Ectopic pituitary neuroendocrine tumors (PitNETs) are uncommon conditions that develop outside of the sella turcica. The sphenoid sinus is the most common site for ectopic PitNET, followed by the suprasellar region, clivus, and cavernous sinus. PitNETs, regardless of whether inside or outside sella, may display avid 18F-fluorodeoxyglucose (FDG) uptake and masquerade as malignant tumors. Herein, we report a case of ectopic PitNET arising in the sphenoid sinus, which was found as an FDG-avid mass during cancer screening. On magnetic resonance imaging, the tumor showed heterogeneous and intermediate signal intensity areas on T1- and T2-weighted images with cystic components, which was consistent with PitNET. The localization and the presence of empty sella were suggestive of ectopic PitNET, and the diagnosis of ectopic PitNET (prolactinoma) was confirmed by endoscopic biopsy. Ectopic PitNET should be considered in a mass similar in nature to an orthogonal PitNET in areas near the sella turcica especially in patients with empty sella. Pituitary neuroendocrine tumors (PitNETs), formerly known as pituitary adenomas, are benign tumors that grow from pituitary gland cells and can cause various hormonal abnormalities. Ectopic PitNETs are uncommon conditions in which PitNETs develop outside of the sella turcica A man in his 60s was referred to our hospital for further evaluation after a routine cancer screening revealed an abnormality in the sphenoid sinus. His past medical history included hypertension, atrial fibrillation (successfully treated with ablation at the age of 57 years), and vertigo, which had been investigated with an MRI at another facility, revealing only sinusitis. The 18F-FDG PET/CT examination performed during the cancer screening showed an FDG-avid mass in the sphenoid sinus . The staEndocrinological examination revealed abnormally high prolactin levels , without any related symptoms. Other hormone levels, including growth hormone, insulin-like growth factor I, adrenocorticotropic hormone, thyroid stimulating hormone, free T3, free T4, luteinizing hormone, and follicle-stimulating hormone, were within normal limits. An endoscopic sphenoidal biopsy was performed, and the tumor displayed an alveolar proliferation of atypical cells with hyperchromatic, enlarged round-to-oval nuclei . The hyaWe report a case of ectopic PitNET (prolactinoma) arising in the sphenoid sinus initially detected on 18F-FDG-PET/CT as an FDG-avid mass.PitNETs are benign tumors that grow from pituitary gland cells and can cause various hormonal abnormalities. PitNETs, formerly known as pituitary adenomas, are renamed in the fifth edition of the World Health Organization (WHO) classification 2021 The pituitary gland is composed of an anterior, a posterior, and an intermediate lobe. The adenohypophysis includes the anterior lobe, the pars intermedia, and the pars tuberalis.The neurohypophysis includes the posterior lobe, the infundibular stalk, and the median eminence. Embryologically, the pituitary gland derives from the developing diencephalon (neurohypophysis) and the primitive oral stomodeum (adenohypophysis) On neuroimaging, ectopic PitNET shows no connection to the intrasellar pituitary gland. Nonenhanced CT typically shows a mass with isodensity compared to gray matter The normal pituitary gland typically shows an FDG uptake of the background level on 18F-FDG PET/CT imaging We reported a case of FDG-avid ectopic PitNET arising in the sphenoid sinus masquerading as malignancy. Ectopic PitNET should be considered in a mass similar in neuroimaging features to an orthogonal PitNET in areas near the sella turcica especially in patients with empty sella.The written informed consent was obtained from the patient for the publication of this case report and accompanying images.


Doege-Potter syndrome is a rare paraneoplastic entity that is often diagnosed incidentally during the work-up of hypoglycemia of unclear etiology. It is characterized by a non-islet cell tumor hypoglycemia mostly associated with solitary fibrous tumors. These uncommon tumors have been reported in <5% of solitary fibrous tumors. Although not unique in its kind, this case is extremely important as this syndrome often conceals unrecognized tumors that can be surgically resolved.We present the case of a 59-year-old non-diabetic man with a 2-month history of severe and recurrent fasting hypoglycaemia presenting with severe dyspnea and sweating. Further work-up revealed low insulin, C-peptide, and IGF-1 levels and a large right in-trathoracic solitary fibrous tumor. Unfortunately, bioassays for IGF-2 were unavailable at our hos-pital. Nevertheless, as hypoglycemia completely resolved after resection of the mass, Doege-Potter syndrome was highly suspected.Doege-Potter syndrome is a complication of rare tumors. If hy-poglycemia is unexplained, this syndrome should always be suspected, and the presence of un-known masses should be investigated. Occasionally, it can manifest endogenous hyperinsulinism . In less than 5% of cases, non-islet cell neoplasms, such as solitary fibrous tumors (SFT), can cause hypoglycemia. This condition is called Doege-Potter syndrome (DPS) [Hypoglycemia is a medical emergency commonly caused by drugs (ss Table . Occasiome (DPS) . This syme (DPS) -5.SFTs are rare neoplasms that arise from mesenchymal cells, accounting for less than 2% of soft tissue tumors. In more than 80% of the cases, SFTs are characterized as slow-growing, indolent neoplasms with low malignant potential .et al., the most common cause of Doege-Potter syndrome is SFTP involving the right hemothorax [Most SFTs are primarily located in the pleura (referred to as SFTP) and typically present as incidental findings. However, in some cases, SFTPs can be associated with respiratory symptoms due to the compression of lung tissue by the pleural mass. According to Han mothorax .Recurrent fusion transcripts caused by inversions at chromosome 12q13 have been associated with SFTs. More specifically, the NAB2-STAT6 gene fusion, resulting in a chimeric protein (STAT6), has been identified as the hallmark of the SFT .Here, we report a case of presumptive Doege–Potter syndrome secondary to SFTP in a 59-year-old male with complete resolution of hypoglycemia after resection of the pleural tumor.2A 59-year-old male was referred to Santa Maria degli Angeli Hospital, Pordenone, Italy, with a complaint of recurrent and documented fasting hypoglycemia that had been occurring for the past two months. He reported experiencing excessive sweating, tremors, and weakness during these episodes. Finger stick tests were used to confirm the hypoglycemia, with blood glucose levels ranging from 20 to 50 mg/dL.The symptoms generally resolved after breakfast, and the postprandial glucose level reached the peak of about 70 mg/dL, which was determined with a fingerstick test. His medical history included hypertension and benign prostatic hyperplasia. He chronically consumed nebivolol, hydrochlorothiazide, and tamsulosin. He did not suffer from diabetes mellitus and denied the intake of any glucose-lowering or herbal medication. He was not a smoker and did not consume alcohol or illicit drugs. His family history was unremarkable. His recent history was notable for frequent sudden onset of severe dyspnea and sweating, with no accompanying chest pain or weight loss.During the lung examination, severely diminished breath sounds were detected in all areas of the right lung, along with dullness upon percussion. No superficial lymph node enlargement was observed. Both cardiovascular and abdominal examinations yielded unremarkable findings.2).A biochemical work-up for hypoglycaemia revealed non-insulin-mediated hypoglycemia with a blood glucose level of 25 mg/dL . Furthermore, there were concomitant low serum insulin levels , low serum C-peptide levels , and low serum IGF-1 levels for sex and age . The pituitary function was found to be normal, and cortisol deficiency was ruled out. Additionally, insulin antibodies tested negative. The renal and hepatic functions were within normal limits. A complete blood count and metabolic panel excluded anemia and electrolyte imbalances (Table 1).Chest X-ray showed a sub-total white right hemithorax with loss of volume lung   for respiratory virus detection and blood cultures, all yielded negative results.Microbiological tests, including 2). CT scan did not show any adenopathy, other mass lesions, or bone metastasis.To further characterize the condition, a chest/abdomen CT scan was performed. The CT images revealed a large heterogeneous enhancing mass measuring 22.5×16.5×22.5 cm in the right lower hemithorax. The mass did not involve the rib cage but exerted pressure on the adjacent lung and cardiomediastinal structures, including the superior vena cava, right atrium, and right pulmonary vein. A large pleural fibroma was hypothesized based on these findings .Transthoracic echocardiography was also performed to rule out a cardiogenic cause of the dyspnea. A large mass compressing the right atrial cavity was revealed  stain, AFB culture, and fungal culture all came back negative.The histological evaluation showed a tumor consisting of simple spindle-shaped