For post processing regions of interests were drawn both inside of target lesions and the liver background. Time–intensity curves were fitted to the CEUS DICOM dataset and the rise time (RT) of contrast enhancement until peak enhancement, and a late-phase ratio (LPR) of signal intensities within the lesion and the background tissue, were calculated and compared between malignant and benign liver lesion using Student’s t-test. Quantitative parameters were evaluated with respect to their diagnostic accuracy using receiver operator characteristic curves. Both features were then combined in a logistic regression model and the cumulated accuracy was assessed. Results: RT of benign lesions , and in a subgroup analysis, particular hemangiomas  differed significantly to malignant lesions (9.3 ± 3.8 s). The LPR was significantly different between benign  and malignant lesions (0.38 ± 0.23). Logistic regression analysis with RT and LPR combined showed a high diagnostic accuracy of quantitative CEUS parameters with areas under the curve of 0.923  and 0.929  between 2008 and 2018. All examinations were performed by a single radiologist with more than 15 years of experience using a second-generation blood pool contrast agent. The standard of reference was histopathology ( Focal liver lesions (FLL) are common and can be found in about 5% of the European population . FLL areContrast-enhanced ultrasound (CEUS) can be performed within the same investigation as B-mode and Doppler ultrasound and provides additional information about the vascularization and contrast dynamics of FLL with a good diagnostic performance comparable to CT and MRI ,4,5. A fn = 52), reported a diagnostic accuracy up to 90.3% [n = 20) [To distinguish benign from malignant FLL in CEUS, specific contrast enhancement patterns are used . The Guito 90.3% . On the [n = 20) , Goertz [n = 20) .In order to evaluate CEUS perfusion quantification parameters in a larger cohort and to evaluate which parameters are best suited to differentiate malignant from benign liver lesions we retrospectively evaluated 139 CEUS examinations with histopathology, MRI or long-term follow-up as the standard of reference.In this retrospective study, 139 FLL from 134 patients who underwent CEUS between March 2008 and September 2018 at our institution were analyzed by quantifying contrast enhancement in the arterial and late phase. Written consent was obtained from all patients prior to CEUS. Seventy-five FLLs were found in women  and 64 in men .n = 24), due to severe motion artifacts (n = 12), invisibility of the hepatic lesion in CEUS (n = 7) or due to incomplete CEUS dataset (n = 2)  .Contrast-enhanced ultrasound was performed by one skilled radiologist with experience since 2000 (EFSUMB Level 3). All CEUS examinations were performed with up-to-date ultrasound devises . Siemens systems provided C4-1 and C6-1 HD transducers and the Philips system provided a C9-2 transducer. All examinations were carried out with low mechanical index (<0.2) to prevent early destroying of the microbubbles.After B-mode ultrasound and Color Doppler, 2.4 mL of Sulphur hexafluoride microbubbles  were injected to a cubital vein followed by a flush of 5–10 mL saline 0.9%. Data sets of the arterial phase were recorded from the first arrival of contrast agent in the liver vessels. To reduce the destruction of the microbubbles, transducers were switched on only temporally for about 30 s to evaluate contrast enhancement during each the arterial (10–45 s), portal (30–120 s) and late phases (120–180 s). No adverse effects were registered during and after CEUS examinations.In order to process and analyze the datasets, we used available proprietary software . For each of the transducers listed above, a calibration file was applied, afterwards delimitation region of interest (ROI) was set for each uncompressed DICOM cine loop and motion correction was performed using a retrospective trigger box over the lung and liver. A ROI was then manually drawn within the target lesion. The entire lesion was included in the ROI, sparing necrotic parts, large vessels or thrombosis that otherwise likely would confound the analysis. In addition, we selected a reference region (REF) within the surrounding, normal-appearing liver tissue in the same depth from the transducer as the target lesion .Both within the target lesion and REF, the brightness of the pixels was fitted over time resulting in time–intensity curves of perfusion. Both the rise time (RT) of contrast enhancement and a late phase ratio (LPR) were calculated. The RT describes the early contrast dynamics until peak enhancement. Its starting point is calculated from the enhancement curve as intersection of a tangent to the maximum slope with the time axis . The LPRt-test and ROC analyses were applied. Tests were considered significant at p < 0.05. For each parameter a cut-off was defined. Sensitivity, specificity, accuracy, positive likelihood ratio (LR+) and negative likelihood ratio (LR−) were calculated.The statistical analysis was performed with MS Excel 2007  and Stata-IC15.1 . For descriptive statistics means ± standard deviations (SD) of all quantitative perfusion parameters were calculated. Benign and malignant FLL, as well as hemangiomas in particular and malignant FLL, were studied and compared. To test for differences of perfusion parameters Student’s To evaluate the relationship between the likelihood of a lesion being benign, or an hemangioma, and the US-derived measures RT and LPR, a logistic regression modelTX, USA) . To illun = 20), hemangioma (n = 16) and adenoma (n = 8). The group of the malignant FLL (n = 95) comprised hepatocellular carcinoma , cholangiocellular carcinoma  and metastases (n = 49) (see example images in n = 60), imaging other than CEUS (n = 75) or follow up (n = 4). For precise distribution of age, tumor entity, and reference standard see Following our inclusion and exclusion criteria, we included 139 FLL in 134 patients . Forty-four benign liver lesions were examined including focal nodular hyperplasia . LPR was 0.38 ± 0.23 (range: 0.02–0.96) for malignant lesions with a ratio less than one for all FLL apart from one single value in the CCC group, which was isoechogenic (0.96) see . For benp < 0.001). Calculating the ROC curve of LPR resulted in an area under the curve (AUC) of 0.898  and must not be confused with a real washout of contrast media. This pseudo-washout appearance is thought to be due to microbubble rupture within the hemangioma in case of a prolonged insonation. Similar findings were reported from Gianetti et al. [Focusing on hemangiomas, those lesions which showed only slight hypoechoic appearance in comparison to the surrounding tissue in the late phase  differed significantly from the hypoechogenicity of malignant lesions which were markedly hypoechoic , whereas FNHs  showed a faster enhancement than other FLLs (12.1 ± 9.4 s). The RT of hemangiomas was significantly longer than in malignant FLLs (p < 0.001) resulting in an AUC of 0.915. Values of RT less than 18.2 s as cut-off resulted in a sensitivity of 98.3%, specificity of 50.0%, diagnostic accuracy of 91.4%, a LR+ 2.0 and LR- of 0.0. When RTs of all benign lesions were compared to those of malignant tumors, values were also significantly different (p = 0.005), however ROC analysis revealed only a weak diagnostic performance resulting in an AUC of 0.584  was 14.8 ± 13.8 s (range: 1.9–66.2 s). Rise time for malignant FLLs was 9.3 ± 3.8 s (range: 3.0–23.2 s). In hemangiomas and liver cell adenomas it took significantly longer until the maximum contrast agent concentration was reached compared with other FLLs  and positively related to RT (exp(ß2_RT) = 1.2, 95% C.I. 1.02–1.30, p = 0.025). Likewise, for hemangioma vs. malignant FLL, LPR showed positive, but not significant, relation (exp(ß1_LPR) = 19.2, 95% C.I. 0.35–1060, p = 0.149) and RT was positively related to hemangioma (exp(ß2_RT) = 1.3, 95% C.I. 1.09–1.63, p = 0.004). An overview over the descriptive statistics of all different sub-entities is presented by the box plots of Logistic regression analysis resulted in higher diagnostic performance for distinguishing benign and malignant FLL than each parameter individually with an AUC of 0.923. For differentiating hemangioma and malignant tumors, the combined area under the ROC curve was comparably good at 0.929 see . The logIn this study, we retrospectively analyzed the quantified contrast enhancement pattern of different focal liver lesions (FLL) in CEUS, considering rise time (RT) and late phase ratio (LPR). Both RT and LPR significantly differed between benign and malignant tumors. The combination of both parameters in a logistic regression further improved the discrimination between those groups. The combination of RT and LRP was particularly useful to distinguish hemangiomas from malignancies.n = 33) [n = 148) [LPR is a quantified parameter of contrast intensity obtained during the late phase, which is, in case of hypoenhancement, a well-established qualitative criterion for malignancy . A signin = 33) . Wildnern = 148)  and founn = 148) ,20,21. In = 100), and Zheng et al. 2013 [n = 60).The RT showed large variations within the heterogeneous group of benign lesions. In our study, RT was particularly long in hemangiomas and adenomas and shortest in FNHs. These findings are in accordance with former studies from Pei et al. 2013 , who foual. 2013 , who obsp < 0.001) than for malignant lesions (9.3 ± 3.8 s) and could discriminate these two entities with a high diagnostic accuracy (AUC: 0.915). When comparing all benign to malignant liver lesions, RT showed only a moderate diagnostic performance (AUC: 0.584), which can be mainly explained by the short RT of FNH (6.4 ± 0.7 s) which appear different than most of the other benign liver lesions and therefore confound the quantitative assessment. To overcome these limitations, we suggest the following algorithm: if the LPR is >1 and the lesion visually presents hyperechoic, we mostly expect a benign focus. In this case a short RT speaks for FNH and strengthens the diagnosis. If the LPR is markedly <1, a diagnosis of malignancy is recommended. An LPR just little below 1 with only mild visual hypoechogenicity and a long RT strongly suggests hemangioma is the correct diagnosis. The good diagnostic performance of the combined parameters in this study is shown by the receiver operator curve (ROC) after logistic regression with an AUC for hemangioma vs. malignant FLL of 0.929 and for benign vs. malignant FLL of 0.923. However, further prospective studies are necessary to investigate the clinical value and diagnostic performance of the proposed diagnostic algorithm.In general, it is assumed that a short RT is related to arterial hypervascularity , as the Its direct accessibility and repeatability, cost-effectiveness, and non-ionizing excellent safety profile make multiparametric CEUS a powerful imaging tool for assessing focal liver lesions . FurtherThere are some limitations to this study. The lesions found in CEUS were evaluated according to clinical standards, e.g., histological diagnostic or further cross-sectional imaging. Especially typical benign tumors or HCC with typical imaging appearance in patients with cirrhosis do not justify an invasive proceed to confirm the diagnosis. Therefore, in four cases , the diagnosis was confirmed as benign by constant CEUS follow-up with a stable size during a period of at least 24 months. In these cases, a repeated misdiagnosis within the benign spectrum is theoretically possible.n = 15) were contributed comparably over the different malignant subgroups.Our study population includes a great diversity in tumor diameter (0.6–10 cm), and pretreatments see . Even ifIn conclusion, we were able to show that quantification of CEUS parameters with assessment of the rise time of contrast enhancement until its peak and calculation of a late phase lesion-to-background ratio is helpful to differentiate malignant from benign liver lesions, particularly in hemangiomas with slight hypoenhancement in the late phase and might contribute to an objective and more specific diagnosis of FLL in CEUS.


