was treated. Non-surgical root canal treatment of the invagination preserved vital pulp, and resulted in the resolution of a substantial peri-invagination lesion and continuous root development of the tooth.A 9-year-old boy complaining pain in the mandibular left central incisor was referred from the Department of Pedodontics in Pusan National University Dental Hospital after having clinical examination. He had recently developed acute and spontaneous pain in the region. Clinical examination revealed no intra- and extra-oral swelling. No specific medical, family and psychosocial history were reported. The central incisor was under eruption with a coronal anomaly. The clinical crown had a conical shape and was slightly larger than that of the contralateral tooth Fig. a and b. Periapical radiography revealed an invagination into the pulp chamber of the tooth and periapical radiolucency with a poorly defined border Fig. c and d. CBCT confirmed the diagnosis of DI with a periapical lesion, surrounded by enamel border in the crown Fig. . The sepThe malformation of the lower incisor made a size discrepancies and the lower dentition was not completely developed on the referral period. Extraction and orthodontic intervention were considered due to the root complexity and unconfident prognosis of conservative treatment. However, the patient’s parent want to keep the natural tooth and pain removal primarily. Patient’s parent agreed to try a conservative treatment with an expectation of potential future treatment of orthodontic and / or prosthetic treatments. The patient’s parent made a signature on the written informed consent form according to the guidelines of the Committee of Institutional Review Board (IRB) and IRB permitted the case report (PNUDH-2019-021).Under the infiltrative local anaesthesia using one cartridge (1.8 ml) of 2% Lidocaine HCl , endodontic access was performed with a small round bur  and safe-ended diamond bur . After access preparation, rubber dam was applied for tooth isolation. After careful inspection under a dental operating microscope , the orifice of invagination was identified using an endodontic explorer  and #15 K-file (Mani). There was no communication between the main root canal and invaginated canal. Upon access and negotiation of the dens, drainage of purulent and bloody exudation from the periapical tissues was obtained. After the enlargement of the narrow invagination, using a gate-glidden drill (Mani), the working length was determined with radiography and an electronic apex locator . The invaginated lumen was instrumented with stainless-steel hand K-files and nickel-titanium rotary instruments  with a caution not to over the length. During procedures, the dens was irrigated copiously with 2.5% sodium hypochlorite and saline. Irrigants were agitated using a sonic activated device  to obtain more effective chemical-debridement. The invaginated canal was instrumented to size #60, a calcium hydroxide paste  was applied, and the access cavity was sealed with temporary filling material . A periapical radiograph was acquired to confirm the canal shape after treatment. The orifice of invagination was very close to the main root canal  solution for 1 min, followed by the application of copious 2.5% sodium hypochlorite solution (NaOCl) using the Endo-Activator. The invaginated canal was then dried with sterilized paper points , before being obturated with mineral trioxide aggregate  using a lentulo spiral (Mani) and endodontic pluggers . A moist cotton plug was placed over the MTA. Access was sealed with a glass ionomer . The patient was recalled after 24 h and the tooth was verified using radiography  and the American Academy of Oral and Maxillofacial Radiology (AAOMR) Joint Position Statement, the limited fields of view should be considered the CBCT imaging modality of choice for initial treatment of teeth with dental anomalies, especially for the pediatric patients . HoweverIn case of immature permanent tooth with an open apex, in particular, as reported here, the aim of the treatment should be to maintain pulp vitality for further development of the root. If the invagination is necrotic or ‘peri-invagination periodontitis’ is present, but the main canal pulp remains healthy, then the invaginated canal alone has to be treated .Endodontic treatment in teeth of DI, which extends to the apical region and is associated with periapical pathosis, generally involves complicated procedures that require delicate and accurate diagnosis and proper treatment planning. Even in cases of Type III DI combined with a symptomatic periapical lesion, peri-invagination periodontitis can be successfully treated, with the use of contemporary endodontic materials, an operating microscope, and MTA. Maintaining the pulp vitality of the main canal allows root development to continue, guaranteeing long-term prognosis.