cells with no apparent nuclear pleomorphism. There was no evidence of necrosis. Immunohistochemical analysis revealed the following findings: Bcl-2 (+), STAT6 (+), CD34 (+), S100 (-), CK7 (−), WT1 (−), D2-40 (−), calretinin (−), MDM2 (−). These findings, along with the presence of non-islet cell tumor hypoglycemia (NICTH) in the context of SFTP, supported the diagnosis of Doege-Potter syndrome.4).A continuous infusion of 10% glucose was promptly administered, and the patient was advised to have frequent meals. However, episodes of hypoglycemia continued to occur. Due to the recurrence of symptoms, the medical team proposed a surgical approach. Consequently, the patient underwent a right posterolateral open thoracotomy for mass resection. The tumor, originating from the anterior mediastinum, was located within the right lung. A portion of the lower lobe of the right lung was resected. The encapsulated mass measured 25.3×19×17 cm and weighed 3720 g  and necrosis rate <10% classified this SFT as a tumor at high risk of recurrence/metastasis (according to WHO classification).5).A multidisciplinary team did not consider any adjuvant treatment necessary. Post-operative serum glucose levels normalized, and the patient was discharged after a few days without re-presenting hypoglycemic episodes. Dyspnea completely resolved as well. Two weeks after discharge, the chest radiograph showed pulmonary re-expansion in the right hemithorax , most commonly associated with solitary fibrous tumors (SFT).Doege-Potter syndrome (DPS) is a rare paraneoplastic entity characterized by NICTH due to excessive secretion of precursor “big” insulin-like growth factor II (IGF-2) from the SFT. This prohormone suppresses growth hormone and leads to decreased synthesis of IGF-binding proteins, resulting in elevated levels of unbound and active IGF-2 . The binWe present a case of suspected Doege-Potter syndrome associated with a solitary fibrous tumor of the pleura.i.e., cortisol, GH). A history of anti-diabetic drugs or alcohol use was also excluded. The biochemical work-up revealed a deficiency in growth hormone (GH) and insulin-like growth factor-1 (IGF-1) for the patient's sex and age.During the diagnostic process, various causes of hypoglycemia were ruled out. The patient exhibited very low levels of insulin and C-peptide, prompting an investigation into common causes of non-insulin mediated hypoglycemia, such as critical illness, renal or liver failure, and hormonal deficiencies , together with a tumor size >15 cm and a patient’s age >55 years, suggested a high risk of recurrence/metastasis, according to WHO criteria [The most characteristic immunohistochemical finding in DPS is the CD34 expression; however, approximately 5% of STFs may be negative for this marker. The NAB2-STAT6 gene fusion, resulting in a chimeric protein (STAT6), has been identified as a consistent finding in SFTs. Nuclear expression of the carboxy-terminal part of STAT6 serves as a highly sensitive and specific immunohistochemical marker for SFT, aiding in the differentiation of this tumor type from histologic mimics . In our 6, Table 3) can be categorized into approaches that directly reduce the tumour burden (such as surgery and chemotherapy) and treatments aimed at mitigating hypoglycemia without treating the underlying tumour [Therapeutic strategies for DPS (Fig. g tumour -19.Complete surgical resection is the definitive curative approach for both benign and malignant SFTs. Resectability is a crucial prognostic factor, and the overall long-term cure rate after complete resection in all patients ranges from 80% to 92% . FurtherIn our case, surgical resection of the thoracic mass resulted in a complete resolution of hypoglycemia. Although not unique in its kind, this case is extremely important for the scientific community as it presents a very rare syndrome that internists should always consider. This syndrome often conceals unrecognized tumors that can be surgically resolved.


Enteric duplication cysts (EDCs) are a benign and uncommon congenital malformation, with a nonspecific and extremely variable clinical presentation. EDCs associated with the pancreas are called pancreatic duplication cysts (PDCs). They are especially rare and can present with recurrent abdominal pain or even severe pancreatitis. These cysts often get confused with pancreatic neoplasms or pseudocysts, thus posing diagnostic and surgical challenges. Here, we report a case of a 20-year-old male patient with a 14-year history of recurrent abdominal pain and many hospital admissions, who had several imaging studies revealing a persistent focal heterogeneous lesion affecting the tail of the pancreas, surrounding a small pseudocyst. An ultrasound (U/S) guided biopsy was avoided due to the location of the mass. Surgical resection was carried out for the suspicion of malignancy and final pathology report showed benign findings while revealing that what was thought to be a pseudocyst turned out to be a gastric-type PDC, and after reviewing the available literature, we encountered 16 similar cases regarding misdiagnosing PDCs. We conclude that PDCs are very rare and have a variable clinical presentation as well as a likelihood of being confused with other pancreatic neoplasms. Therefore, PDCs need a high index of suspicion to avoid recurrent hospital admissions and unnecessary procedures due to the fact that sometimes a simple cystectomy is adequate. Enteric duplication cysts (EDCs) are rare and very uncommon congenital malformations with a reported incidence of 1 in every 4,500 live births . The oriAn EDC is named based on its anatomical location, as it generally shares the same smooth muscle and blood supply of the adjacent organ , but mayMost EDCs are detected within the first two years of life and scarcely in adulthood. The most common ones are ileal duplication cysts and the rarest being the isolated EDCs, which have their own blood supply and muscular wall .EDCs that are present in the pancreas are called Pancreatic duplication cysts (PDC), and are considered a very rare entity  that mayHere, we report a case of a 20-year-old male patient with a history of recurrent abdominal pain, who had several imaging studies revealing a persistent lesion affecting the tail of the pancreas. Surgical resection was carried out and the final pathology report revealed benign findings with a gastric-type PDC.A 20-year-old male patient presented to our hospital in February 2022, for further evaluation of recurrent attacks of abdominal pain of 14-year duration. He had free past medical and surgical histories.The patient was 6 years old when he started to complain of severe dull aching pain in the mid upper abdomen that radiated to the back and was associated with vomiting of normal gastric content. The attacks happened at least 4 times per year. During each attack, an abdominal ultrasound showed unremarkable findings, and the patient was only treated with intravenous analgesics.In 2018, the pain became intolerable as it increased in severity and frequency. An abdomino-pelvic computed tomography (CT) scan was done and revealed splenic vein thrombosis with a Pancreatic Pseudocyst. The patient was treated with anticoagulation, and a follow-up U/S showed the resolution of the thrombus. However, the patient was still complaining of the same attacks of abdominal pain, for which he underwent Magnetic resonance cholangiopancreatography (MRCP) that showed a small pseudocyst formation measuring about 0.8 cm and surrounded by heterogeneous pancreatic tissue measuring about 2.3 cm with features of inflammatory changes; which led to the suspicion of malignancy. Therefore, surgery was advised, but the patient refused and continued to have the same attacks with no improvement.In January 2022, the patient underwent a CT scan, which revealed a persistent focal heterogeneous mass like lesion containing a small pseudocyst affecting the pancreatic tail. Then in February 2022, an abdominal ultrasound showed a hypovascularized, heterogeneous mass at the most distal portion of the pancreatic tail. Therefore, he was admitted to our hospital on February 27, 2022 as a case of a suspicious pancreatic tail mass. The physical examination was unremarkable, and the last episode of abdominal pain was one week prior to admission.Serum lipase and amylase levels were within the normal range and Carcinoma embryonic antigen (CEA) and Cancer antigen 19-9 (CA19-9) were 1.8 ng/dl and 8.1 U/ml respectively. U/S guided endoscopic biopsy was disfavored due to splenic flexure interposition and a risk of colon perforation or splenic hemorrhage.The patient remained stable with no complaints and a laparoscopic distal pancreatectomy was planned for March 06, 2022. A CT-Scan Pancreas Protocol (three phases) showed a lobulated hypodense lesion in the tail of the pancreas, measuring 3 cm × 2.5 cm with minimal rim enhancement that contains at least three cysts; the largest measuring 1.5 cm with stranding of the adjacent mesenteric fat .Due to the suspicion of malignancy and to look for other primary malignancies; a gastroscopy was done which showed mild superficial antral gastritis and a colonoscopy only reached the splenic