The incidence of gossypiboma is considerably higher in open cavity surgeries, among which cesarean section ranks number one. However, it is difficult to diagnose abdomen or pelvic gossypibomas after cesarean section. We retrospectively analyzed the clinical and imaging data of three pathologically confirmed gossypiboma patients at varied durations after cesarean section. In case one, at four months after cesarean section, a gossypiboma near the small intestine caused fistula and intestinal obstruction. Soft tissue density lesion along the intestinal canal made the “segmental honeycomb sign" and "truncation" with metal markings on the edge on computed tomography (CT). Magnetic sensitivity artifacts were demonstrated as hypointensity on T1 weighted image (T1WI) and T2 weighted image (T2WI), while hyperintensity was seen on the diffusion weighted image (DWI). In case two, a gossypiboma in the peritoneal and intestinal space was revealed with MRI at 18 months after cesarean section. It was featured as a cystic and solid lesion, with "vortex like sign" and obvious ring enhancement on contrast-enhanced MRI scan. In case three, five years after cesarean section, a mass was palpated in the right middle and lower abdomen. MRI revealed a round mass of T1 hypointensity with mixed T2 signal, as well as swirling hypointensity in T2WI, T2WI-fat suppression (FS), and DWI. In CT and MRI examinations for suspected gossypiboma after cesarean section, "honeycomb sign" and "vortex like sign" are the characteristic appearances; gauze translocated into the intestine may show the "truncation sign". Accurate diagnosis is based on the surgery history, symptoms, and imaging features. A gossypiboma or textiloma is an infrequent complication after any surgical procedure associated with potentially dangerous healthy problems for the patient -3 and leDepending on the retained time of foreign bodies or sponge, exudative, and aseptic fibrous alterations may occur, leading to early abscess or late fistulas . It may In this study, we retrospectively enrolled three women, who were diagnosed with gossypibomas at varied durations after cesarean section and tried to correlate their imaging features with the pathological findings.Case One: Gossypiboma in a woman at four months after cesarean sectionA 29-year-old female was admitted to the hospital due to intermittent abdominal pain, abdominal distension, and constipation of gas and feces for more than one month, which got worse in the last two weeks. Intermittent abdominal pain occurred without obvious reason, mainly in the upper abdomen a month ago. The pain became worse after eating, with occasional nausea and vomiting. Recently, she has lost about 15 kg of body weight, which was probably normal after giving birth to a child four months ago. A 10-cm transverse surgical scar was observed at the lower abdomen, together with the whole abdomen tenderness, especially the middle and lower abdomen. Abdomen plain radiograph revealed high density fold line within the lower abdomen Figure . CoronalCase Two: Gossypiboma in a woman at 18 months after cesarean sectionA 38-year-old female was admitted to the hospital due to intermittent abdominal pain and discomfort for six months. Physical examination showed an old surgical scar in the middle of the lower abdomen, and a soft mass about 8cm×5cm in size was palpable in the left abdomen, with low mobility. She had a caesarean section 18 months ago and had a history of massive bleeding and blood transfusion. MRI examination showed a round 5.5 cm×4.4 cm size mass with hypointensity T1 Figure  and heteCase Three: Gossypiboma in a woman at five years after cesarean sectionA 30-year-old female with intermittent abdominal pain for two months and abdominal mass for one week was admitted. She underwent cesarean section five years ago, tubal ligation four years ago, and myomectomy one year ago. MRI examination showed a round T1 hypointensity mass Figure  in the rGossypiboma developed after cesarean section is the most common gossypiboma . HoweverImaging is the most efficient diagnostic approach for gossypiboma after cesarean section. Plain radiography is the most common technique that is easy to diagnose gossypiboma containing a radiopaque marker . UltrasoIn the current study, we presented typical "honeycomb sign" and "vortex like sign" for all three cases of gossypibomas after cesarean section, which is consistent with previous studies showing a spongiform pattern with a radiodense linear structure ,15,16. BIf not correctly diagnosed, gossypiboma developed after cesarean section will lead to severe consequences. Imaging plays an important role in accurately diagnosing gossypiboma after cesarean section. The "honeycomb sign," "vortex-like sign," and "truncation sign" on cross-sectional imaging are the characteristic appearances of gossypiboma. Accurate diagnosis is based on the surgery history, symptoms, and imaging features.


Aspergillus flavus endocarditis is extremely rare and reported in only 7% of the total Aspergillus endocarditis cases. The most common predisposing factors are immunocompromised state, prosthetic valve, and previous cardiac surgery. In most cases, the diagnosis is delayed and occasionally missed. Prompt medical management combined with early surgical intervention is recommended once the diagnosis is established since the mortality rate is nearly 100% without surgical intervention. We report a rare and fatal case of native aortic valve endocarditis in a 49 years old diabetic patient who presented with fever and abdominal pain, complicated by multiple septic embolizations , and in which A. flavus was confirmed post mortem.Fungal endocarditis is a rare condition, specifically in immunocompetent patients. Aspergillus species are the etiology in less than 30% of the cases. Moreover,  Aspergillus flavus endocarditis that affected the native aortic valve in a 49-year-old diabetic patient.Fungal endocarditis represents around 2% of infective endocarditis cases. Candida species are the major causative organism and account for more than 70% of fungal endocarditis cases A 49-years-old male presented to the emergency department (ED) with a history of intermittent fever and abdominal pain for one week. He had a history of diabetes mellitus (DM)  and coronary artery disease. One year earlier, he underwent cardiac surgery for mitral valve fibroelastoma resection and coronary artery bypass grafting (CABG). There was no history of smoking, alcohol intake, or substance abuse. On examination, he was afebrile initially, and other vital signs were within the normal range. Abdominal examination revealed tenderness in the left upper quadrant without guarding or rigidity. Examination of the cardiovascular and respiratory systems was unremarkable. Laboratory results were significant for normocytic anemia (hemoglobin was 10.9 g/dL) and elevated C-reactive protein level (147.5 mg/L), but normal renal and liver functions parameters. Abdominal computed tomography (CT) showed a wedge-shaped hypodense lesion in the spleen suggestive of splenic infarction A. EchocaAfter six days of admission, he developed acute chest pain associated with severe breathlessness. He was tachypneic and tachycardic; he was desaturated to 90%; chest examination revealed bilateral crepitation, so immediate medical management for acute pulmonary congestion was initiated with intravenous diuretics and nitroprusside infusion, and non-invasive ventilation. As his respiratory parameters did not show significant improvement, he was electively intubated. Repeated echo showed severe aortic regurgitation with normal ejection fraction. A decision was made for surgical intervention, and surgical aortic valve replacement was done. Intraoperative findings included the presence of abscess formation at the aortic valve annulus and aortic wall at the level of the sinus-tubular junction, in addition to the destruction of the left coronary leaflet. The mitral valve leaflets were normal in appearance.flavus.Postoperatively, clinical examination revealed unequal pupils and cold extremities. CT brain showed multiple brain hypodensities, suggesting thrombo-embolic stroke B. CT aorAspergillus fumigatus, whereas A. flavus constitute 7% of all AE cases Aspergillus endocarditis (AE) is a rare condition that is associated with fatal sequela. More than 60% of the cases are caused by The diagnosis of AE is clinically challenging that is attributed mainly to the non-specific and insidious presentation. The main presenting symptom is fever Systemic embolization is encountered in around 75% of AE cases which is related to the usual large vegetation size, high mobility, and fungal ball friability. Our patient developed multiple embolic complications, including splenic infarction, aortic embolism, and embolic stroke. Medical and surgical management should be started simultaneously as early as possible. The mortality rate in medically treated patients alone may approach 100%. However, despite surgical removal of infected cardiac tissue, the mortality rate remains high and is estimated to reach 68% Aspergillus endocarditis is a rare and fatal condition that carries diagnostic and therapeutic challenges to the treating physicians. A high index of suspicion and serology test is essential for the early diagnosis. A combination of medical and immediate surgical management strategies is recommended to attain the best outcomes.Ethical approval was obtained from Medical Research Centre (MRC) in Hamad Medical Corporation (HMC).This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Abdulrahman F. Al-Mashdali: Acquisition of data; Drafting the manuscript; Approval of the version of the manuscript to be published, Mohammed Altayeb: Drafting the manuscript; Approval of the version of the manuscript to be published, Ammar M. Kanaan: Revising the manuscript critically for important intellectual content; Approval of the version of the manuscript to be published, Abdulaziz Alkhulaifi: Revising the manuscript critically for important intellectual content; Approval of the version of the manuscript to be published, Dawoud Al Kindi: Analysis and interpretation of data; Revising the manuscript critically for important intellectual content; Approval of the version of the manuscript to be published.