Metastatic tumors in the orbit, especially from gastric cancer, are rare. We present a rare case of extraocular muscle metastasis from gastric cancer and raise consideration of metastasis to extraocular muscle as a differential diagnosis of proptosis/lid swelling in a patient with history of malignancy.A 54-year-old Japanese woman presented with proptosis, lid swelling, diplopia, and retro-orbital pain in her left eye, which she had been experiencing for 1 day. She had a medical history of poorly differentiated adenocarcinoma of the stomach, which had metastasized to several organs. A computed tomography scan showed enlargement of the medial rectus muscle in her left eye. She was diagnosed as having gastric cancer metastasis to the medial rectus muscle of her left eye, and received a total of 20 Gy radiation therapy to the orbit, which resulted in resolution of her ocular symptoms. She died 3 months after her initial visit to our ophthalmic department.Metastasis from malignancy should be considered in the differential diagnosis of a patient presenting with proptosis or lid swelling who has a history of gastric cancer. Radiation therapy of metastases in the orbit may be an effective treatment in such cases. Metastatic tumors in the orbit, especially from gastric cancer, are rare in the USA, Europe, and Japan , 2. In JHere we report a case of metastases from gastric cancer to the medial rectus muscle of the left eye, as demonstrated by the clinical symptoms and CT imaging.A 54-year-old Japanese woman visited our ophthalmology department after experiencing proptosis, lid swelling, diplopia, and retro-orbital pain in her left eye lasting for 1 day. She had a medical history of poorly differentiated adenocarcinoma of the stomach, which had metastasized to her ovary and mesentery, diagnosed 2 years earlier. She had undergone four regimen courses of chemotherapy, yet these had failed and she thus received palliative treatment. There were metastases to subcutaneous tissue of her neck and thoracic bone marrow 3 months before her initial visit to our ophthalmic department. She had been admitted to our hospital 5 days previously without symptoms in either eye. She had undergone stenting in her esophagus against eating difficulties but she lived a self-reliant life at home.At her first visit, an external examination showed lid swelling, red coloration, and proptosis of her left eye. A motility examination revealed an adduction deficit of − 4.0 and an abduction deficit of − 1.0. Ophthalmological examinations revealed a best-corrected visual acuity of 20/20 and an intraocular pressure of 15 mmHg in both eyes. No abnormal findings were found in the anterior segment. Her pupils were equally reactive without any relative afferent pupillary defect. A funduscopic examination showed partial optic disc edema in her left eye .Extraocular muscle metastasis of gastric cancer is very rare. Symptoms such as diplopia and ocular pain are strong obstacles to QOL. It is difficult to diagnose extraocular muscle metastasis especially before symptoms develop, but it is necessary to follow up on patients with gastric cancer with the possibility of metastases to the orbit in mind.


Intramedullary schwannomas without neurofibromatosis are exceedingly rare. They are rarer in children with only 8 cases reported so far. The association of intramedullary schwannomas with syringomyelia is also rare. Here, we present a case of intramedullary schwannoma with syringomyelia treated surgically in an 9-year-old boy.We reviewed the clinical course of a 9-year-old boy, who presented with both lower extremity weakness of 6-month duration. Neurophysical examination revealed a decreased sensation below the T10 dermatome. Magnetic resonance imaging (MRI) showed an well-demarcated intramedullary lesion located at the level of T8 vertebra with isointensity on T2WI and hypointensity on T1WI, which was homogeneous enhanced after gadolinium injection. There was associated syringomyelia extending from T7 down to the level of T10. A mild scoliotic deformity was also observed. The lesion was totally resected after an T7-T8 laminoplasty. Histopathological findings were consistent with schwannoma. Postoperative MRI did not reveal the presence of a residual tumor with syringomyelia reducted. By 2 weeks after treatment, the patient had experienced nearly complete recovery. Management with external bracing was performed on this patient for 3 months after surgery to prevent spinal deformity. However, mild spinal kyphosis occurred 5 months after surgery, and a progressive postoperative spinal kyphosis was observed during these 3 years of follow-up. Continued conservative management with observation was performed as there is no association with functional decline and impairment in health-related quality-of-life measures.Although extremely rare and uncommonly associated with syringomyelia, schwannomas need to be considered in the preoperative diagnosis of solitary intramedullary tumors in children as total resection can be achieved improving surgical outcome; Pediatric patients should be monitored closely for the development of spinal deformity following resection of intramedullary schwannoma, particularly possessing preoperative scoliotic deformity and/or tumor-associated syringomyelia. Schwannomas are the most common primary tumors of the spine, and are usually located intradurally extramedullary . IntrameV/V) and decreased sensation below the T10 dermatome with bilateral knee tendon hyperreflexia and Babinski sign positive. Magnetic resonance imaging (MRI) showed an well-demarcated intramedullary lesion located at the level of T8 vertebra with isointensity on T2WI (Fig. A 9-year-old Han Chinese boy presented with both lower extremity weakness of 6-month duration. Neurophysical examination revealed weakness of the lower extremities (power grade I2WI Fig. . The pat2WI Fig. . The les2WI Fig. , and a pIntramedullary schwannomas are very rare, and only about 60 cases have been reported without neurofibromatosis and generally present in the fourth decade of life , 4, 5. IMRI is the modality of choice for diagnosing spinal cord tumors. Many imaging studies have been conducted to characterize intramedullary schwannoma. Intramedullary schwannomas are usually isointense or hypointense on T1-weighted images and hyperintense on T2-weighted images –10, 15. Total surgical resection should be attempted because of the benign nature of schwannomas , 4. HoweAlthough extremely rare and uncommonly associated with syringomyelia, schwannomas need to be considered in the preoperative diagnosis of solitary intramedullary tumors in children as total resection can be achieved improving surgical outcome; Pediatric patients should be monitored closely for the development of spinal deformity following resection of intramedullary schwannoma, particularly possessing preoperative scoliotic deformity and/or tumor-associated syringomyelia.