flexure, with no further progression either due to severe angulation or extra colonic compression. Then, the patient underwent surgery that consisted of distal pancreatectomy, splenectomy and segmental resection of the colonic splenic flexure that were sent to the histopathology lab.The surgery started laparoscopically by dissecting around the splenic flexure and the inferior and superior pancreatic borders, but due to the mass adherence to the colon, and the need for colonic resection and anastomosis it was difficult to continue laparoscopically. So, through a reverse Kocher incision, the abdomen was opened.During the procedure, the lesion was found to be proximal to the spleen, but a splenic-preserving pancreatectomy was not possible due to the inability to isolate and protect both of the splenic artery and vein, thus necessitating the removal of the spleen.On postoperative day 7, the patient was ready to be discharged as he was stable and tolerating a regular diet, with the right drain being kept in place.On follow-up (December 2022) the patient was doing well, he got all of the indicated vaccines two weeks after discharge that included: pneumococcal, meningococcal and Haemophilus influenzae vaccinations. In addition, he only experienced one attack of abdominal pain two months after the surgery; it was mild, did not require hospitalization and was relieved with non-steroidal anti-inflammatory drugs. After that, he did not experience any abdominal pain.Final pathology report demonstrated a 0.8 cm cyst near the tail of pancreas with a smooth muscle wall and gastric mucosa lining consistent with a gastric-type pancreatic duplication cyst and no evidence of malignancy, as the suspected mass consisted of inflammatory tissue with hemosiderin deposition and fibrosis. , MRI or a CT scan, it's not guaranteed to identify the cystic nature of a PDC. Even though some modalities are superior to others like the EUS, the thick proteinaceous cyst fluid makes it difficult to assess . TherefoIt's worth mentioning that a CT scan can provide helpful information about the precise anatomical relationship between the cysts and surrounding structures, making it easier to distinguish duplications arising from the stomach, duodenum, and pancreas . Also, wDespite this, a 50% incidence of misdiagnosis still remains , often lAs a part of evaluating pancreatic cystic lesions, fine needle aspiration is used to determine malignant potential, but this contributed to some cases of PDCs being misdiagnosed as pancreatic neoplasms , 22, 25,Therefore, most cases of PDCs are diagnosed after surgical resection by histopathologic examination of the surgical specimen, which was the case in our patient. Classically on histologic examination, a duplication cyst wall will show layers of smooth muscle mimicking those of the adjacent gut wall; which is demonstrated in our specimen . And theBut once a PDC is diagnosed, surgical resection is the mainstay of therapy, and the approach depends upon the pathology encountered. If the separation of the cyst from the surrounding structures is possible, simple cystectomy is sufficient . In our To conclude, PDCs are difficult to differentiate from other tumors of the pancreas unless some clues appear on imaging studies. Thus, they might remain misdiagnosed until they are surgically resected. Recurrent abdominal symptoms or events such as bleeding, perforation and the reported possibility of a malignant transformation point towards having surgical resection as the first treatment option for PDCs.


Aneurysmal bone cysts are benign osseous lesions containing blood-filled cavities separated by walls of connective tissue. They can be difficult to identify clinically due to similarities in presentation, imaging, and histology with other pathologies. Specifically, it is important to distinguish these benign lesions from malignant processes, as both surgical and medical management differ. We present the case of a 21-year-old patient who presented with impaired motor and sensory function in his lower extremities. Radiologic findings were concerning for an invasive neoplasm, and the intraoperative frozen section supported this conclusion. However, an additional histological investigation was confirmatory for a diagnosis of an aneurysmal bone cyst. The patient underwent corpectomy, laminectomy, and a posterior spinal fusion, and regained motor and sensory function shortly thereafter. This report details the importance of considering aneurysmal bone cysts in the differential of infiltrative bone lesions, despite their benign nature, as medical and surgical management can vary greatly. In 1942, physicians Henry Lewis Jaffe and Louis Lichtenstein first described two cases of an odd blood-filled bone lesion in patients presenting with advanced neurologic deficits, coining the term aneurysmal bone cyst (ABC) . ABCs ocA 21-year-old male presented to the emergency department with severe back pain and the inability to walk for five days. He had not had prior trauma and did not have a significant personal or family medical history. He had a spontaneous pneumothorax 18 months prior which resolved without intervention. A chest computed tomography (CT) image was obtained during that hospitalization with no evidence of any extra-pulmonary processes. On physical exam during the present admission, the patient demonstrated 5/5 motor strength in his upper extremities bilaterally, but he had 1/5 strength on bilateral lower extremity dorsiflexion and testing of the extensor hallucis longus, as well as 4/5 strength on plantarflexion, hip flexion, and knee extension bilaterally. Additionally, he exhibited 4-5 beats of ankle clonus bilaterally and decreased sensation to light touch in the T9-T10 dermatomes bilaterally. Magnetic resonance imaging (MRI) with contrast using both T1- and T2-weighted sequences revealed a diffuse marrow-replacing process with complete infiltration throughout the T8 vertebra, as well as resulting effacement of the T7-T8 CSF spaces and severe spinal cord compression  of the vertebrae are a rare but important diagnostic consideration in the workup of a young patient with a vertebral column mass. Unlike systemic malignancies or sarcoma, aneurysmal bone cysts of the spine are a proliferative, hemorrhagic bone disease that can be cured with surgical resection without requiring oncologic margins. Upon initial radiographic analysis, ABC can disguise itself as an osteosarcoma or hemangioma, as in this case. Careful histopathological evaluation is required to properly distinguish an ABC from a cancerous process, as the surgical and perioperative management of an ABC is considerably different than that of a malignant neoplasm. ABC should be considered during the evaluation of paraspinal masses even when classical radiographic findings are not present.


A 37-day-old male was evaluated in the emergency department for 24 hours of fever to 102°F, abdominal erythema, and irritability. The patient was also reported to have 10 days of watery, gray stools on an appropriate diet of generic formula and breastmilk. The patient was the product of a full-term pregnancy and a C-section delivery due to breech positioning with no perinatal complications.On initial assessment, the patient was febrile to 38.6°C, tachycardic to 190 bpm, tachypneic to 70 breaths/minute with normal oxygen saturations and blood pressure. He was fussy and difficult to console, and he had obvious erythema of the umbilical and periumbilical region . The abdPertinent laboratory findings included a normal complete blood count and complete metabolic profile, C-reactive protein of 10.7 mg/dL (ref.: 0.0-1.0 mg/dL), and procalcitonin of 1.47 ng/mL (ref.: <0.05 ng/mL). Urinalysis was unremarkable, urine and blood cultures were drawn, and an attempted lumbar puncture was unsuccessful.Plain films demonstrated diffuse gaseous distension of bowel throughout the abdomen without dilated loops of bowel. Intraluminal gas extended to the rectum. No appreciable free intraperitoneal air, pneumatosis, or portal venous gas was noted. Abdominal ultrasound showed hyperemic soft tissue with surrounding inflammatory stranding and a small amount of fluid with mild hyperemia of the bowel near the site of the herniation suggestive of an incarcerated umbilical hernia without strangulation. An abdominal computed tomography (CT)  suggestePiperacillin/tazobactam (80 mg/kg), vancomycin (20 mg/kg), and normal saline (20 mL/kg) were given in preparation of operative intervention for a presumed incarcerated umbilical hernia and resulting intra-abdominal infection.During operative exploration, the periumbilical subcutaneous tissue and surrounding skin was inflamed and friable, and the umbilical stalk was woody and friable, suggesting omphalitis. No umbilical hernia with strangulated viscera was identified; however, an intraperitoneal abscess was found abutting the underside of the anterior abdominal wall at the base of the umbilical stalk. Extensive debridement of all associated fibrinopurulent tissues revealed a perforated Meckel’s diverticulum approximately 10 cm proximal to the ileocecal valve abutting the abscess cavity. A small defect at the base of the umbilical stalk