We retrospectively analyzed the diagnosis and treatment process of one patient with recurrent undifferentiated pleomorphic sarcoma (UPS) of infratemporal fossa and made a definite diagnosis by combining the imaging and pathological examination results. After treatment failure with 2 cycles of chemotherapy and several surgeries, UPS was eventually treated by surgery + carbon ion radiotherapy, and MRI reexamination showed no relapse. Head and neck UPS is located deeply, easily recurs after operation, and difficult to be resected completely by surgery, with a gradually shortened interval of relapse over the number of surgeries, which becomes a treatment challenge. After the last surgery, the patient received carbon ion radiotherapy, with a good therapeutic effect, and no sign of relapse just before sending this article. Based on the above advantages, we have concluded that surgery + carbon ion radiotherapy is a new effective pathway to treat head and neck UPS. The above findings met the diagnostic criteria of (skull base) UPS .On 5 and 25 April 2016, the patient successfully completed 2 cycles of chemotherapy with IFO+mesna+doxil in Sun Yat-sen University Cancer Center. Skull base MRI examination in May 2016 showed compression-caused displacement of left temporal lobe, and a mass shadow in left infratemporal fossa—middle cranial fossa, with non-uniform signals, predominantly T1 and T2 equisignals in the lesion, patchy slightly low T1 and significantly high T2 signals in the lesion center, nearly a clear and smooth border, and localized mild lobulation, in a size of 30.5 mm (AP) × 39.2 mm (LR) × 29.5 mm (HL), and surrounded by multiple circuitously routing flowing-void vascular shadows. Enhanced scan indicated a significantly enhanced mass in left infratemporal fossa—middle cranial fossa, a patchy low signal non-enhancement area in the center, and linear enhancement nearby meninges. The size of lesion had no significant change as compared with before chemotherapy .On 25 May 2016, the patient underwent endoscopic transnasal resection for left infratemporal fossa—middle cranial fossa tumor in Otolaryngology Hospital , and the postoperative pathology indicated that the lesion complied with UPS. After operation, the lesion recurred.On 13 October 2016, the patient underwent subtemporal-preauricular resection for left infratemporal fossa—middle cranial fossa tumor in the same hospital, and the postoperative pathology indicated that the lesion complied with common osteosarcoma (co-presence of chondroblastic osteosarcoma and fibroblastic osteosarcoma). After operation, the lesion recurred.On 14 October 2017, the patient underwent subtemporal-preauricular resection for left infratemporal fossa—middle cranial fossa tumor in the same hospital, and the postoperative pathology indicated that the lesion complied with common osteosarcoma. After operation, the lesion recurred again.According to skull base MRI examination in May 2018, there were changes after surgeries for left infratemporal fossa—middle cranial fossa tumor, local bone defect in left maxillary sinus wall, cribriform plate, sphenoid bone and middle nasal concha, compression-caused displacement of left temporal lobe, and an enlarged mass shadow in left infratemporal fossa—middle cranial fossa, with non-uniform signals, predominantly T1 and T2 equisignals in the lesion, patchy slightly low T1 and significantly high T2 signals in the lesion center, nearly a clear and smooth border, and localized mild lobulation, in a size of 35.6 mm (AP) × 42.3 mm (LR) × 35.9 mm (HL), and surrounded by multiple circuitously routing flowing-void vascular shadows. Enhanced scan indicated a significantly enhanced mass in left infratemporal fossa—middle cranial fossa, a patchy low signal non-enhancement area in the center, linear enhancement nearby meninges, a few long T2 abnormal signals in left middle ear and mastoid process, thickened mucosa in bilateral maxillary sinus and ethmoid sinus as well as left sphenoid sinus, a cerebral spinal fluid (CSF)-like signal shadow in sellar region, and compression-caused flattened pituitary. Tumor relapse was considered .On 21 May 2018, the patient underwent subtemporal (preauricular) resection for left infratemporal fossa—middle cranial fossa tumor in the same hospital. The surgical procedures were as follows: The patient was in a supine position. After successful tracheal intubation and general anesthesia, the patient was routinely kept in a required position with left ear upward, followed by routine disinfection with iodophor and draping. A “C” surgical incision was made at the original incision scar on the hairline of anterior left ear edge and extended to left external acoustic meatus orifice, the skin, subcutaneous tissue and superficial fascia were dissected layer by layer using low-temperature plasma radiofrequency ablation, the skin flap was dissociated, zygomatic arch was exposed at lateral inferior parotid gland, and then its superficial muscular fasciae was dissected. Subsequently, the incision was dilated with a distracter, and the operation space was exposed under endoscope, observing a white fish-like mass with a smooth surface. Then, the mass border was dissected using a stripper upward to cerebral dura mater, and the mass was cut open at the center and mostly resected with a curette. Thereafter, under endoscopic view, the inferior tumor was resected to mandibular ramus and lateral pterygoid of infratemporal fossa and medially to os petrosum, internal carotid artery of os petrosum was exposed, and tumor tissues were fully curetted with a curette at middle cranial fossa base in an up-to-down manner along middle skull base meninges, without residual tumor. During operation, cerebral dura mater of middle cranial fossa base wall was thin, and there were no CSF leakage but slight blood exudation; full hemostasis was performed using bipolar coagulation scalpel, the operation space was rinsed with iodophor and physiological saline and then filled with iodoform gauzes after cerebral dura mater was covered with SURGICEL Absorbable Hemostat and Biodesign Surgisis Dural Graft, these gauzes were withdrawn from external auditory meatus, and the subcutaneous tissue and skin were sutured layer by layer after finishing the surgical count of instruments and gauzes. The surgery was successful, the intraoperative bleeding volume was 1,200 ml, and the resected tumor was sent for pathological examination.From 16 July to 13 August 2018 after operation, the patient received carbon ion radiotherapy  for recurrent tumor and treatment-extending safe area. In March 2019, brain MRI reexamination showed no recurrent tumor lesion .The above examination and treatment items have obtained the informed consent from the patient who participated in clinical investigations.UPS, also known as malignant fibrous histiocytoma (MFH), is an extremely rare soft tissue malignant tumor. According to WHO latest classification standard in 2013, the concept of MFH was replaced by UPS  for the publication of any potentially identifiable images or data included in this article.ZW, ZT, and QZ: concept and design. ZW, ZT, HZ, XZ, and QZ: supervision. ZW, ZT, HZ, XZ, XH, and QZ: resources. ZW, ZT, XH, and QZ: materials. ZW and ZT: data collection and processing, analysis and interpretation, literature search, and writing manuscript. QZ: critical review. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Raynaud's phenomenon (RP) is a frequent syndrome and often indicative of connectivitis or hemopathy. The association with solid cancers is exceptional. We report the observation of a patient hospitalized for severe RP whose etiological assessment revealed the existence of colorectal cancer. We discuss, through this clinical case, the potential physiopathological links and underline the importance of looking for underlying cancer in the face of severe, refractory to treatment, or atypical RP. Raynaud's phenomenon is a transient, paroxysmal vasomotor disorder following a vasospastic response to cold or to emotional stress.The etiological investigation consists of distinguishing the primary Raynaud's phenomenon (the most frequent) from the secondary one. As for the secondary Raynaud's, it can be indicative of many benign pathologies or fit with a paraneoplastic syndrome. We report the case of a patient who presented with Raynaud's phenomenon, which was widely explored before it could be linked to colonic adenocarcinoma.A 42-year-old female patient with a history of iron deficiency anemia without smoking history or familial neoplasia consulted for inflammatory low back pain with paresthesia and pain in the fingers rebellious to simple analgesics evolving for a month before her hospitalization. The clinical examination revealed Raynaud's phenomenon of the two hands Figure , which wAs part of the aetiological paraneoplastic assessment and given the history of an iron deficiency anemia, computed tomography revealed two tumor-like thickenings of the rectum and the sigmoid extended to the left colon, associated with deep lymph nodes , and nodules peritoneal carcinosis Figure , and bonThe diagnostic process was completed by colonoscopy with biopsies of all lesions identified as suspect; histological study confirmed that it was a colonic adenocarcinoma Figures -4 and thRaynaud's phenomenon is an immunological entity affecting peripheral microcirculation, testifying to an exaggerated physiological response to cold and stress. It is classically described with a triphasic color change of the digits resulting from the succession of three phases: ischemic phase, deoxygenation phase, and reperfusion phase. The diagnosis is confirmed if these three phases are present, however, capillaroscopy, biology, and radiology have an etiological interest.There are two types of Raynaud's phenomenon: primary and secondary. The aetiological spectrum of secondary Raynaud's phenomenon encompasses several causes; the main ones of which are vasculitis (scleroderma being the most common), toxicants or drugs, vascular disease, and neoplasms. Table Paraneoplastic causes are rarely reported - 68 cases in Guigne's study and 33 cases in Schildmann's study - it is often a pulmonary, mammary, uterine, or ovarian site -2. The dThe mechanisms of the pathogenesis of Raynaud's phenomenon are not fully understood. They may be due to intravascular, neuroregulatory, or vascular disorders; the latter involving vasoconstriction phenomena occurring with the help of vasoactive agents: endothelin, angiotensin II and tyrosine kinase. Any increase in the production of these cytokines could be responsible for excessive vasoconstriction.In cancers , there is an overexpression of the endothelin-1 and angiotensin II systems and their receptors. Colorectal cancer cells are endowed with a characteristic ability to activate angiotensin II, which has both a vasoconstrictive and pro-fibrotic effect . They alThese physiopathological mechanisms suggest that it could have a causal link between tumor pathology, colorectal in our case, and the occurrence of Raynaud's phenomenon.Although colorectal cancers are manifested by digestive and general symptoms, the association with Raynaud's phenomenon has only been described in one case .Protective measures, prostacyclin analogs, and calcium channel blockers are the treatment of choice for idiopathic forms; otherwise, the management is that of the cause. Regarding paraneoplastic Raynauds, the regression of the phenomenon after treatment of the tumor was noted in 48% of cases ,6.From a diagnostic point of view, the rather unusual nature of this association makes it essential to conduct an exhaustive preliminary search for all the other causes, particularly the more classic ones of Raynaud's phenomenon, before attributing the paraneoplastic cause, which can only be retained on the exclusion of other aetiologies and especially on the improvement of clinical signs after remission of the neoplasia. In our case, all the causes of Raynaud's phenomenon were excluded and the clinical outcome was quickly favorable after the beginning of the cancer treatment.In most cases, Raynaud's phenomenon is idiopathic, especially when it occurs at a young age. However, a more exhaustive etiological investigation, including the search for neoplasia, is necessary if the phenomenon appears after the fourth decade. Our observation shows the value of researching a malignant cause before opting for the diagnosis of Raynaud's disease, especially if the initial assessment is negative and the symptoms persist despite the usual treatment.