Actinomycosis is a rare infectious disease that presents as three entities, cervico-facial, abdominal and genital, with cervico-facial being the commonest. Due to its subacute presentation and indolent course, abdominal actinomycosis is difficult to diagnose and is often confused with malignancy. We present a case of an elderly diabetic with no known other risk factors of the disease with complaints of right sided abdominal swelling and presence of abdominal mass on imaging, diagnosed post operatively as a case of abdominal actinomycosis, on histopathology. Abdominal actinomycosis should be considered in differentials in cases with abdominal masses. Diabetes Mellitus is not an established risk factor for development of abdominal actinomycosis. Studies are required to link its association with the disease. Actinomyces israelli, a gram positive microaerophilic organism that is part of normal oral, gastrointestinal tract and genital tract flora.Actinomycosis is a rare, progressive infiltrating disease that is caused by A 61-year-old diabetic female patient, presented with the complaint of right sided abdominal swelling for the preceding two months. She had no history of trauma, surgery or immunosuppression. On examination, she had stable vitals and had an abdominal swelling. Ultrasonography showed a hypo-echoic mass arising from abdominal wall invaginating into peritoneal cavity. The case was further investigated using CT scan of abdomen and pelvis. A large soft tissue enhancing lesion, measuring 8.0 x 2.4 x 8.8 cm was noted to be arising from the mesentery and involving right lateral abdominal wall laterally and lateral wall of ascending colon extending upto the hepatic flexure medially, along with reactive adjacent wall thickening of colon. Surrounding pericolic fat stranding and puckering of the adjacent vessels were also seen. A few subcentimeter pericolic lymph nodes and multiple subcentimeter para-ortic and mesenteric lymph nodes were also present. The liver was enlarged. Radiological differentials included sclerosing mesenteritis, fibromatosis and pseudo-tumor. A right hemicolectomy was planned. Intra-operatively a hard 10 x 10 cm mass was seen arising from ascending colon and extending anterior to external oblique muscle. Approximately 15 cm of small bowel from ileo-cecal junction was found adherent to tumor. Small bowel, cecum, ascending colon and the ascending colon mass were resected. The specimen was sent for histopathology. The small bowel, cecum, appendix, ascending colon and hepatic flexure mass were received in formalin. Grossly, the small bowel mesentery along with peri-colonic fat of cecum and ascending colon showed an ulcerated nodular lesion measuring 10 x 9 x 7 cm. The lesion was adherent to wall of ascending colon and terminal ileum. At the periphery of lesion skeletal muscle fibers of external oblique muscle were seen.Sections examined reveal focally ulcerated small bowel mucosa with its wall and mesentery exhibiting a fibrotic area showing dense lymphoplasmacytic and neutrophilic infiltrate along with granulation tissue formation. There were centrally placed colonies of Actinomycetes composed of basophilic radial filaments, highlighted on special stain Gomori Methenamine Silver (GMS) stain Periodic acid–Schiff (PAS). Features were compatible with Actinomycosis.Nocardia and Streptomyces species.5Abdominal actinomycosis has been reported to be increasing  while the overall incidence of the disease is known to be decreasing.The findings in our case are consistent with other reports with mucosal breach present as a risk factor, however uptil now no association of diabetes mellitus and abdominal actinomycosis have been found.In conclusion, abdominal actinomycosis is a rare entity with non-specific radiological findings and may mimic malignancy and should be considered as a differential in cases presenting with abdominal masses on radiology. Early intervention and antibiotic course may prevent progress of the disease and development of complications associated with the disease. Association of abdominal actinomycosis. As such further studies are needed to explore their association.RAM: Took the history, handled the specimen and identified the etiology, drafting the initial case report manuscript, literature search.YS: Drafting the case report, literature search and gave intellectual input in the manuscript development.NY: Involved in micro-photography, final drafting and review of manuscript.