where the abscess had eroded through the anterior abdominal wall was repaired. Pathology report would confirm a Meckel’s diverticulum with gastric heterotopia, transmural inflammation, focal necrosis, and acute serositis.Postoperative care for sepsis required admission to the pediatric intensive care unit where the patient was treated with ceftriaxone (50 mg/kg) daily and metronidazole (10 mg/kg) every 8 hours concurrently for 5 days, then metronidazole alone for an additional 6 days. Blood and urine cultures had no growth, and abscess cultures were unable to be obtained. Total parenteral nutrition was required for 7 days, after which enteral feeds were initiated and well tolerated. The patient was discharged in good condition. One year from surgery, the patient is growing and developing appropriately.14 as is omphalitis occurring outside of the newborn period.6 However, to our knowledge, this is the first reported case of a ruptured Meckel’s diverticulum leading to omphalitis in infancy outside of the newborn period.A ruptured Meckel’s diverticulum in infancy is rare, Omphalitis typically presents as a superficial cellulitis. Infection is typically an external source, associated with cutting of the umbilical cord. Infections are often polymicrobial, and common pathogens include staphylococcal and streptococcal species, E. coli, Klebsiella, and anaerobes. These track internally from the severed external umbilical stump, then infect the nearby soft tissues.9 Because there was no guidance provided by culture results in our patient, empiric therapy was aimed at coverage of these organisms.Omphalitis is an infection of the umbilical stump, the umbilicus, and/or the surrounding tissues, and is distinct from peritonitis, which is infection of the peritoneum, or abdominal wall.9 has high morbidity,9 and mortality ranges 7% to 15%, thus, early recognition is critical. Because of the cause associated with cutting and healing of the umbilical cord, it is uncommon for omphalitis to occur outside the newborn period.510 In these cases, the differential should be broadened, and internal sources that then infect the umbilical stump and surrounding tissues need to be considered, including infected remnants of prenatal structures associated with the umbilicus.11 As such, advanced imaging is typically required to identify the source, and surgical management is often warranted.7Omphalitis can rapidly progress,12 It is a vestigial remnant of the omphalomesenteric duct, also known as the vitelline duct or yolk stalk.12 Diagnosis of a Meckel’s diverticulum is typically made only when pursued due to clinical complications, and is challenging since CT and ultrasound may conflate a diverticulum as normal bowel. A technetium-99m pertechnetate scan is considered the gold standard, but is not widely available, and is specific only to the Meckel’s diagnosis. Ruptured Meckel’s diverticulum is itself an uncommon complication.4 Although there are case reports and series occurring in the neonatal period and in children older than 12 months,13 the incidence occurring in nonnewborn infancy has only been reported twice since 1975.14 Presenting symptoms are variable, but common complications include bloody stool, bowel obstruction, sepsis, peritonitis, and much less commonly, as reported in our case, omphalitis.15A perforated or ruptured Meckel’s diverticulum is one of these rare causes of nonneonatal omphalitis. A Meckel’s diverticulum is a true diverticulum that involves all 3 layers of the bowel wall.Ruptured Meckel’s diverticulum with resulting umbilical stalk abscess and omphalitis.In summary, omphalitis outside of the neonatal period is rare and requires consideration of internal causes, including infections and complications of primitive remnants. Complications of Meckel’s diverticulum are numerous, but less commonly known is perforation, which can then lead to local and systemic infection, including omphalitis and sepsis. Surgical consultation was required, and despite advanced imaging, the final diagnosis was not made until operative management, highlighting the need to involve surgery early if either of these diagnoses is considered.Omphalitis outside of the neonatal period is a rare entity, and likely to have an internal cause that must be evaluated with the assistance of imaging and surgical consultation.A ruptured Meckel’s diverticulum is a rare complication of a diagnosis that already requires a high index of suspicion.Dr. Smith authored the original draft and all subsequent edits. Drs. Tiller, Lagomarsino, and Murphy provided mentorship, specialty-specific insight, and reviewed and edited all drafts.


There is a high association between umbilical cord hemangiomas or cysts with fetal mortality. However, favorable outcome is possible with proper prenatal monitoring and careUmbilical cord hemangiomas are rare neoplasms of vascular origin, commonly found in the free section of the umbilical cord proximal to placental insertion. They are associated with an increased risk of fetal mortality. We present a rare co‐occurrence of an umbilical cord hemangioma and a pseudocyst managed conservatively, with favorable fetal outcome despite the interval increase in size, decreased caliber of the umbilical arteries, and fetal chest compression. An umbilical pseudocyst and hemangiona compressing the arteries but with positive end diastolic flow. Her antenatal profile and aneuploidy screening were unremarkable. Her first pregnancy was complicated with pre‐eclampsia at term, but had a spontaneous vaginal delivery, following induction of labor with good outcome.On the anomaly scan, a large complex multi‐cystic mass with solid components was noted proximal to the cord insertion Figure . The lesFollow‐up ultrasound done every 2 weeks showed an interval increase in size of the solid components. Despite the variance in caliber and velocity of the umbilical arteries, the positive EDF in the vessels persisted till delivery. From 32 weeks onward, the mass appeared to compress the chest, but there were no signs of obstruction, and the lung volumes remained normal for gestational age. The abdominal circumference and estimated fetal weight were above the 90th centile and the amniotic fluid volume was normal  performed was normal. A live male infant was subsequently delivered with a birthweight of 3480 g and an Apgar score of 10 at 5 min. The umbilical cord cyst ruptured during delivery. The placenta spontaneously separated. The umbilical cord mass was noted Figure . The plaThe gross formalin‐fixed specimen showed a translucent and hyper‐coiled cord with prominent vascular pattern and a multinodular mass at the insertion site measuring 7 × 7 × 4 cm and a collapsed cyst measuring 15 × 10 cm Figure . Upon diHistology confirmed an umbilical hemangioma with a pseudocyst, mild acute funisitis, intervillous hematomas, delayed villous maturation and avascular fibrotic villi Figure . The fin2Umbilical cord hemangiomas are rare benign endothelial‐derived neoplasms composed of blood vessels. Typically, hemangiomas are found in skin and soft tissues, but their presence in other organs has been demonstrated.Prenatal ultrasound can reliably differentiate hemangioma and pseudocyst from other umbilical cord tumors.Even though rare, umbilical cord neoplasms are predominantly hemangiomas and less commonly teratomas.Hemangiomas may present as fusiform swellings of the cord comprising of an angiomatous nodule, surrounded by edema of the Wharton's jelly with myxoid cystic degeneration. They are clearly demarcated from surrounding stroma. These nodules vary in dimensions, ranging from 0.2 to 7 cm in largest dimension, and if associated with edema may measure up to 18 cm.A strong association exists between cord hemangioma and intrauterine fetal demise (IUFD). Possible reasons include vascular compression, intravascular thrombosis, intravascular tumor proliferation, and hemorrhage from ruptured vessels. The risk of IUFD is highest if compression of the umbilical veins is present.Management of fetuses with umbilical cord hemangiomas depends on gestational age and early delivery may reduce the risk of IUFD, but the decision is weighed against possible complications of prematurity.3The outcome of cord hemangiomas is not well understood, and neither is their pathophysiology elaborated. However, despite its high association with fetal mortality, a favorable outcome is possible with close monitoring of the umbilical artery Doppler flows and timely delivery, the size of the lesion notwithstanding.Sikolia Wanyonyi: Conceptualization; supervision; validation; writing – original draft; writing – review and editing. Felix Nyagaka: Conceptualization; formal analysis; writing – original draft; writing – review and editing. Patricia Okiro: Formal analysis; resources. Lilian Ogutu: Formal analysis; resources. Alice Nyaichowa: Conceptualization; formal analysis. Felix Oindi: Resources; writing – review and editing. Evan Sequeira: Conceptualization; supervision; writing – review and editing.The authors have no conflict of interest to declare.Written informed consent was obtained from the patient to publish this report in accordance with the journal's consent policy.