Biliary tract cancers (BTCs) have limited response to systemic therapy and poor prognosis. Immunotherapy in BTCs has been investigated in recent years. Here, we report a case of locally advanced, unresectable gallbladder adenocarcinoma that progressed on chemotherapy. The patient was then treated with ipilimumab and nivolumab, which resulted in tumor shrinkage and autoimmune hepatitis, but established technical resectability. He underwent complete resection through extended right hepatectomy with en bloc cholecystectomy bile duct resection, hepatic and portal lymphadenectomy and Roux-Y hepaticojejunostomy reconstruction. The final pathology revealed a pathologic complete response. The scope of operative intervention after immunotherapy is still evolving for BTCs. Establishing resectability in tumors not susceptible to cytotoxic agents but responding to immunotherapy not only facilitates curative intent resection but also enhances the importance of infection prevention through operative stent-free long-term biliary decompression. Immunotherapy may also carry a unique risk profile for post-operative morbidity potential as in this case with autoimmune hepatitis. Biliary tract cancers (BTCs), including cancers of gallbladder, extrahepatic and intrahepatic biliary tracts, vary in their etiology, pathophysiology and clinical presentation. Most patients (>65%) present with advanced stage disease, and distant relapse remains common after apparently complete resection , 2. SystWith continued improvements in systemic therapy, goals, indications and timing of operative intervention in treatment of BCTs are expected to change. We present a case of locally advanced gallbladder carcinoma in which operative options and challenges were determined by the response to immunotherapy.A 59-year-old male presented with abdominal pain for several months. Computed tomography (CT) showed a 9.3-cm gallbladder mass with direct extension into the right and left hepatic lobes , porta hThe patient received systemic chemotherapy with gemcitabine and cisplatin. After more than 2 months, he developed grade 3 neuropathy and experienced several episodes of cholangitis with liver abscess and bacteremia requiring multiple stent exchanges, and systemic therapy was discontinued. He then received trial-based immune check point inhibition with ipilimumab and nivolumab. There was good radiological  and tumoSurvival statistics from systemic therapy for gallbladder cancer remain poor; in the ABC-02 trial, doublet therapy of gemcitabine + cisplatin led to a median overall survival of 11.7 months, with radiologic responses only at 26% . Our patImmunotherapy is also not without complications as observed here. Check point inhibitor-related hepatotoxicity has been reported in up to 16% depending on the class of drugs (CTLA4 > PD/ PD-L1 inhibitors), combination versus monotherapy and dosage . The treP < 0.001) [The role of resection in patients on immunotherapy is evolving. Aside for curative-intent tumor resection, an important indication rests with resolving biliary tract obstruction and the considerable stent-related infectious morbidity , 14. A m< 0.001) . As in oThis case may serve as an illustration of future role of surgeons in the era of immunotherapy, where indications for operative interventions, resectability and other patient benefits may be all affected differently by the therapeutic response from newer agents. Several challenges still remain. Currently, the only FDA approval for the use of immunotherapy is for dMMR/MSI tumors that constitute less than 2% of all BTCs. Predictors on efficacy and durability of responses to immunotherapy are still lacking. Nevertheless, we expect an emerging role of immunotherapy in a pre-operative setting for locally advanced or borderline resectable BTCs. Operative procedures will quite possibly be selected more often for responding disease, and perhaps at times with a specific indication for biliary tract infection prevention management. Such combined immunotherapy and operative treatment can hopefully establish improved survival and quality of life outcomes for patients with BTCs in the future.The authors have no conflicts of interest to disclose.


Antiangiogenic agents can induce a distinct MRI pattern in glioblastoma, characterized by a decrease in the contrast enhancement on T1‐weighted images and a simultaneous hyperintensity on T2‐weighted or fluid‐attenuated inversion recovery images. Antiangiogenic agents can induce a distinct MRI pattern in glioblastoma, characterized by a decrease in the contrast enhancement on T1‐weighted images and a simultaneous hyperintensity on T2‐weighted or fluid‐attenuated inversion recovery images. Although antiangiogenic agents lead to a reduction in tumor contrast enhancement, it does not necessarily reflect a radiological response. We describe an MRI pattern of “pseudoresponse” in a case of glioblastoma treated with regorafenib, characterized by a “T2‐dominant growth pattern.”Glioblastoma multiforme (GBM) is the most common primary malignant tumor in the central nervous system accounting for more than 48% of all brain tumors.It has a highly aggressive nature with extremely high morbidity and mortality rate.The standard treatment for newly diagnosed GBM consists of maximal safe surgical resection followed by concurrent radiotherapy and temozolomide chemotherapy followed by the 6 cycles of chemotherapy alone with temozolomide.Despite multimodality approach, relapse is inevitable, and the prognosis is poor with a median overall survival of less than 24 months and a 5‐year survival rate of approximately 5%.In the setting of recurrent disease, the standard of care is less well defined, with little evidence for treatment options prolonging overall survival and a significant proportion of patients no longer eligible for second‐line therapy. Systemic treatment options include nitrosoureas, modestly effective agents, although they were evaluated before routine use of first‐line temozolomide.The need for additional therapeutic avenues and the evolving insights into the pathophysiology and molecular biology of GBM have allowed the development of new targeted therapeutic approaches: In particular, due to the highly vascularized nature of GBM, a strong interest in targeting “neovascularity” has led to a variety of studies assessing the effectiveness of antiangiogenic agents.Bevacizumab, a humanized monoclonal antibody against VEGF, received accelerated approval from the US Food and Drug Administration for treatment of recurrent GBM in the United States, based on the success of two Phase II clinical trials Nevertheless, antiangiogenic treatments are biologically active in GBM, and other agents have demonstrated favorable antitumor activity.The REGOMA phase II trial demonstrated the superiority of the antiangiogenic tyrosine kinase inhibitor regorafenib compared to lomustine, in the treatment of recurrent GBM, with significant improvement of the median overall survival from 5.6 to 7.4 months.The clinical practice with antiangiogenic therapy in GBM has pinpointed the issue of the radiological assessment of disease progression: Since angiogenesis is inhibited, blood‐brain barrier is less disrupted and MRI may detect a decrease in tumor enhancement; however, a large proportion of patients exhibit a diffuse infiltrating non‐enhancing tumor progression after 3–5 months, suggesting that antiangiogenic therapy can be responsible for a more aggressive GBM phenotype, with a pattern of diffuse progression.These MRI alterations are well known for GBM patients treated with bevacizumab but are poorly described in patients treated with regorafenib, and have required a revision of the response assessment in neuro‐oncology (RANO) criteria, to include the detection of non‐enhancing T2/fluid‐attenuated inversion recovery (FLAIR) lesions as a new criterion for GBM progression.Herein, we describe a distinct “T2‐FLAIR dominant” MRI pattern of pseudoprogression in a case of recurrent GBM treated with regorafenib, partially resembling a MRI pattern largely described for bevacizumab treatment.A more accurate, standardized, and reproducible assessment of treatment response seems mandatory, since regorafenib is associated with a spectrum of adverse effects heavily impacting on the quality of life: in the REGOMA trial, in fact, 59% of patients in the regorafenib arm have experienced grade 3–4 adverse events.2O‐6‐methylguanine‐DNA methyltransferase (MGMT) status by methylation‐specific polymerase chain reaction (PCR).A 61 year‐old man was admitted to our hospital at the end of March 2019 with a history of headache lasting for 10 days and sudden onset of left hemiplegia. Brain MRI scans indicated a space‐occupying enhancing hemorrhagic lesion with surrounding edema in the right temporal lobe. Urgent surgical resection of the lesion was performed, and histopathological examination revealed a wild‐type IDH1 GBM. Tumor cells tested positive for 2 daily) followed by 6 adjuvant cycles of temozolomide  was given.A 48‐h postoperative MRI confirmed the presence of residual disease. Adjuvant radiotherapy for a total of 60 Gy in 30 fractions over 6 weeks with concurrent temozolomide  of the temporal lesion and reduction of the perilesional edema on T1‐weighted images  and progression‐free survival (PFS) compared with lomustine.Antiangiogenic agents produce a stabilizing effect on the hematoencephalic barrier resulting in a decrease of the vasogenic edema and of the mass effect, with slight improvement of the patients’ symptoms and quality of life, but this does not always correspond to an effective regression of the disease.It is demonstrated that, if on the one hand, an initial reduction in the enhancement of the tumor mass is observed, on the other, when blocking angiogenesis with bevacizumab, GBM’s growth pattern changes and become more infiltrative.This growth pattern change results in distinct MRI alterations consisting in “T2‐dominant growth pattern,” that is a decrease of CE on T1‐weighted MRI despite the appearance of a progressive, infiltrative non‐enhancing growth pattern on T2/FLAIR images.