Introduction: Ectopic parathyroid glands occur in 6–16% of cases of PHPT and they constitute a potential cause of failed primary surgical therapy. In particular, aberrant adenomas located deeper in the mediastinum, as in the presented case, remain a severe challenge for the surgeons.Presentation of case: A 54-year-old Caucasian female proceeded to our institution with signs and symptoms of PHPT. Imaging studies performed identified a large mass localized in the lower anterior mediastinum, on the left of the median line. A mid-sternal thoracotomy was performed and the aberrant adenoma was finally detected anterior to the pericardium and the left pericardiophrenic vessels and the left phrenic nerve. The operation was uneventful. A meticulous review of the literature was conducted as well.Discussion: Single parathyroid adenomas are the key culprits of PHPT. Anatomic aberrations of the location of the parathyroid glands and their adenomas are more common than described in the literature and there are possible anatomic aberrations that have not been described yet. All these anatomic variations constitute major risk-factors of thoracic bleeding and of nerve injury.Conclusion: Detailed preoperative detection in addition to meticulous exposure of the operative field are fundamental in order to perform a safe adenoma excision without harmful impacts to the patient. Parat2A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia  and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).Then, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line . FollowiDuring the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve . The adeThen, the operation continued in the usual fashion and a drainage was placed into the left side of the thoracic cavity. The patient was discharged the 5th postoperative day with instructions, when the drainage was finally removed.Histology of the mass confirmed the diagnosis of ectopic parathyroid adenoma that was composed predominantly of oxyphil cells arranged in an acinar pattern. Serum calcium level was 2.60 mmol/L and iPTH 17.6 pg/mL 12 h after the operation. Serum calcium and iPTH remained normal after 6 months’ follow-up.3Primary hyperparathyroidism (PHPT) affects approximately 25 per 100,000 in the general population and it is more prevalent among older people, aged 50-years old or more, as in the presented case ,7. The dPHPT is caused by the presence of a single adenoma (75–85%), of a carcinoma 1%) or multiple adenomas (4–5%) and due to hyperplasia of the parathyroid glands 10–20%) as well [–20% as w% or multEctopic parathyroid glands have been firstly reported in 1932 by Churchil  and theiThe reported prevalence of ectopic parathyroid glands reaches up to 20% of the general population . Thus, iEctopic parathyroid adenomas are often detected either in the preoperative work up or in post parathyroidectomy patients with persistent hypercalcemia, as the localization of an ectopic parathyroid adenoma may be challenging . NeverthHowever, there is some controversy when it comes to choosing the optimal preoperative imaging techniques ,12,15. AIn the presented case, technetium sestamibi imaging was used in conjunction with CT for the establishment of the diagnosis of PHPT due to a large ectopic mediastinal parathyroid adenoma and for the prompt, preoperative planning of the safe surgical excision of the adenoma.Conclusively, there are several documented ectopic locations of single parathyroid adenomas into the mediastinum . Neverth4Imaging modalities are of paramount clinical importance in preoperative diagnostic steps of ectopic parathyroid adenomas. In fact, combination of several techniques, as in the presented case, may provide better localization of the ectopic adenoma and detection of its relationship with adjacent anatomical structures. Hence, meticulous preoperative detection of the mediastinal parathyroid adenoma and detailed exposure of the operative field is the cornerstone of a safe mid-sternal thoracotomy in addition to surgeons’ perpetual awareness concerning this scarce anatomical aberration.All authors declare that there are not any competing interests.There is no source of funding.This is a Case Report for which the patient provided written informed consent. Ethical approval has also been provided by the ethical committee of the General & Oncologic Hospital of Kifissia “Agii Anarguri”.Written consent for the publication of this case report and accompanying images was obtained from the patient. The consent can be provided to the Editor if he asks so. The written approval of the Ethical Committee of our Institution may be provided to the Editor as well.Mariolis-Sapsakos and Dimakakos conceived of the study. Sgantzos and Noussios were senior consultants at this case report and participated in its coordination. Zoulamoglou, Kakaviatos and Theodoropoulos contributed to the acquisition of clinical data, its analysis and interpretation and to the preparation of images. Tsiaoussis, Zarokosta, Kakaviatos and Piperos contributed to literature review. Zarokosta and Piperos contributed to the preparation of the manuscript. Mariolis-Sapsakos, Noussios and Dimakakos contributed to the refinement of the case report. All authors have approved the final article.This is a Case Report and according to the Research Registry, its registration is not essential.The Guarantor who is responsible for the present case report is Theodoros Mariolis-Sapsakos. He coordinated the preparation of the case report and revised it critically for important intellectual content.Not commissioned, externally peer-reviewed.