Adrenal myelolipoma is considered a benign neoplasm that accounts for 6% to 16% of adrenal incidentalomas, and it is the second most common incidental adrenal tumor after adrenal adenomas. They are usually asymptomatic; however, in the presence of symptoms, significant growth, or complications, open surgical resection is indicated. We present the case of a 46-year-old woman with obesity and diabetes who experienced five years of left hemiabdominal pain, which was unsuccessfully treated symptomatically. A computed tomography scan revealed findings suggestive of pancreatic lipoma and a suggestive image of left adrenal myelolipoma. Resection of the tumor was performed using an anterior midline approach, and histopathological examination confirmed left adrenal myelolipoma. The presented case represents the typical presentation of these tumors in a patient in the fifth decade of life with obesity, diabetes, and nonspecific abdominal pain possibly related to the size of the lesion found. Surgical intervention was indicated due to the presence of symptoms, lesion size, contiguity with abdominal organs, and the absence of a precise diagnosis. An anterior midline approach was chosen, and histopathological examination provided a definitive diagnosis. Adrenal myelolipoma is a rare entity that is often asymptomatic and incidentally diagnosed through imaging studies. However, they should be resected when symptomatic to prevent complications. Open surgical resection is the preferred approach. Adrenal myelolipoma is a benign neoplasm composed of adipose and myeloid tissue ,2. It acWe present the case of a 46-year-old woman with a history of type 2 diabetes treated with metformin, laparoscopic cholecystectomy for cholelithiasis, and scheduled cesarean section. The patient started experiencing left flank pain radiating to the left hypochondrium five years ago. The pain was accompanied by abdominal distension. She initially sought care from a colorectal surgeon who performed a colonoscopy, which revealed Kudo I polyps versus subepithelial lesion in the ascending colon. The patient received symptomatic analgesic treatment with partial improvement and was later referred to our service and attended an outpatient consultation. On physical examination, the patient had grade I obesity . The abdomen was distended due to adipose tissue, with a Pfannenstiel scar. Normal bowel sounds were auscultated, and there was no superficial tenderness, but deep palpation elicits pain predominantly in the epigastric and left hypochondriac regions. There was no visceromegaly or signs of peritoneal irritation. A computed tomography scan was recommended to rule out colorectal pathology, which revealed a hypodense image in the pancreatic tail without enhancement after contrast administration, measuring 5.9x5.6x4.0 cm. The left adrenal gland's lateral arm showed loss of typical morphology due to a thin-walled and well-defined solid lesion, internally heterogeneous with poorly defined areas of higher attenuation up to -60 Hounsfield Units (HU), enhancing to -15 HU after contrast administration, measuring 4.3x4.6x4.7 cm (Figure The first case of this entity was presented by Gierke in 1905, and in 1926, Oberling named it myelolipoma. The case presented corresponds to a patient with a left adrenal myelolipoma, which is a benign tumor characterized by the presence of adipose and hematopoietic tissue. Its prevalence ranges from 0.08% to 0.2% in histopathological studies, and it is the second most common incidental adrenal tumor, accounting for 15% of cases ,14. The Adrenal myelolipoma often remains asymptomatic and is discovered either during the investigation of other pathologies or incidentally through radiological studies. Definitive diagnosis is only achieved through histopathological examination of the surgical specimen. Surgical treatment is recommended for tumors larger than 5 cm, symptomatic tumors, those with adhesions or infiltration of surrounding structures, or when changes in their characteristics during follow-up suggest potential major complications such as malignancy or bleeding.


This review describes the sonographic appearances of the neonatal bowel in Necrotising enterocolitis. It compares these findings to those seen in midgut-Volvulus, obstructive intestinal conditions such as milk-curd obstruction, and slow gut motility in preterm infants on continuous positive airway pressure (CPAP)-CPAP belly syndrome. Point-of-care bowel ultrasound is also helpful in ruling out severe and active intestinal conditions, reassuring clinicians when the diagnosis is unclear in a non-specific clinical presentation where NEC cannot be excluded. As NEC is a severe disease, it is often over-diagnosed, mainly due to a lack of reliable biomarkers and clinical presentation similar to sepsis in neonates. Thus, the assessment of the bowel in real-time would allow clinicians to determine the timing of re-initiation of feeds and would also be reassuring based on specific typical bowel characteristics visualised on the ultrasound. A plain abdominal radiograph is the current standard investigation for detecting diseased neonatal bowel states . AbnormaThere is a growing interest in the utility of neonatologist-performed point-of-care abdominal ultrasound to assess the bowel, mainly when the plain radiograph findings are non-specific and the clinical suspicion for severe intestinal conditions is high . For neoRecently, international evidence-based guidelines on point-of-care ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) stated that the point-of-care abdominal ultrasound is helpful to detect signs of NEC; however, a pediatric radiologist should perform a detailed assessment for a definitive diagnosis . There iThis review describes the sonographic appearances of the neonatal bowel in NEC. It compares these findings to those seen in midgut-Volvulus, obstructive intestinal conditions such as milk-curd obstruction, and slow gut motility in preterm infants on continuous positive airway pressure (CPAP)—CPAP belly syndrome. Point-of-care bowel ultrasound is also helpful in ruling out severe and active intestinal conditions, reassuring clinicians when the diagnosis is unclear in a non-specific clinical presentation where NEC cannot be excluded. As NEC is a severe disease, it is often overdiagnosed, mainly due to a lack of reliable biomarkers and clinical presentation similar to sepsis in neonates . Thus, tThe superficial location of the bowel within the abdomen warrants high-frequency linear transducers for optimal image acquisition . A high-A normal bowel sonographic appearance is characterized by the presence of the “gut signature” forming a hypoechoic layer (Muscularis Propria) between two hyperechoic layers (Serosa and Intima) . The ech1.Bowel wall thickening or thinning2.The loss of bowel peristalsis3.The presence of pneumatosis intestinalis4.The presence of portal venous gas5.Specific patterns of vascularity in NEC6.Pneumoperitoneum: a sign of perforation7.Intraluminal and extra-luminal fluid collectionsThe diagnostic bowel ultrasound findings in NEC have been well established by radiologists more than a decade ago, with a growing interest in this area amongst neonatologists . For a c1.Using bowel ultrasound when the plain abdominal x-ray findings are non-specific in the clinical setting of early NEC to allow the complete radiological assessment for NEC2.Detecting clinical deterioration inconsistent with plain abdominal x-ray abnormality changes3.Detecting portal venous gas on point-of-care BUS compared to the plain abdominal radiograph early4.Detecting free abdominal fluid (anechoic or echogenic) on ultrasound only5.Detecting specific vascularity associated with NEC  detected on ultrasound only6.Deciding on restarting feeds post-diagnosis of NEC, using peristalsis, bowel wall assessment—normal “gut signature”, and vascularity as a guideBowel wall thickening and thinning are changes within the bowel wall seen during various stages of NEC  Figure . DiffereThe pathognomonic sign of NEC is the detection of pneumatosis intestinalis  or portaFurthermore, these microbubbles escape through the venules surrounding the bowel wall into the portal vein, racing with high amplitude. The most impressive feature of BUS finding in NEC is the real-time detection of these gas bubbles spurting through the portal vein seen amidst the slow-moving, low-pressure flow of the portal venous blood. The episodic loud crackling sound effect can be heard on the application of the Doppler sound setting, with the cursor gate within the lumen of the portal vein.As this intraluminal air traverses through the portal vein vasculature, its entrapment into the smaller tributaries of the portal venous architecture within the liver parenchyma produces a characteristic starry sky appearance of the hepatic echotexture. Bright echogenic dots scattered throughout the liver with loss of the normal homogenous sonographic liver echotexture are seen , 16, 17.Specific vascular patterns are detected in NEC . These cNEC is an inflammatory condition; thus, extra-vascular