“Pseudoresponse” was coined to describe this phenomenon, observed in 20%–60% of patients treated with bevacizumab, characterized by a decrease in the tumor enhancement according to Macdonald's criteria, without a true antitumor effect.T1 flare‐up progression, that is initial decrease in and subsequent flare‐up of the CE at progressionT2‐diffuse progression without new or only speckled CET2 circumscribed progression without new CEprimary nonresponders, that is, no decrease in CE or development of new lesions at first follow‐up imaging.Nowosielski et al. They observed that patients presenting a T2‐diffuse pattern of disease progression showed longer survival, while primary nonresponders had poorer survival.It has been shown that adding the T2/FLAIR criteria to the response assessment in recurrent GBM treated with bevacizumab reduces the response rates by approximately 5% and may lead to earlier detection of progression.In this paper, we describe a case of pseudoresponse to regorafenib partially resembling MRI patterns described for bevacizumab treatment.In our case, a T2‐dominant growth pattern has been observed despite initial decrease in tumor‐enhancing T1‐weighted images.Practically, since CE decreased in T1‐weighted images at first follow‐up MRI, we detected an infiltrating non‐enhancing recurrence, accompanied by progressive clinical deterioration, which preceded by about three months the detection of radiological disease progression established by the classic Macdonald and Response Evaluation Criteria in Solid Tumors (RECIST).While the issue of pseudoresponse is well known for bevacizumab treatment, for regorafenib it is poorly described in literature.classic progressive disease pattern, defined by a 25% or more increase in enhancing lesions on T1 post‐contrast imaging, or the T2‐dominant growth pattern characterized by an overall decrease in CE on T1 post‐contrast imaging and, simultaneously, an increase in non‐enhancing tumor on T2 imaging. Patients with a T2‐dominant growth pattern showed a significantly better survival  in contrast to patients with classic disease progression that had a median survival of 10 weeks.Zeiner et al. were the first to categorize the disease progression in GBM patients treated with regorafenib into two distinct MRI patterns: the Despite current research on antiangiogenic treatment, the observation that GBM may progress also without the process of neoangiogenesis and the understanding of biological mechanisms of tumor escape like vessel “co‐option,” a mechanism in which tumor cells obtain a blood supply by migrating along preexisting vessels,Improving radiological assessment in recurrent GBM treated with regorafenib remains a challenge: MRI interpretation is not easy, but, new imaging techniques are emerging to overcome this limitation.18F]‐fluoroethyl)‐L‐tyrosine (FET) as a valuable tool for response assessment in GBM, especially during antiangiogenic treatment. In a small case series, FET‐PET was able to detect both pseudoresponse and pseudoprogression and allowed earlier diagnosis of tumor progression although MRI findings were unchanged during follow‐up.The PET/RANO group One of the most substantial weakness of RANO criteria is the poor accuracy in discriminating between non‐enhancing progressive tumor and other causes of hyperintensity on T2‐FLAIR such as vasogenic edema, microvascular ischemic events, and leukoencephalopathies. Advanced MRI sequences that allow the functional assessment of tumors can overcome this limitation, such as diffusion‐weighted imaging (DWI), MR spectroscopy, and perfusion‐weighted imaging.4GBM remains the most aggressive malignancy of the central nervous system despite long‐standing efforts to improve treatment options and diagnostic tools.Regorafenib and antiangiogenic agents created an open debate about the imaging assessment of GBM response in both clinical trials and clinical practice.Measuring and interpreting changes in T2 and T2/FLAIR MRI pattern to identify the presence of non‐enhancing disease progression in patients with recurrent GBM under regorafenib treatment are challenging in order to avoid overestimation of radiological response and PFS.This is even more important when considering the toxicity profile of regorafenib, which is often burdened with major side effects that impact on quality of life.The development of advanced imaging tools such as amino acid PET, MR diffusion, perfusion, and spectroscopy to evaluate the therapeutic effect of novel antiangiogenic agents and the standardization of neuro‐radiological response patterns are challenging for future prospective research.All authors declare no conflict of interest.L.G. and E.F. involved in conceptualization, and writing original draft preparation. L.G., E.F., and A.A.B. involved in writing review and editing. All authors involved in supervision, have read and agreed to the published version of the manuscript.The patient has signed a informed consent.


Desmoid tumors are benign fibrous entities developed from connective tissue, and they result from muscle fascia or aponeurosis. Surgical excision is the main pillar of treatment.A 29-year-old female patient presented with a left postero-lateral cervical swelling that had been evolving for 11 months. Cervical MRI showed a mass at the expense of the trapezium muscle measuring 41 × 68 × 81 mm. A biopsy of the mass was performed, concluding a desmoid tumor. The patient underwent a large resection of the tumor involving the left trapezius muscle. An immunohistochemistry staining was performed, demonstrating cytoplasmic labeling with anti AML antibody, and nuclear labeling of tumor cells with anti-beta-catenin antibody. The case was analyzed by a multidisciplinary committee, and it was decided to follow the patient for surveillance.The localization of desmoid tumors in the trapezius muscle is extremely rare. The main risk of these benign lesions is infiltration of surrounding tissue leading to morbidity and mortality. Recurrence is a main feature of these tumors, even if complete excision has been performed. Unresectable desmoid tumors require medical and non-surgical treatment such as hormone therapy (tamoxifen), and chemotherapy with vinblastine and methotrexate.Desmoid tumor of trapezius muscle is classified as benign without metastatic power, and the main risk is infiltration of surrounding tissue. •Desmoid tumors are benign fibrous entities developed from connective tissue.•Desmoid tumors comprise only 12–15% of cases in the head and neck, and can occur at any age.•The localization of desmoid tumors in the trapezius muscle is extremely rare.•The symptomatology of a desmoid trapezius muscle tumor remains aspecific.•Complete resection with clear miscroscopic margins is the treatment of choice for resectable symptomatic desmoid tumors. These lThis rare condition, also called aggressive fibromatosis, is without metastatic power. They present a high risk of recurrence, and a potential for infiltration and invasion of surrounding structures. Surgical excision is the main pillar of treatment ,2.In this article, we report the clinical case of desmoid tumor of trapezius muscle, and refer to recent review of literature to discuss the difficulties of surgical management. This case has been reported following the SCARE criteria .22. Family history was unremarkable for cancer. The patient was used a combined oral contraceptive for menstrual regulation.A 29-year-old female patient, gravida 1, para 1, with no significant pathological history, had presented herself in consultation complaining of a left cervical swelling that had been evolving for 11 months in a context of general state conservation. The mass was increased in size rapidly after the end of the breastfeeding period (three months). The clinical examination at admission found normal vital signs, and Body mass index of 26.3 kg/mThe cervical examination showed a postero-lateral mass of the left neck measuring 6 cm in diameter, painless, of firm consistency, unilobed, soft, adherent to the superficial and deep plane. There was no palpable cervical lymphadenopathy or inflammatory signs of the adjacent skin.A cervical magnetic resonance imaging (MRI) was performed, revealing a mass of the left posterior cervical soft parts, at the expense of the trapezium muscle, tissue, oval, of regular contours, well-defined, measuring 41 × 68 × 81 mm, enhanced after injection of Gadolinium, with multiple homolateral supraclavicular and lateral cervical lymph nodes . The monA biopsy of the mass with Tru-cut® was performed, concluding a desmoid tumor. Abdominopelvic and thoracic computed tomography, indicated for staging, showed the absence of other progressive lesions elsewhere.In view of these clinical, radiological and pathological findings, a large resection of the tumor was indicated. The patient was installed in the supine position. Access to the posterior neck area was via a direct surgical approach (Fusiform incision). The mass was found to originate from the trapezius muscle without local infiltration of surrounding structures. A sharp dissection over the mass of the tumor away from the muscle was not possible. Complete excision of the mass was accomplished involving the fascia and trapezius muscle . A closeThe pathology examination of the surgical specimen showed proliferation of spindle-shaped cells arranged in long fascicles in a collagenous stroma. This proliferation infiltrates the striated muscle, with negative excision margins. An immunohistochemistry staining was performed, demonstrating cytoplasmic labeling with anti AML antibody, and nuclear labeling of tumor cells with anti-beta-catenin antibody. This pathological and immunohistochemical aspect highlights the diagnosis of a desmoid tumor .Fig. 3 or Gardner syndrome . Lately,The circumstances of the discovery of desmoid tumors are variable, and depend primarily on the size and location of the tumor. The clinical presentation of a desmoid tumor of the trapezius muscle remains aspecific. The desmoid tumor of the neck is presented in the majority of cases as a painless mass of hard consistency, gradually increasing in size . The othComputed tomography CT scan and MRI imaging confirm a site and a size of the lesion, suggest a diagnosis of desmoid tumor, and determine the locoregional extension and resectability of the tumor. The CT scan shows in most cases well-limited isodense lesions, homogeneously enhanced after injection of contrast product . MRI is The complete resection with clear microscopic margins is the treatment of choice for resectable symptomatic desmoid tumors . There iThe radiotherapy, as primary treatment, is usually used for inoperable or inaccessible desmoid tumors. The Adjuvant radiotherapy is recommended to decrease the rate of spontaneous recurrence which is 33–75% of patients operated in 5 years, but its efficacy is controversial, given the fact of adverse side effects  ,15.The clinical and radiological follow-up should be indicated for asymptomatic desmoid tumors . Unresec4As in other locations, desmoid tumor of trapezius muscle is classified as benign, and the main risk is infiltration of surrounding tissue, leading to morbidity and mortality. This lesion is extremely rare that must be evoked in front of any isolated lateral cervical mass.The author(s) received no financial support for the research, authorship and/or publication of this article.Dr Harouachi Abdelhakim: Have written the article, have consulted the patient, prescribed all of the tests and prepared the patient for surgery and participated in the surgery.Dr Ramdani Abdelbassir: have helped writing the article, data collection.Dr Kharkhach Ayoub: have helped writing the article, data collection.Dr Akouh Nada: Interpretation of pathological data.Pr Bouhout Tariq (oncology surgery professor): supervised the writing of manuscript.Pr Bennani Amal (Pathology professor): confirm the histological diagnosis.Pr Serji Badr (oncology surgery professor): Writing, review and editing of the manuscript, and had been the leader surgeon of the case.Pr El Harroudi Tijani (oncology surgery professor): have supervised the writing of the paper.No ethical approval necessary.Our paper is a case report; no registration was done for it.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Harouachi Abdelhakim.Not commissioned, externally peer reviewed.The authors declared no potential conflicts of interests with respect to research, authorship and/or publication of the article.