Abdominal massage for the resolution of constipation has been reported to be safe and recommended in some studies. It is conventionally performed for the elderly suffering from intractable constipation. Meantime, isolated mesenteric injury after blunt abdominal trauma is uncommon. Here, we report a case of isolated mesenteric injury following self-abdominal massage for constipation.A 68-year-old man consulted a local hospital due to a sudden abdominal pain. He had a history of prostate cancer treated with radiation therapy 3 years ago, and he had been suffering from chronic constipation for many years. A plain computed tomography (CT) revealed a fist-sized homogeneous mass-like lesion located in the left upper abdomen and a moderate amount of ascites. With the initial diagnosis of a malignant tumor accompanied by peritonitis carcinomatosa, he was hospitalized for further examinations. On the next day, his hemoglobin concentration dropped from 11.6 to 6.6 g/dl, and diagnostic paracentesis showed bloody ascites. He was urgently transferred to our tertiary emergency center. An enhanced CT demonstrated a non-enhanced, homogeneous, 8.5 cm in diameter, mass lesion located to the posterior of the stomach with massive bloody ascites. He underwent an emergency exploratory laparotomy, and it showed a 5 cm of laceration in the transverse mesocolon adjacent to Treitz’s ligament and approximately 1.5 l of intraabdominal hemorrhage. Hemostasis of the bleeding from the laceration was achieved by suture ligations, but the gap of the laceration could not be closed by suturing because the tissue was too fragile. Blood transfusion with 4 units of packed red blood cells and 10 units of fresh frozen plasma was performed during operation. He was discharged without any significant complications except for postoperative paralytic ileus. Later on, it turned out that he had a habit of massaging his abdomen for the resolution of intractable constipation and did it hard 1 day before the onset.This is the first report of life-threatening mesenteric injury caused by self-abdominal massage to resolve constipation, though other etiologies such as rupture of small aneurysms could not perfectly be excluded. Abdominal massage is reported to be effective and safe for the resolution of constipation; however, this case demonstrated it could be detrimental. Isolated mesenteric injury is uncommon, though the intestine and the mesentery are the third most common injured organs caused by blunt abdominal trauma . The mesConstipation is one of the most common disorders seen in the elderly. It is known to cause uncomfortable symptoms and a variety of medical problems. To avoid aggravation of constipation, preventative measures such as laxatives and enemas are often taken in the clinical settings . InteresA 68-year-old man with chronic constipation visited a nearby hospital complaining of sudden-onset upper abdominal pain. His past medical history was significant for prostate cancer treated with radiation therapy 3 years ago. He also underwent endoscopic polypectomy for colonic polyps a year ago. At the initial evaluation, he was totally conscious but in a shock state with his heart rate 100 beats per minute, blood pressure 65/39 mmHg, respiratory rate 20 times per minute, body temperature 36.6 °C, and oxygen saturation 98% in room air. He responded to fluid resuscitation. A computed tomography (CT) without contrast demonstrated a moderate amount of ascites and a fist-sized, homogeneous, mass lesion located between the stomach and the tail of the pancreas , moderate anemia (hemoglobin 6.6 g/dL), elevated urea nitrogen level (34 mg/dL), and high serum amylase (812 U/L). His venous blood gas result revealed his pH 7.436, HCOA CT with contrast demonstrated an unenhanced, high-density, homogeneous, 85 mm in diameter, mass-like lesion located to the ventral side of the pancreatic tail, and a large amount of ascites, which suggested a hematoma and massive intraabdominal hemorrhage. There was no evidence of extravasation or ruptured visceral aneurysms Fig. . ConsideMesenteric laceration after blunt trauma is the third common type of abdominal injury but is often accompanied by other abdominal organ injuries . IsolateChronic constipation not only often causes abdominal discomfort like abdominal bloating or crampy pain but also may give rise to serious complications such as intestinal perforation, cancer, diverticulosis, bowel obstruction, and colonic volvulus . UsuallySudden onset of abdominal pain followed by hemodynamic instability with intra-abdominal hemorrhage instantly evokes the possibility of ruptured aortic or visceral aneurysms such as splenic, hepatic, and mesenteric arteries . The iniAs demonstrated in this case, a history without recent trauma may confuse us to make a correct diagnosis. When the patient was referred to our hospital, the tentative diagnosis made by the previous doctor was a malignant tumor with a large amount of bloody ascites. Usually, peritonitis carcinomatosa show serous or thin bloody ascites and it is rare to see sudden hemodynamic instability in such cases. On the other hand, we could not obtain any trauma history from the patient and the patient did not show any evidence of trauma on physical examination; therefore, we did not have any idea that this was a trauma case. Primarily, we put importance on the patient’s systemic condition and findings of abdominal hemorrhage, and then we made a decision of emergency laparotomy.Regarding the type of the operation, it may have been reasonable to perform expiratory laparoscopy, considering that he was shock in shock-grade 2 when transferred. However, we put more importance on the amount of hemorrhagic ascites and his initial hemodynamic instability at the previous hospital. He could have easily fallen in shock during or after induction of anesthesia; therefore, we think it was appropriate to proceed to laparotomy first.In recent years, for the purpose of dieting, the habit of massaging the abdomen with hands or electronic devices has become more common, and we should remember that it could be a cause of abdominal organ injury. In addition, severe constipation should be prevented before it causes a fatal problem.Upon considering similar mechanisms of mesenteric laceration, Heimlich maneuver for choking, rope wounds across the waist in the game of “tug of war”, and seatbelt injuries are reported as possible culprits of mesenteric injury , 9, 10. This is the first report of life-threatening mesenteric injury caused by self-abdominal massage to resolve constipation, though the possibility of other etiologies such as ruptured small aneurysms could not perfectly be excluded. Abdominal massage has been reported to be effective and safe for the resolution of constipation; however, this case demonstrated that it could be detrimental. Although it is a very rare case, such complication should be reminded.