fluid loss is an expected finding seen as an anechoic fluid collection. However, when this develops, a granular, echogenic appearance suggestive of exudative fluid collection is seen, suggesting a more severe stage of NEC . This coMidgut-volvulus is a time-critical emergency; early detection is critical to salvage the ischemic bowel and prevent the consequences of short-gut syndrome. The detection of the “whirlpool sign”  is the oThe primary diagnostic challenge for neonatal clinicians is to differentiate volvulus from severe NEC clinically as the line of management differs in determining the clinical decision for an urgent surgical exploration. The “whirlpool sign” is not detected in classical segmental volvulus.Differentiating NEC from volvulus is the key clinical question. While the Whirlpool sign is pathognomonic of Mid-gut Volvulus, NEC on BUS is associated with the detection of Pneumotosis intestinalis, Portal venous gas, bowel wall thickening affecting variable non-peristaltic bowel segments, specific vascularity, loss of the gut signature, omental thickening, complex fluid collections. A scoring assessment to determine a minimum-threshold score for the diagnostic features of NEC on BUS will improve the clinical accuracy of NEC detection and timely differentiation from volvulus.This is a sagittal image showing the relationship of the superior mesenteric artery to the aorta and the coeliac trunk. Normally, the superior mesenteric vein is anterior and to the right of the superior mesenteric artery at the 11o᾽clock position. A reversal of this relationship, with the SMV positioned to the left of the SMA, suggests midgut malrotation . HoweverMilk-curd obstruction or “inspissated milk syndrome” is a rare phenomenon due to the formation of faecolith within the intestinal lumen, typically affecting preterm infants . With thThe classic radiological sign of milk-curd obstruction on a plain abdominal radiograph includes scattered heterogeneous opaque masses often described as white or grey, which are either homogenous or with a “soap bubble̕” or “ground glass̕” appearance pattern and surrounded by a black halo representing air . Unlike The utility of neonatologists-performed point-of-care abdominal ultrasound findings in milk-curd obstruction has never been described. Based on the clinical and laboratory parameters of plain abdominal radiograph findings and utilizing point-of-care BUS, we may be able to scale down the clinical possibility of NEC, adding value to the diagnostic assessment and interpretation of cases with milk-curd obstruction. Early diagnosis of milk-curd obstruction may prompt the cessation of milk-feed fortifiers and prevent complications such as bowel perforation.Milk-curd obstruction on BUS appears as islets of homogenous bright echogenicities within the intraluminal cavity, clearly demarcating the bowel wall, maintaining the “gut signature”, differentiating it from NEC ; Table 1The sonographic characteristics of “CPAP-belly syndrome” include the presence of a normal “gut signature” of the bowel wall, normal bowel vascularity, normal bowel peristalsis, and intraluminal bowel gas seen as echogenic dots that move with peristalsis. NEC is a severe intestinal condition, and with the lack of biomarkers, it is often overdiagnosed. Thus, screening neonates with BUS is useful in reassuring clinicians, preventing overdiagnosis of NEC and the implications of empiric antibiotics, and cessation of enteral feeds.Thus, in conclusion, the utility of point-of-care abdominal ultrasound in the hands of point-of-care neonatologists can enhance the diagnostic accuracy of intestinal conditions in newborn infants along with using standard plain abdominal radiographs as the first line of investigation. BUS allows further comprehensive bowel screening vital to make the correct diagnosis. There is no doubt that bowel ultrasound has a steep learning curve. Still, practice and clinicopathological correlations, particularly intra-operative findings, have resulted in meaningful interpretations of the bowel ultrasound findings to allow us to learn this skill to guide clinical management for newborn infants with suspected diseased bowel conditions.


In both patients, en bloc right nephrectomy was performed along with the resection of the thrombosed IVC without further reconstruction. In the case of the patient with right vein sarcoma, preservation of the left renal and caval intrahepatic vein was possible, whilst in the second case diagnosed with clear cell renal carcinoma, the associated left renal thrombosis also enforced the resection of the left renal vein. (3) Discussion: Postoperative evolution was favorable in both cases and did not exhibit major complications. Antibiotic therapy, analgesics, and anticoagulant medication were administered at therapeutic doses after surgery in both cases. The histopathological examination of the surgical specimen confirmed the diagnoses of renal vein sarcoma in the first case and clear cell renal carcinoma in the second case. Surgical treatment and adjuvant chemotherapy prolonged survival for two years for the first case and for two months, up until this moment, for the second case. The survival of clear cell renal carcinoma is currently at two months. (4) Conclusions: The resection of the inferior vena cava, without subsequent reconstruction in cases presenting diffused distal thrombosis, can represent an alternative to IVC reconstruction, which might lead to a major ulterior risk of thrombosis. In some cases, this can result in long-term survival. Retroperitoneal tumors are a heterogeneous group of diseases; most of them are lesions. Renal carcinomas, retroperitoneal liposarcomas, leiomyosarcomas, and retroperitoneal metastatic lymph nodes are the most common forms of malignant diseases located within this area. Radical resection (R0) is the only potentially curative option, even when the prognosis could remain unfavorable. The involvement of the inferior vena cava is uncommon and needs major vascular resection in most cases. The reconstruction of the IVC after resection is still controversial and open for debate. The first inferior vena cava resection was performed by Thomas Starzl, who was also the surgeon of the first liver transplant 1967) 2]. The rThe first case presents a 57-year-old female patient with no significant medical personal history. The symptomatology started a month earlier when the patient reported pain in the right lower limb, along with swelling, paresthesia, difficulty in walking, moderate dyspnea, and fatigue, all of which were experiences that motivated her to contact our cardiology service. Our laboratory investigations revealed altered coagulogram values, highlighting an increase in D-dimers. A venous echo Doppler was performed on the lower limbs, which showed left ileo-femoral deep vein thrombosis (DVT). Abdominal–pelvic computed tomography (CT) identified a voluminous right inter-reno-caval retroperitoneal mass, with the invasion of the right renal hilum, stage III renal hydronephrosis, and IVC thrombosis .Subsequently, after surgical evaluation, it was decided that a right nephrectomy with an inferior vena cava resection without ulterior reconstruction was needed. Intraoperatively, thrombosis was identified, which determined inflammatory phenomena that did not allow for recanalization of the intrahepatic-reno-periumbilical vena cava. The IVC was obliquely sectioned, and the preservation of the left renal vein at its implantation site was carried out. Sectioning was performed at approximately 2 cm above the IVC’s bifurcation with the help of a 45 mm TEA stapler, along with the application of a clip on the right renal artery .Postoperative evolution was favorable under the anticoagulant treatment administered in therapeutic doses with low-weight-molecular heparin, with ulterior indications of continuing oral treatments using apixaban. The patient’s initial discharge took place nine days after surgery but with a second admission two weeks later for a deep venous thrombosis located in the right lower limb. It was decided that the dose of anticoagulants should be increased for the acute condition along with a new imaging examination, which ulteriorly did not show significant postoperative changes.The histopathological examination correlated with immunohistochemical (IHC) tests and advocated for low-grade leiomyosarcoma with neuroendocrine components and an apparent origin in the renal wall. The proliferation index, ki67, was 15%. NSE was positive with moderate intensity (++) on 100% of tumor cells .2 on the first and third days and once every three weeks. At the end of the first cycle, grade I neutropenia was discovered, for which it was decided that the doses of carboplatin that start the second cycle should be decreased, along with the subsequent administration of the G-CSF granulocyte growth factor at 0.5 mu/kgc/day 24 h after the end of the cycle.The patient was discharged with recommendations of starting chemotherapy treatment targeted for retroperitoneal G2 leiomyosarcoma with