This case shows the MRI and CT features of a rare entity, namely arachnoiditis ossificans, which should be recognized in patients with long-standing history of multiple spine surgery. Figure 1A, 1C, arrows) areas with hypointense T2  rims were found, suggesting calcifications, ossification, or hemosiderin deposits. In order to better differentiate between ossification and hemosiderin, computed tomography (CT) was performed. The hypo- T2 and hyper- T1 signals corresponded to bony densities , so MRI and CT features were consistent with arachnoiditis ossificans (AO).We report the case of a 77-year-old man who presented with long-standing back pain and paraparesis, but normal reflexes and no sphincter disturbances. His medical records include multiple operations of the spine with multi-level laminectomy. He experienced increased walking and balance disorders, for which he underwent a lumbar spine magnetic resonance imaging (MRI). It revealed multi-level discarthrosis and diffuse thickening of the terminal thecal sac with aggregated nerve roots, likely resulting from previous arachnoiditis. Within the canal some hyperintense T1 , trauma, arachnoid hemorrhage, intrathecal drug injection, and spinal infections. Symptoms are variable, up to severe disability, regardless of the extent of ossification. AO may also affect other spinal segments, most often the thoracic and rarely the cervical. The differential diagnosis includes ossification of the posterior spinal ligaments, retained Pantopaque or Lipiodol, intrathecal primary neoplasm or metastases, calcified dural plaques or hemosiderin. CT and MRI are complementary for the diagnosis, as shown in our case. MRI shows irregular thickening and clumping of nerve roots of the cauda equina, while CT is useful to confirm the diagnosis by showing the mineral component. Various patterns of AO were reported by Domenicucci and classified as: Type I, at the thoracic level, as a semicircular pattern of ossification that involves part of the thecal sac; Type II, at either the thoracic or lumbar level, as a circular pattern that involves the circumference of the thecal sac; and Type III, exclusively at the lumbar level, with ossification of the entire content of the thecal sac . Current


Pseudoaneurysm of the uterine artery (UPA) is a rare cause of potentially life-threatening hemorrhage during pregnancy and puerperium. It is an uncommon condition that mainly occurs after traumatic injury to a vessel following pelvic surgical intervention, but also has been reported based on underlying endometriosis. There is an increased risk of developing UPA during pregnancy. Diagnosis includes clinical symptoms, with severe abdominal pain and is confirmed by sonographic or magnetic resonance imaging (MRI). Due to its potential risk of rupture, with a subsequent hypovolemic maternal shock and high fetal mortality, an interdisciplinary treatment should be considered expeditiously.We present the case of a 34-year old pregnant symptomatic patient, where a large UPA was detected at 26 weeks, based on deep infiltrating endometriosis (DIE). The UPA was successfully treated by selective arterial embolization. After embolization, the pain decreased but the woman still required intravenous analgesics during follow-up. At 37 weeks she developed a sepsis from the intravenous catheter which led to a cesarean section and delivery of a healthy boy. She was discharged 10 days postpartum.UPA should be considered in pregnant women with severe abdominal and pelvic pain, once other obstetrical factors have been excluded. DIE might be the underlying diagnosis. It is a rare but potentially life-threatening condition for mother and fetus. Uterine pseudoaneurysm (UPA) is a condition in which the arterial vessel wall has lost intraluminal continuity and blood accumulates between the two outer layers of the artery. It can present with severe abdominal and pelvic pain, and sonographic imaging or magnet resonance imaging (MRI) can detect a pulsatile growing mass. UPA occurs mainly after a traumatic injury of the vessel following pelvic surgical intervention, but rarely, it is based on severe endometriosis as DIE (Deep infiltrating endometriosis) –5. The mDue to the potential risk of rupture, with subsequent hypovolemic shock of the mother and a high fetal mortality, the diagnosis of UPA in pregnancy requires urgent interdisciplinary treatment. The standard of care is a selective arterial embolization of the uterine artery by the interventional radiologist, which has a good risk-benefit profile , 11.Here, we present the observation of a pregnant patient with a successfully treated symptomatic UPA that occurred in the second trimester, on the basis of a DIE in the left uterine artery and cervix.The 34-year old, first gravida, was admitted to our obstetrical department by ambulance at 23 + 0 weeks of gestation (WG) with progressive severe pain over 24 h in the left lower abdomen irradiating to the rectum and the vagina. The previous day, she had an unremarkable clinical and sonographic examination and a normal laboratory investigation. Her past medical history included a conization due to cervical dysplasia, dysmenorrhea and dyspareunia with suspected endometriosis, and the use of a combined oral contraceptive for 16 years prior to the current pregnancy. The pregnancy occurred spontaneously, with a single fetus. The otherwise healthy patient showed pain on palpation in the two lower abdominal quadrants: speculum examination revealed cervical ectopy and two black dots were visible at six o’clock. The vital signs were normal with an unremarkable pulse, respiratory rate, body temperature, blood pressure, and the hemoglobin was stable at 129 g/l. The laboratory tests and urine analysis showed no signs of infection. The cardiotocogram (CTG) was normal without contractions. Cervical length was 34 mm, measured by transvaginal ultrasound. Fetal sonography and Doppler studies revealed normal biometry with a fetus appropriate for gestational age at 42nd percentile, normal amniotic fluid, a posterior wall placenta without signs of hematoma and a normal uteroplacental resistance. Caudal and adjacent to the left ovary, a solid, ill-defined adnexal mass of 40x45mm and moderate blood flow was detected  opiate therapy. Additionally, the patient complained of newly occurring dyschezia and a single episode of brown vaginal discharge. A follow-up MRI after 6 days, at 24 + 1 WG showed progression of the lesion, with expansion into the rectovaginal space (Fig. The patient presented for follow-up at 6 weeks postpartum. She had lactation amenorrhea, persisting dyschezia and newly developed hematochezia. Rectovaginal sonography and palpation identified an unchanged endometriosis node. We started suppressive therapy with Desogestrel and scheduled a colonoscopy to exclude another origin for the hematochezia and an MRI for staging. The MRI showed an endometriosis node 3x2cm adjacent to the septum rectovaginale with expansion to the left ovary and in close proximity to the sigmoid without infiltration according to an Enzian score A2, B1, C1. (Fig. This case illustrates the difficulty to diagnose the rare entity of a UPA during pregnancy. In our case, the appearance of the lesion changed over time and finally led to the correct diagnosis with the combination of sonography and MRI. There is an increased risk of developing or diagnosing UPA during pregnancy. It is assumed that the physiological changes of the hormonal milieu and cardiovascular system, together with the pressure on the vessels promote the development of UPA . AdditioEndometriosis further increases the risk of UPA during and after pregnancy, in particular DIE –15. The In this patient, the combination of preexisting DIE and pregnancy probably caused the UPA. The close follow-up, with ultrasound and MRI, enabled us to detect the development of the UPA from the endometriosis node during the second trimester. Previously, ruptured or unruptured UPA have been detected in pregnant patients with a known history of endometriosis or previous surgery –15. Van Transcatheter arterial embolization has been established as an effective technique for the management and prevention of obstetric and gynecologic hemorrhage , 28–30. Our patient suffered long-term from severe immobilizing pain, which was difficult to control. Furthermore, the hospitalization and treatment were physically and emotionally very stressful. This raises the question regarding early diagnosis and treatment of such cases through monitoring pregnancies of patients with endometriosis. Currently, there is no evidence that endometriosis has a significant effect on pregnancy outcome , 32.; hoUPA should be considered in pregnant women with severe abdominal and pelvic pain, once other obstetrical factors have been excluded. Endometriosis can cause UPA during and after pregnancy, in particular DIE. It is a rare but potentially life-threatening condition for the mother and fetus, as a rupture of the UPA will result in hemoperitoneum and hypovolemic, hemorrhagic shock. The standard of care in a stable situation is selective arterial embolization, which has a good risk-benefit profile. There is currently no evidence that endometriosis has a harmful effect on the pregnancy outcome, therefore, no special monitoring of conventional pregnancies for patients with endometriosis is required. Nevertheless, awareness should be raised among physicians, and similar cases should be reported to establish treatment guidelines.