Pneumoperitoneum poses an important diagnostic sign determining the urgency of management of patients in an emergency department. Chilaiditi sign is a rare radiologic finding of large intestines transposition between the diaphragm and the liver. If the patient becomes symptomatic, then the condition is called Chilaiditi syndrome.We present a rare case of a 49-year-old Egyptian man who presented to our emergency department complaining of cough and vague abdominal discomfort who was found to have Chilaiditi syndrome diagnosed radiologically by computed tomography scan. He was conservatively managed rather than undergoing invasive non-warranted diagnostic and therapeutic testing that may have resulted in increased morbidity.A review of the current literature on Chilaiditi syndrome is provided with a focus on increasing the familiarity of health care professionals with the conditions and stressing the importance of a physical examination in evaluating patients with what appears to be air under the diaphragm. Chilaiditi sign is a rare radiologic finding where colonic interposition occurs between the diaphragm and the liver: hepatodiaphragmatic interposition . The diaA 49-year-old Egyptian man presented to our emergency department with a 48-hour history of cough. The cough was productive of a small amount of sputum and caused abdominal discomfort. He denied a previous similar episode. He was fatigued but recalled no chest pain, emesis, fever, chills, night sweats, melena, constipation, or diarrhea. His past medical history was only significant for obesity but he denied having diabetes mellitus, hypertension, or ischemic heart disease. His past history was significant for laparoscopic Roux-en-Y gastric bypass electively done for weight loss. He denied tobacco, alcohol, or illicit drug use. His family history was noncontributory.In the emergency department, he was afebrile with a temperature of 36.9 °C, and a blood pressure of 152/74 mmHg, pulse of 98 beats/minute, respiratory rate of 18 beats/minute, and oxygen saturation of 98% on room air. His physical examination showed that he was in mild distress, cooperative, alert, and oriented to person, place, and time. His respiratory examination revealed that his lungs were clear to auscultation bilaterally, with no wheezes, no rhonchi, and no rales. His cardiovascular examination showed regular rate and rhythm, no murmurs, rubs, or gallops. His abdomen was soft, nontender, nondistended, no hepatosplenomegaly, normal bowel sounds, stool guaiac negative, no guarding, no rigidity, and no rebound tenderness. Inspection showed scars consistent with a previous abdominal laparoscopic surgery.Basic laboratory investigations were ordered. Levels of cardiac enzymes were normal with troponin-I levels being undetectable. A basic metabolic panel showed that the electrolyte levels were within normal limits. Complete blood count with differential was unremarkable. Kidney function tests were within normal limits except for a low urea (1.52 mmol/L).A chest X-ray was ordered to rule out possible differential diagnoses for the presenting symptoms. An anteroposterior chest X-ray showed a collection or air under the right diaphragmatic copula Fig. . FurtherHe was managed with intravenously administered fluids, cough suppressants, and pain control. The pain resolved with supportive treatment and he was in a stable condition before being discharged home. After informing our patient of the results of the imaging studies, he chose to be discharged home after the pain subsided. Follow up after 1 year showed that he had been asymptomatic with no acute complaints and no further workup or interventions were warranted.We present a patient complaining of cough and abdominal pain who was found to have air under the diaphragm on imaging prompting a possible surgical intervention. Pneumoperitoneum, air under the diaphragm, poses an important diagnostic sign determining the urgency of management of patients in the emergency department. In most cases, a radiologic finding suspicious of the presence of air under the diaphragm will prompt surgical consultation and a possible emergent surgery. A radiologist by the name of D. Chilaiditi first described a radiologic finding of air under the diaphragm due to colonic transposition between the right hemidiaphragm and the liver and, hence, the sign became known as Chilaiditi sign . When a The etiology is rather unclear with pathologic transposition of the colon into the potential space between the liver and the diaphragm playing a major suspected role in the pathogenesis and can be due to multiple factors including ligamentous laxity, elevation of the right diaphragmatic copula due to phrenic nerve paralysis, liver cirrhosis, chronic obstructive pulmonary disease, among other causes .Symptoms may range from less emergent such as constipation, anorexia, and vomiting to medical emergencies such as chest pain, respiratory distress, abdominal pain, volvulus, and bowel obstruction . The cliThe diagnosis is typically a radiologic diagnosis with imaging diagnosing the abnormal position of the colon which may result in colonic air appearing as air under the diaphragm in plain images. Chest and abdominal plain X-rays are not as sensitive for the diagnosis as CT scans .Conservative management is the only required treatment in most cases with bed rest, intravenously administered fluid support, and bowel decompression playing a significant role in alleviating the symptoms. In patients who present with complicated abdominal pathologies, including obstruction, volvulus, or perforation, conservative management cannot correct the underlying pathology and surgical intervention is warranted. Surgical options for complicated Chilaiditi syndrome range from resection of the involved part of the colon  or fixation of the liver  to the abdominal wall to obliterate the potential space and prevent colonic displacement , 8.This case highlights the importance of treating the patient as a human rather than numbers and images. Medical students are taught that air under the diaphragm is always a surgical emergency. It almost always is, but a thorough physical examination that does not show signs of peritonitis should prompt further investigations to understand the underlying pathology. Physicians should be aware of possible causes of pneumoperitoneum that might not need emergent surgery in order to avoid exposing patients to unnecessary surgeries resulting in increasing risk to the patients.