the neuroendocrine component. The first chemotherapy cycle was initiated 10 weeks after surgery with carboplatin 5 AUC IV for 30 min on the first day, followed by etoposide at 100 mg per mThe second case presents a 45-year-old male patient who presented to our service for lumbar back pain, asthenia, fatigue, and functional problems in both lower limbs. An abdominal CT was performed, which revealed a giant tumor mass affecting the upper 2/3 of the right kidney, which was slightly increased in size whilst also presenting a tumorous invasion of the right renal vein and the proximal IVC along with the presence of multiple collateral circulation paths .The initial histopathological examination was performed in another oncology institute and revealed G2 clear cell renal carcinoma. Following the surgical examination performed in our service, it was decided that an en bloc right nephrectomy and resection of the inferior vena cava without subsequent reconstruction were needed. During surgery, thrombectomy of the inferior retrohepatic caval vein and ligature of the left renal vein was carried out without the need for an ulterior reconstruction, ensuring a complete resection of the tumor and thrombus. As a final surgical step, para-aortocaval and inter-aortocaval lymphadenectomies were performed, further providing a clean R0 resection. Postoperatively, the patient presented chylous ascites, requiring the prolonged maintenance of drain tubes for one month after the surgery. Under anticoagulant treatments in therapeutic doses, the evolution of the patient was favorable, allowing his discharge at 10 days after surgery .The histopathological examination correlated with the IHC tests and reconfirmed clear cell renal carcinoma: SUP G2 grade, localized in the right kidney, and pT3b N1 (1/17) Mx L1 V1 Pn0 R0 .This case is being discussed in the oncology committee, and starting therapy with oral sunitinib once a day for 28 days with the repetition of the cycle every 6 weeks  was proposed.The postoperative evolution in both cases was favorable. In the case of the first patient, approximately two weeks after the intervention, she presented a Class II Clavien right lower limb thrombosis, which was treated with intravenous anticoagulants, whilst in the case of the second patient, chylous ascites was highlighted, requiring the maintenance of drain tubes for one month after surgery. The survival rate in the case of the first patient was set at 20 months, and in the case of the second patient, the survival rate was set at 2 months.The surgical algorithm was proposed by the multidisciplinary team of the St. Constantin Hospital Brasov, presenting various surgical options in the case of renal tumors that simultaneously present IVC thrombosis, and the algorithm can be used if there is no proof of metastatic disease. The algorithm was developed after the two successful IVC resections, which did not require an ulterior reconstruction .The invasion of the IVC by tumors located in the retroperitoneal space may require resection of the IVC with or without reconstruction. For lesions involving more than half of the circumference, resection is indicated. The reconstruction of the IVC after resection is still controversial, and the availability of information is limited.Vicente et al. —in a retThe postoperative complications experienced by our patients were deemed to be deep vein thrombosis and chylous ascites. In a study conducted by Duty et al.  on six pThe survival rate in the case of our first patient was set at 20 months currently, whilst in the case of the second patient, it was set at 2 months. A study conducted by the British Association of Urological Surgeons (BAUS)  in 2021—Cocchi et al.  conducteIn a research study published in 2020, Ceccanti et al. ,9 reportAccording to the algorithm proposed by our team, in a retrospective analysis of 87 patients conducted between 1997 and 2008 at the Urology Department of the University of Miami—led by Ciancio et al. —an algorHorodyski et al.  further However, some authors still suppose that the reconstruction of the IVC after a cavectomy is mandatory. Baldrich et al.  claimed Another important aspect to be considered in these cases is represented by the pre- and postoperative imaging done with the help of computed tomography (CT) and ultrasound, showing the extent of the IVC invasion of the thrombus as well as of the tumorous formation.The non-invasive evaluation of fluid responses appearing in the inferior vena cava was addressed by Luigi La Via et al.  in a stuFurthermore, one of the primary expressions of the caval thrombus presence in re-nal cell carcinoma (RCC) patients is given by the extensive wall invasion, which could alter the surgical outcome. Qui-Yang Li et al.  concludeThe involvement of the inferior vena cava in the context of oncological pathology is considered a criterium of inoperability, even more so when it is related to thrombotic vascular obstruction. Our multidisciplinary team wants to highlight the fact that even with a thrombus at the IVC level, which preserved functional blood flow, a safe R0 surgical resection of the tumorous formation can be performed with the help of a thrombectomy via a cavotomy followed by cavoraphy. This will further ensure a long-term disease-free survival rate.


Congenital lobar emphysema (CLE) is a rare developmental malformation that presents as neonatal respiratory distress and can be successfully managed with prompt intervention. Hyperinflation of the affected lobe with mediastinal shift is the characteristic radiological finding. However, the etiology mostly remains unknown. Here, we report a case of CLE that microscopically revealed bronchial cartilaginous hypoplasia as an underlying cause of this malformation. Congenital lobar emphysema (CLE), also known as congenital alveolar overdistension, congenital large hyperlucent lobe, and congenital lobar overinflation, is a rare developmental malformation of the lower respiratory tract that poses a diagnostic and therapeutic dilemma due to its wide range of presentations. CLE is characterized by respiratory distress due to the over-expansion of one or more pulmonary lobes, with compression of surrounding lung parenchyma, in the absence of tissue destruction . The estA 2.75 kg term baby, delivered through cesarean section, was admitted to the neonatal intensive care unit (NICU) with findings of respiratory distress immediately after birth. Oxygen saturation of 98% was observed. She had tachypnea, tachycardia, and retractions. A provisional clinical diagnosis of pneumonia was considered, and the baby was started on antibiotics. On the third day, respiratory distress started improving, and a chest x-ray revealed a radiolucent zone in the left side of the chest. A clinical diagnosis of pneumothorax was made and an intercostal drain (ICD) was inserted, which led to decreased, but persistent respiratory distress. On day 13, the baby was sent for a computed tomography (CT) scan as respiratory distress was persistent and progressing even after ICD. The CT report showed hyperinflation of the left upper lobe with mediastinal shift, which led to suspicion of CLE , followed by the renal, musculoskeletal, and gastrointestinal systems, are well documented. Clinical manifestations of other anomalies can sometimes be so prominent that CLE is easily overlooked 0%, follo. PreoperImaging studies can confirm the diagnosis of CLE before surgery. Overinflation of the affected lobe(s) with or without pulmonary vessel anomalies, atelectasis of the adjacent lobes, and mediastinal shift to the contralateral side are typical findings ,8,9. A vDifferential diagnoses of congenital lobar emphysema include congenital cystic airway malformations, pneumothorax, pneumatocele, bronchogenic cyst, pneumonia, lung hypoplasia, opposite lung hyperinflation due to atelectasis, mucous plug or foreign body aspiration ,8.In older patients and conservatively managed patients, pre-operative bronchoscopy is very useful for detecting bronchomalacia, anatomical variations, endobronchial obstruction, and removing mucous plugs or foreign bodies. However, in newborns with respiratory distress, bronchoscopy should be performed with caution ,2.Surgical lobectomy is the most widely used treatment option, with excellent results; however, medical management can be considered for asymptomatic or mildly symptomatic patients ,7. A fewThis is a case of a term female born with respiratory distress who was initially misdiagnosed as pneumonia and pneumothorax and was treated conservatively. Later on, the characteristic findings of CLE on chest CT prompted an immediate surgical intervention. Hence, congenital anomalies should be taken into consideration while dealing with newborns presenting with respiratory symptoms in order to minimize unnecessary delays in proper management and alleviate the patient’s suffering. Symptomatic CLE in a newborn is a medical emergency that requires immediate attention. It is noteworthy to remember that once diagnosed, a search for associated congenital anomalies is warranted.