Actinomyces is a spore-forming gram-positive facultative-anaerobe bacillus. Grocott–Gomori staining shows sulfur granules and fungus-like branched networks of hyphae leading to the name Actinomyces, ‘ray fungus’.A female in her seventies presented with altered bowel habit, anorexia and abdominal discomfort with history of diverticulosis and no previous IUD use. Her abdomen was distended with left-iliac-fossa tenderness. She had raised inflammatory markers and normal tumor markers . CT-AP revealed large bowel obstruction due to a sigmoid mass . She undThe initial differential diagnosis included locally perforated diverticular disease or colorectal neoplasm with the latter more likely given significant CT progression. MRI showed uterine, left adnexal and mesenteric root involvement broadening the differential to include uterine sarcoma and ovarian carcinoma. Actinomycosis was not considered in the work-up differential.The lower gastrointestinal cancer multi-disciplinary meeting recommended surgical exploration due to non-diagnostic investigations and concern regarding malignancy. She underwent an open total abdominal hysterectomy, bilateral salpingo-oophorectomy, high anterior resection, ureteric stent insertion and small bowel resection. Her surgery was challenging due to extensive inflammation, causing dense adherence to the left pelvic sidewall. The lesion extended to the left external iliac vein and mobilization resulted in vascular injury. Specimen evaluation revealed extensive Actinomyces-induced inflammation, abscesses and fibrosis involving bowel wall, uterus, left ovary and adnexa, without evidence of endometritis, likely originating from diverticular disease.She was commenced on intravenous benzylpenicillin and changed to intravenous ceftriaxone before discharge to facilitate outpatient antibiotics. Intravenous ceftriaxone was continued for 6 weeks post-operatively, followed by long-term oral amoxicillin for 12 months.Actinomyces is a difficult diagnosis based on clinical and radiological findings but should be considered in differential diagnoses of inflammatory and particularly progressive pelvic lesions. Given the vague presenting symptoms, often mimicking malignancy, it is estimated 10% are diagnosed pre-operatively.While many cases of pelvic actinomycosis in women are associated with IUDs, representing 20% of actinomycosis cases reported,,Treatment of actinomycosis involves high-dose penicillin, recommended as intravenous therapy for 6 weeks and 12 months oral therapy to prevent recurrence.There are minimal case reports of Actinomycosis due to diverticular disease although it is likely they coexist more often than reported.This is a novel atypical case of pelvic actinomycosis, likely due to underlying diverticulosis.Pelvic actinomycosis appears radiologically similar to progressive malignancy and should be considered in the differential diagnosis for unusual and extensive pelvic masses.Treatment involves surgical resection if extensive and penicillin for 1 year.Informed consent was obtained from the patient for publication of this case report.Conflict of interest. None declared.


Primary cerebral tumors rarely provoke sudden death. The incidence is often underestimated with reported frequencies in the range of 0.02 to 2.1% in medicolegal autopsy series. Furthermore, primary cerebral melanoma is an uncommon neoplasm. It represents approximately 1% of all melanoma cases and 0.07% of all brain tumors. This neoplasm is very aggressive, and its annual incidence is about 1 in 10 million people. In the present study, a 20-year-old male was admitted to hospital with vomiting, headache, paresthesia and aggressive behavior. A computed tomography (CT) scan of the head was performed showing a hyperdense nodule in the right parietal lobe with inflammation of the Silvian fissure. A complete autopsy was performed 48 h after death. A blackish material was displayed on the skull base, and posterior fossa. Microscopic examination diagnosed primary brain melanoma. A systematic review of the literature was also performed where no previous analogous cases were found. The forensic pathologist rarely encounters primary cerebral melanoma, and for these reasons, it seemed appropriate to describe this case as presenting aspecific clinical symptoms and leading to sudden unexpected death. Histopathological observations are reported and discussed to explain this surprising sudden death caused by a primary cerebral melanoma. Sudden unexpected death due to a primary nervous neoplasm is not frequent in medico-legal activity  because The aim of this study was to present a case report and a systematic review of this rare pathology, in order to improve the overall knowledge of forensic pathologists on sudden death from brain tumors, especially in the case of cerebral melanoma. A complete autopsy, comparing radiological findings and histological presentation, could provide a comprehensive overview of such sudden deaths.A 20-year-old male was admitted to hospital with vomiting and headache; he was a cannabis user and cigarette smoker (40 cigarettes a day). He referred paresthesia in the upper limbs, psychomotor agitation and aggressive behavior. The neurological examination pointed out a palpebral ptosis and a right eye ophthalmoplegia including paralysis of the left facial nerve. A CT scan of the brain was performed and showed a hyperdense nodule in the right parietal lobe and along the Sylvian fissure, the leptomeningeal spaces were described as affected by an inflammatory process . FifteenNo ethical committee was required. Written informed consent was obtained from his relatives.A complete autopsy was performed 48 h after death. External examination revealed abrasions on the hands and the upper limbs. The autopsy revealed the dura was full of clots. The brain weighed 1550 g and was diffusely swollen. In the subarachnoid space of the fronto-parietal lobes and along the interhemispheric cleavage of the parietal left lobe, some nodular blackish rounded soft formations with blood were observed. Moreover, in the temporal and parietal lobes, similar formations were present . A soft During the autopsy, brain samples were collected that were fixed in 10% buffered formalin. After washing, the water was removed, and they were embedded in paraffin. The obtained blocks were cut (4 µm thickness), using a microtome , sectioned, and stored at room temperature. Sections were stained with Hematoxylin and Eosin (H&E) and Von Gieson’s method. The immunohistochemical analysis of the samples was performed through antimelanoma-antibody (HMB45+), Melan A-antibody, CD3-antibody, CD20+-antibody, PenCK-antibody, Ki67+, as suggested by Tosaka et al.  for the A systematic review was conducted according to the PRISMA guidelines .Pubmed and Google Scholar were used as search engines from 1 January 1980 to 1 February 2021 to evaluate the association between sudden death and brain tumor. meSH was used for the following words: (sudden death) AND .The following exclusion criteria were used: (1) review, (2) articles not in English, (3) animal studies, (4) abstract, (5) editorial, (6) poster, and (7) communications at conferences. The inclusion criteria were as follows: (1) Original Article, (2) Case Report, and (3) Articles in English.A.M. and A.P. initially evaluated all the articles, evaluating the title, the abstract, and the whole text. Once, P.G. and M.E. reanalyzed the articles chosen independently. In cases of conflicting opinions between the articles, they were submitted to G.V.A total of 388 articles were collected (66 from PubMed and 322 from Google Scholar). Of them, 27 duplicates were removed. A total of 339 articles did not meet the inclusion criteria. In conclusion, 22 articles were included in the present systematic review .Most of the studies were case reports (n. 16), some cases series (n. 4), and a few original articles (n. 2). Most of the tumors related to sudden death were matched with glioblastoma multiform or astrocytomas in the different world health organization (WHO) grades. Other tumors related to sudden death were oligodendrogliomas, gliomas, adenomas, and colloid cysts. The most frequent autopsy findings were cerebral edema, solid tumor mass, and hemorrhagic infarction of surrounding tissue. The most frequent cause of death was due to intracranial hypertension from the tumor; sometimes it was due to hemorrhage caused by the tumor ; only one case was due to respiratory arrest due to the location of the tumor near the center of breathing control .Sudden death due to brain tumors has a low incidence and is often underestimated . This syPrimary cerebral melanoma is a very uncommon neoplasm derived from melanocytes present in the leptomeninges. This pathology, first described by Virchow , is veryAge is also an additional factor to distinguish a primary cerebral melanoma from metastatic melanoma. Primary cerebral melanoma develops primarily in patients under 50 years of age and rarely metastasize to other organs. Metastatic melanomas develop mainly in the elderly, have a rapid clinical course and multiple intracerebral diffusion . In the The surprising case of sudden death stresses the need for a careful analysis in all patients with psychiatric disorders or no-specific neurological signs, especially when these manifestations show-up unexpectedly in a healthy person. Despite the fact that modern genetic ,63,64, r


Surgical intervention was unachievable and the patient was given 45 Gy to the surgical cavity followed by a 5.4 Gy boost to visible tumor with external radiotherapy. Patient reported significant relief of her symptoms. We aim to contribute to the formation of a treatment algorithm for this rare entity.Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare neoplasm arising from spindle cells and most commonly arising from pleura. Spinal SFT/HPC is a rare entity; hence, it is not on the top of the differential diagnosis list when a clinician faces a spinal lesion. In the review of the literature, there exist less than 50 case reports of intradural extramedullary SFT/HPC. Here, we present a 54-year-old female patient who underwent subtotal surgical excision of an intradural extramedullary spinal mass pathologically reported to be SFT/HPC and had symptomatic recurrence in the 3 Solitary fibrous tumors (SFT) (formerly known as hemangiopericytoma (HPC)) are rare mesenchymal neoplasms originating from spindle cells . AlthougOur patient is a 54-year-old female with a past medical history including asthma and peptic ulcer disease. Her family history is free of malignant diseases. In 2016, patient's chest X-ray examination found a suspicious lesion. Magnetic resonance imaging (MRI) was ordered for further investigation in November 2017 since the patient was complaining of back pain. MRI revealed a spinal lesion 12 × 10 mm in diameter at the level of second thoracic vertebra (T2) Figures . The patThe patient was presented at the multidisciplinary tumor board for treatment options. Given the critical anatomic location and close involvement with nerve roots, the patient was found unsuitable for surgery. Eventually, the board decided on the referral to the radiation oncology clinic. A repeat contrasted thin-slice MRI of cervical and thoracic spine was performed Figures . The repPrimary spinal cord tumors are rare neoplasms that constitute 4.5% of central nervous system (CNS) tumors in adults . Their pDue to their rareness, SFTs are not on the top of the differential diagnoses list when the clinician is faced with a lesion in the spinal cord . MRI is Achieving complete surgical resection is the main goal in extrathoracic SFTs, and it is associated with improved local control and survival. Routine long-term follow-ups must be ensured for the early detection of recurrence . Althougth case of a recurrent SFT treated with radiotherapy [Herein, we present a case of IDEM SFT who had STR 27 months prior to presentation to our clinic with bilateral pain over the arms and legs and newly developed radiological evidence of recurrence. Radiotherapy was the treatment of choice for this patient due to the location of the tumor. To our knowledge, we present the 5otherapy , 33–35.Spinal type IIA SFT is a rare entity with less than 50 case reports in the literature. GTR is the required treatment option while the role of adjuvant radiotherapy and its indications is yet to be discussed. We contribute to the literature by presenting a rare case in which close follow-up ensued STR, and radiotherapy was performed when the lesion recurred. We believe that the increase in the number of cases in the literature will help and contribute to the embodiment of the therapeutic algorithm of the disease in question.