Chondrosarcoma is a malignant tumor originated from cartilage cells. The most common sites of chondrosarcoma are pelvis, femur and ribs. The temporo-mandibular joint (TMJ) chondrosarcoma is extremely rare, with approximately 30 cases reported in worldwide.In this report, we present a case of chondrosarcoma in the left TMJ, which was successfully treated with surgery and radiation therapy. A 47 year-old women was admitted to our hospital with a mass in left pre-auricular region. On examination and para-clinical test results, the initial diagnosis was parotid gland cancer. In operation, the lesion was a mass originating from the left TMJ. Tumor resection was performed with close margin. The post-operative pathological result was well-differentiated chondrosarcoma. She was indicated adjuvant radiation therapy due to inadequate surgical therapy. There was no evidence of recurrence after 6 months follow-up.The TMJ chondrosarcoma is needed to distinguish from other diseases especially parotid gland tumor. Surgery and adjuvant radiation therapy are standard care with the aim of preserving joint function. It appeSurgery is first choice in management strategy of chondrosarcoma, whereas radiation is used as an adjuvant therapy in selective cases. Besides, the role of chemotherapy is unclear . TreatmeIn this report, we present a case of chondrosarcoma in the right TMJ, which is treated successfully with surgery and radiation therapy. This work has been reported in line with the SCARE criteria .2A 47-year-old woman was admitted to our hospital complaining of a mass in her face for 2 months. She had mild pain in her left face when chewing, without any limitation in mouth opening movement. She did not experience any fever or weight loss. On examination, there was a 2-cm mass in the left pre-auricular region . The lesHead and neck magnetic resonance imaging (MRI) showed a tumor in the left pre-auricular region with size of 16 × 19 mm, continuing with the left parotid gland. This tumor appeared as a mild decreased signal lesion in T2 and a mild increased signal lesion in T2 fatsat, comparing to the parotid gland. The tumor had clear and regular border, did not invade to surrounding tissue, and was associated with heterogeneous and widespread contrast enhancement. These characteristics suggested a parotid gland tumor . A fine-Pre-operative diagnosis was suspicious left parotid gland cancer and the original treatment plan was total parotidectomy. In operation, after removing the superficial lobe of the left parotid gland, the lesion was found as a mass originating from the left TMJ with size of 2 × 2 cm, and without involvement in adjacent muscles or facial nerve . As a reBecause the patient was evaluated as high risk of recurrence, she was indicated post-operative radiation therapy with total irradiated dose of 60 Gy in 30 fractions (5 days a week) with 3D conformal radiation technique. No severe radiation-related complications were reported during treatment. This patient was closely followed up afterwards. No adverse events were recorded and MRI performed a year after treatment showed no recurrence.3Chondrosarcoma is a malignant tumor originated from cartilage cells, which is commonly seen in adults from 30 to 60 years of age and hardly occur in those under 20 years old . It accoPanorama X-ray, maxillofacial computed tomography (CT) scan and MRI play essential roles in the diagnosis of the TMJ chondrosarcoma. Because X-ray normally provides inadequate information of the extension of the lesion, other imaging modalities such as maxillofacial CT or MRI should be carried out to confirm the diagnosis and decide treatment plan. The specific lesion characteristics are a non-enhancing mass with flocculent calcification at the level of the condyle affected, condylar deformity, with or without erosion of adjacent bone such as the skull base and the external auditory canal. In most cases, expansion of the articular space and rise in the length of condylar neck with radiopacity of the condyle are frequently observed ,8,9,12.Generally, fine needle aspiration is insufficient to distinguish the TMJ chondrosarcoma from the TMJ osteogenic sarcoma, parotid pleomorphic adenoma, parotid carcinoma and the TMJ chondroma. Therefore, open biopsy is important to reach the final diagnosis ,9,12. HoThe goals of treatment for patient with the TMJ chondrosarcoma include minimizing the risks of local recurrence, metastatic disease, and death from disease, whereas maintaining the function of the patients ,6. Norma4Chondrosarcoma of the TMJ is very rare. It need to distinguish from some diseases likely to TMJ osteogenic sarcoma, parotid pleomorphic adenoma, parotid gland carcinoma and TMJ chondroma. The most important treatment is wide tumor resection. Radiation therapy is useful in unresectable disease or adjuvant treatment in post-operative patients with inadequate surgical therapy.None.None.The study was approved by our research committee, Hanoi Medical University Hospital, Hanoi, Vietnam and National Cancer Hospital, Hanoi, Vietnam.The publication of this study has been consented by patient.Quang V. Le: Professor, main surgeon.Dang V. Nguyen: Radiation oncologist, treated the patient.Hung V. Nguyen: Radiation oncologist, wrote manuscript.Thanh D. Hoang: Assistant surgeon, wrote manuscript.Duy Q. Ngo: Assistant surgeon, revised manuscript.Tung T. Ngo: Professor, revised manuscript.This is not a first-in-human study, thus it is not needed.Quang V. Le, Professor, M.D, Ph.D.Not commissioned, externally peer-reviewed.