Gastric glomus tumor is a rare mesenchymal neoplasm. There are only a few cases of the tumor showing malignancy, and there are no specific guidelines for the management of this entity.We present the case of a 53-year-old Caucasian male who was hospitalized for anemia. Computerized tomography of the abdomen depicted a mass between the pylorus of the stomach and the first part of the duodenum. Preoperative diagnosis was achieved with pathology examination of the biopsies taken via endoscopic ultrasound and upper gastrointestinal endoscopy. An antrectomy with Roux-en-Y anastomosis and appendicectomy, due to suspicion of appendiceal mucocele, were performed. The patient had an uneventful postoperative recovery and was discharged 5 days later.Preoperative diagnosis of a gastric glomus tumor is difficult owing to the location of the tumor and the lack of specific clinical and endoscopic characteristics. Furthermore, it is exceptional to establish diagnosis with biopsies taken through endoscopic ultrasound or upper gastrointestinal endoscopy, prior to surgical resection. Although most glomus tumors are benign and are not known to metastasize, there are rare examples of glomus tumors exhibiting malignancy. Treatment of choice is considered wide local excision with negative margins. However, long-term follow-up is required as there is the possibility of malignancy.The aim of this report is to enlighten doctors about this uncommon pathologic entity. Surgical resection is considered the golden standard therapy to establish a diagnosis and evaluate the malignant potential. Glomus tumor (GT) is a rare mesenchymal neoplasm and accounts for approximately 1% of gastric mesenchymal tumors . Barre aThe neoplasm arises from the glomus body, which is an arteriovenous anastomosis consisting of tightly convoluted capillaries surrounded by modified muscle cells , 10. TheGastric glomus tumor (GGT) lacks specific clinical and endoscopic characteristics, which renders it difficult to distinguish from other gastric submucosal neoplasms prior to surgical resection –14. The Currently, the main diagnostic modalities for evaluating GGT are endoscopic ultrasound (EUS) and computerized tomography (CT) , 18. TheWe report the case of a 53-year-old male whose gastric glomus tumor was diagnosed preoperatively with biopsies obtained via upper gastrointestinal endoscopy and EUS.We present the case of a 53-year-old Caucasian male who was admitted to the hospital owing to fatigue and black stools. His vital signs on the admission were: temperature  36.8 °C, heart rate 70 beats per minute, respiratory rate 17 breaths per minute, and blood pressure 120/80 mmHg.2]. He did not consume alcohol or tobacco. He was married and had two children aged 15 and 19 years.The patient was pale but with good nutrition status [body mass index (BMI) 23.1 kg/mHe was taking no medication and had no other underlying disease. Moreover, his medical history was free of any previous surgical interventions. During the clinical examination, there was no sensitivity or tenderness in the abdomen and the bowel sounds were normal. Digital rectal examination revealed the presence of black stools. Clinical examination of cardiopulmonary and urogenital systems showed no abnormal signs. Apart from fatigue, there were no other findings on physical and neurological examination.The blood tests depicted anemia . The results of all other markers were within normal range  scan of the abdomen was performed. The CT scan of the abdomen revealed a mass with vague limits (dimensions 6.8 × 5.7 cm) between the pylorus of the stomach and the first part of the duodenum. Around that mass, there were several lymph nodes with diameter up to 1.6 cm. Furthermore, the presence of appendiceal mucocele was indicated as an incidental finding.On the third day of his hospital stay, the patient underwent EUS and upper gastrointestinal endoscopy, in which the biopsies showed morphologic and immunochemical features compatible with glomus tumor. Twelve days after his admission, the patient underwent open laparotomy with a midline incision. An antrectomy with Roux-en-Y anastomosis and appendicectomy were performed owing to suspicion of appendiceal mucocele from the CT scan Figs. , 2.Fig. The postoperative period was without any incident, and the patient was released in good condition 5 days after the operation. After the surgery and during his hospital stay, he was receiving intravenously 3 g cefoxitin/day for 3 days, 1.5 g metronidazole/day for 3 days, 4 g paracetamol/day for 4 days, and 200 mg tramadol/day for 3 days. The initial postoperatively intravenously administration of fluids was followed by oral feeding after 3 days.Pathology examination showed a 5.5 × 5 × 4.2 cm intramural gastric mesenchymal neoplasm compatible with glomus tumor. Although there was no prominent nuclear atypia, and no mitotic activity or any atypical mitosis, because of the tumor’s size, > 2 cm, and the location, deep in the layers of gastric wall, the final diagnosis was glomus tumor with uncertain malignant potential Figs. , 4, 5. AAfter discharge from the hospital, the patient underwent regular follow-up meetings with clinical examination, blood tests, and computerized tomography of the brain, the chest, and the abdomen. His last follow-up was in January 2021, 20 months after his admission to the hospital, in which he was found in good clinical status and with no signs of recurrence. There were no findings of pathological entity on the CT of the chest and the abdomen. He was scheduled for a meeting again after 6 months.We report the case of a rare gastric neoplasm, gastric glomus tumor, in a 53 year-old Caucasian male who was hospitalized for fatigue, black stools, and anemia. There were no pathological findings neither on clinical and physical examination nor on laboratory investigation, apart from black stools in digital rectal examination and signs of anemia in blood tests, but the CT scan of the abdomen that was performed during his admission to the hospital revealed a mass with vague limits between the pylorus of the stomach and the first part of the duodenum. Preoperative diagnosis of GGT is difficult owing to the deep location of the tumor and the lack of specific clinical and endoscopic characteristics –14. It iGastric glomus tumor shares many features with other gastric submucosal lesions, making preoperative diagnosis difficult –17. It iAs it can easily be understood, the clinical signs are insufficient to establish the diagnosis of a gastric glomus tumor. Most of these clinical symptoms are common in several pathological entities. Therefore, computerized tomography of the abdomen, EUS, and upper gastrointestinal endoscopy are essential in the diagnosis of a GGT , 18. CT Due to intramural location, which makes diagnosis with endoscopic biopsy difficult, GT is commonly diagnosed after pathology examination of the surgical specimen –17. Howeet al. for defining malignancy in GGT and estimating the risk of recurrence and metastasis [As previously mentioned, GT is commonly diagnosed after pathology examination of the surgical specimen –17. The tastasis . These ctastasis . Tumors tastasis .et al. performed an analysis of 52 cases of glomus tumors located in the extremities and found that 8 of them had histologically confirmed metastases [et al. reported the case of a malignant gastric glomus tumor with metastases to liver and brain [et al. [Although most glomus tumors are benign and are not known to metastasize, there are rare examples of glomus tumors exhibiting malignancy –8, 14. Fnd brain . The his [et al. .As far as the surgical operation, treatment of choice is considered the wide local excision with negative margins . There iFurthermore, excision of a gastric glomus tumor through EUS has been proposed . HoweverAs there is a potential for malignancy, long-term follow-up is suggested , 20. LonGastric glomus tumor is a rare pathologic entity. It is mainly considered benign and can be cured by surgical resection with excellent outcomes. Some reports present gastric glomus tumors with metastases, which make necessary for a patient carrying a potential malignant GGT to undergo long-term follow-up. Unfortunately, there are no definitive diagnostic criteria or evidence-based treatment guidelines for this entity; thus, it is necessary to have a larger number of cases and studies to acquire the adequate knowledge.