Cholecystocutaneous fistulas (CCFs) are an increasingly rare consequence of chronic gallbladder inflammation and disease. Historically, they were commonly noted in the literature by Courvoisier, Naunyn, and Bonnet in the late 1800s. Due to improvements in diagnostic imaging and treatment options in the last century, there has been a marked decrease in the incidence of the CCF cases in the literature. From the late 1890s to 1949, there were only 37 cases presented in the literature; only 28 cases have been reported since 2007. This case is only the second noted CCF in the literature that followed percutaneous cholecystostomy drain placement and removal.General surgery was consulted on a 60-year-old morbidly obese female, who presented to the emergency department after one week of fever, right upper quadrant (RUQ) pain, nausea, emesis, and shortness of breath. She had a history of acute cholecystitis treated with a cholecystostomy tube the year prior, but after the removal of the tube, she was lost to follow up. She was found to have a 14cm x 5cm fluctuant abdominal wall abscess in her RUQ that was treated with incision and drainage (I&D) along with ertapenem. She continued to improve until day 7 post-I&D when yellowish-green discharge was noted draining from the wound. After a negative hepatobiliary iminodiacetic acid scan, a follow-up abdominal computed tomography (CT) showed a contracted gallbladder with fistula formation underlying the abscess location, near the site of her prior cholecystostomy tube. A robotic-assisted cholecystectomy was performed, which improved the wound drainage, and the patient was discharged home 5 days later.This case is the only noted CCF presenting as a RUQ abscess after cholecystostomy drain placement. The patient lacks follow up after the removal of her percutaneous drain and continued inflammation in the gallbladder provided perfect nidus for the fistula formation. As seen in other CCF patients, cholecystectomy is the treatment of choice, and this case was successfully treated via robotic-assisted cholecystectomy with adhesiolysis. Biliary fistulas are pathologic connections formed from chronic inflammation between the gallbladder and adjacent organs -2. HistoA 60-year-old morbidly obese, white female was admitted to the floor with one week of worsening shortness of breath, right upper quadrant (RUQ) pain, nausea, emesis, and a fever. General surgery was consulted after a large, fluctuant and erythematous mass was visualized on the RUQ abdominal wall. The patient noted a history of severe cholecystitis the year prior that was managed by a percutaneous cholecystostomy drain. After the drain was removed, she was lost to follow up. Initial laboratory evaluation revealed: leukocytosis with 91% neutrophils , international normalized ratio of 2.51 (reference range 0.90-1.10), alkaline phosphatase of 162 (reference range 20-130 U/L); lactic acid, aspartate aminotransferase, and alanine aminotransferase were within normal limits. A computed tomography (CT) scan of the abdomen revealed a 14 cm x 5 cm abdominal wall fluid and air collection suspicious for an abscess in the RUQ as seen in Figures Incision and drainage (I&D) of the abscess were performed with a cruciate incision over the indurated RUQ of the abdomen as seen in Figure Once inside the abdomen, dense adhesions were visualized in the RUQ of the peritoneal cavity along with a laterally adhered, contracted gallbladder. Two hours of adhesiolysis was performed due to the numerous dense adhesions in the RUQ. An intraoperative cholangiogram confirms the suspected anatomy and demonstrated mild distension of the common bile duct. The gallbladder was removed and sent for histopathological examination. It was 6.7 cm x 3.0 cm x 2.2 cm in size with associated cholelithiasis and chronic inflammatory changes. Postoperatively the patient remained stable throughout her course and received daily packing changes, ertapenem, and eventual negative pressure wound therapy placement. The patient was discharged on day 5 post-operation with subsided drainage, early granulation tissue, and improving wound erythema as seen in Figure Biliary fistulas can be divided into the following categories: primary or secondary. Primary fistulas are generally associated with chronic cholelithiasis or biliary cancer, whereas secondary fistulas are associated with abdominal procedures. Biliary fistulas can further be broken down into external or internal categories, with the majority occurring internally. Internal connections include the duodenum, colon, stomach, jejunum, and common bile duct ,10,12-15Upon literature review, only one other case of a CCF associated with percutaneous cholecystostomy drain placement was noted . In thatPercutaneous cholecystostomy drains are used in patients whose condition prevent them from having a cholecystectomy. They have been shown to be a safe and effective temporary treatment for patients with acute cholecystitis with severe comorbid conditions. Generally, the placement of these drains reduce inflammation and manage comorbidities prior to definitive treatment by cholecystectomy -17. MostCCFs are generally treated with cholecystectomy, but some are left to close on their own depending on the patient’s comorbidities -19 In thAlthough CCFs were historically a common outcome of gallbladder disease, they are now rarely seen due to improvements in the identification and treatment of gallbladder pathology. In this report, we presented a 60-year-old morbidly obese female who developed a CCFs secondary to continued cholecystitis with an associated preformed tract from prior cholecystostomy drain placement. The authors of this study hope that this case presentation will educate other clinicians to explore the diagnosis of an EBF when presented with a RUQ abdominal abscess.