There are very few cases of primary renal Ewing sarcomas, which are characterized by a high rate of metastasis. These tumors are often mistaken for other more common kidney tumors due to their rarity and lack of pathognomonic symptoms in the early stages. A 28-year-old male patient presented to our clinic with a 2-month history of nonproductive progressive cough and left flank pain. The chest was scanned with contrast-enhanced computed tomography, which showed a heterogeneously enhancing mass with central vascularity on the left retroperitoneal. An abdominal dynamic multiphasic magnetic resonance imaging with contrast revealed a large mass that was highly suggestive of neoplastic pathology and multiple metastatic nodules. The pathology report indicated a renal Ewing sarcoma as the result of a core needle biopsy. In order to initiate chemotherapy promptly, early detection is crucial, and radiology plays an important role in diagnosing. The Ewing sarcoma family of tumors (ESFT) represents a group of the previous terminologies such as Ewing sarcoma of bone, extra-osseous Ewing sarcoma, peripheral primitive neuroectodermal tumor, Askin tumor of thoracopulmunary region that are characterized by small round blue cells on histopathology and show similar chromosomal translocations Primary renal ESFTs is clinically rare, accounting for less than 1% of renal tumors and have been characterized by a high potential for rapid metastasis Due to their rarity and not having pathognomonic symptoms in early stages, these tumors are easily mistaken for other more common tumors arising from the kidney. The 4-year overall survival for patients without metastasis is 85% compared to 47% for patients with metastasis We report the case of a young male with primary renal ESFTs that presented to us with an unusual symptom.A 28-year-old male patient referred to our clinic with a 2-month history of nonproductive progressive cough and left flank pain. After undergoing a contrast-enhanced computed tomography scan of his chest to determine the cause of his cough, a heterogeneously enhancing mass with central vascularity was partially visualized on the left retroperitoneum. On presentation, his vital signs were stable and apart from abdominal distention with a large mass in the left upper quadrant and left flank tenderness, his physical examination was otherwise unremarkable.For further evaluation, dynamic multiphasic magnetic resonance imaging of the abdomen with contrast showed a large mass measuring 155 × 140 × 150 mm with fine lobulated margin and central cystic changes in left suprarenal fossa with diffusion restriction and heterogeneous pattern of enhancement with a metastatic lymph node at left side of abdominal aorta and multiple metastatic nodules in the lower lobes of both lungs and liver which was highly suggestive of neoplastic pathology . Also, tAfter multidisciplinary consult including urologist, oncologist, and radiologist, the patient underwent ultrasound-guided core needle biopsy of the renal mass. Microscopic examination of the hematoxylin and eosin-stained sample showed small round cells .Fig. 2TiOn immunohistochemistry (IHC), the tumor cells were negative for LCA, WT-1, DESMIN, Myogenin, phox-B2, CD99, SOX10, Chromogranin, and GATA3 and positive for CK, FLI-1, and Synaptophysin. The pathology report was compatible with renal PNET/Ewing sarcoma.This patient was diagnosed as metastatic (stage 4) upon presentation and was being treated with a combination of chemotherapy regimen including vincristine, doxorubicin, and cyclophosphamide.Approximately 60% of cases of primary renal ESFT occur in young males, with an average age of 30.4 years at the time of diagnosis In view of its atypical location, renal ESFT is diagnosed through an integrated approach encompassing histomorphology, IHC, and confirmatory molecular genetic testing. The light microscope demonstrates small round blue cells with a high nucleocytoplasmic ratio that can be arranged in sheets and form Homer-Wright rosettes. Tumor cells exhibit neuro-ectodermal IHC markers, including neuron-specific enolase and synaptophysin.Nephrectomy in conjunction with neoadjuvant and adjuvant chemotherapy has become the accepted standard of treatment for nonmetastatic renal ESFT Our case report emphasizes the importance of performing a diagnostic biopsy prior to nephrectomy in patients with atypical renal masses, particularly those with metastatic disease. An important objective is to avoid unnecessary surgery since a nephrectomy could delay or even prevent the delivery of effective systemic chemotherapy, such as high-dose ifosfamide. Additionally, recently approved antitumor agents, such as apatinib, were promoted as potential therapeutic options for patients suffering from ESFTs Even though neoadjuvant therapy, surgery, and adjuvant therapy have improved the survival rate of patients with renal ESFT, future research is needed to validate their recurrence-free and overall survival.In the presence of a renal mass, especially if it is large, it is imperative to keep in mind that primary renal ESFT may occur primarily in the kidney. Ultimately, a diagnosis is determined by histopathology with IHC. An early diagnosis is essential for prompt treatment initiation, and radiology plays an increasingly important role in the diagnosis, staging, monitoring, and surveillance of treatment.A written informed consent for publication of this case was obtained from the patient.


When evaluating patients with abdominal pain, it is important to consider SAM in the differential diagnosis, along with vasculitis, fibromuscular dysplasia (FMD), atherosclerosis, mycotic aneurysms, and cystic medial degeneration.Segmental arterial mediolysis (SAM) is a rare arteriopathy which is an under‐recognized and commonly missed diagnosis of abdominal pain. We report a case of a 58‐year‐old female who presented with abdominal pain and was misdiagnosed with a urinary tract infection. The diagnosis was made with CTA and managed with embolization. Despite appropriate intervention and close hospital monitoring, further complications were inevitable. We conclude that though literature has shown better prognosis and even complete resolution after medical and/or surgical intervention, close follow up and monitoring is needed to avoid unexpected complications. Urinalysis revealed blood and leukocyte esterase and the patient was discharged on Cephalexin for suspected urinary tract infection. Her abdominal pain did not improve, and she started having nausea, prompting her to visit the emergency department. In the ED, a Computed Tomography (CT) of her abdomen showed findings consistent with recently passed calculus and the patient was again discharged home with a plan for outpatient follow up.She returned after 12 h as her abdominal pain got worse. Her vital signs at presentation were blood pressure 154/80 mm Hg, heart rate 85 beats per min, respiratory rate 17 per min and oxygen saturation of 100% on room air. Physical examination revealed diffuse abdominal tenderness along with right costovertebral angle tenderness. Her initial laboratory test results showed white blood cell count 9.1 bil/L, hemoglobin 13 g/dL, platelets 257 bil/L and INR 4.4. Basic metabolic panel was unremarkable. Liver function panel showed aspartate aminotransferase 658 U/L (compared to 104 U/L 12 h prior), alanine aminotransferase 772 U/L (compared to 82 U/L 12 h prior), bilirubin 0.5 mg/dL, alkaline phosphatase 70 U/L and albumin of 4.6 g/dL. Extensive workup including infectious and rheumatologic testing to understand the etiology of acute elevation in transaminases was grossly unremarkable as in Table An axial CT angiography abdomen/ pelvis with contrast showed new right hepatic lobe infarct measuring 6.5 × 6.5 cm with hypervascular lesion suspicious for pseudoaneurysm of right hepatic artery as in Figure 3SAM was initially described by Slavin et al in 1976 as “Segmental mediolytic arteritis”.The pathophysiology of SAM has been the topic of extensive study and is mainly guided by histologic findings.3, but most studies, reported hypertension in a significant number of patients with the disease.10. A small percentage of patients (4% of patients with unruptured aneurysms) will develop new aneurysms according to Shimohira et al.Most studies concur that SAM most commonly affects men aged 50–60. Most of the studies published agree on the most common presenting symptom being abdominal pain in over two thirds of cases.Diagnosing SAM always poses a clinical challenge.5.Differential diagnosis of this disease is very important, as there are multiple mimics that could make diagnosing SAM particularly challenging.Fibromuscular dysplasia requires special mention, as it shares many similar features with SAM.In the background of medical history such as protein C and S deficiency, deep vein thrombosis, systemic lupus erythematosus, and hypothyroidism in our patient, it is possible that they contribute to vasculopathy. The prevalence of vasculitis in SLE is reported to be between 11% and 36%.10. Most patients will have stable disease, with some having complete resolution of SAM, whereas others will have aneurysm progression or development of new lesions.Treatment of SAM is conservative with blood pressure control, anticoagulation, or antiplatelet therapy,4SAM is a rare non‐inflammatory, non‐atherosclerotic disease of medium sized intra‐abdominal vessels, most commonly affecting men between ages of 50–60. The most common presenting symptom is abdominal pain, and it is usually diagnosed with CTA. Differential diagnosis should include vasculitis, FMD, atherosclerosis, mycotic aneurysms, and Cystic medial degeneration. Most patients presenting with unruptured lesions will need continued surveillance but will not require surgical intervention. Patients with disease progression as well as patients with rupture will need surgical intervention, either endovascular or open surgery, with mortality being around 25%. Clinicians need to have a high suspicion for the diagnosis of this disease, especially if presenting acutely.Ashbina Pokharel: Conceptualization; writing – original draft; writing – review and editing. Ioannis Karageorgiou: Writing – original draft; writing – review and editing. SANGAM SHAH: Writing – review and editing. Madhur Bhattarai: Writing – review and editing. Indira Acharya: Writing – review and editing. Judith Bateman: Writing – review and editing.Authors' have no conflict of interest to declare.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Myeloid sarcoma, also known as granulocytic sarcoma or chloroma, is an extra-medullary accumulation of malignant myeloid blast cells, leading to a solid tumor formation. Herein, we report a rare presentation of a case with acute myeloid leukemia (AML), whose disease relapse was clinically evident as acute flaccid paraplegia with a certain sensory level. On thoracic spine magnetic resonance imaging (MRI), an epidural mass compressing the spinal cord at the level of the thoracic spine segment 4 (T4) was found. The mass histology confirmed the diagnosis of myeloid sarcoma. Myeloid sarcoma is a collection of malignant myeloid blasts that form a solid mass that substantially changes the tissue architecture . “ChloroThe site of chloroma cannot be predicted, and it can be in different sites, such as the soft tissue, lymph nodes, skin (leukemia cutis LC) , and theThe presence of myeloid sarcoma (chloroma) is enough to treat a patient with the AML protocol even if the bone marrow is clear . ChloromA 20-year-old male was previously diagnosed with AML after presenting with fever, gum bleeding, cervical lymphadenopathy, and leukocytosis with a WBC count of 64,000 cells/uL. However, at that time, he did not suffer from any neurological, respiratory, or gastrointestinal symptoms. The diagnostic workup, including bone marrow examination and molecular cytogenetic, confirmed the diagnosis of AML with complex cytogenetic abnormalities: an addition of chromosomes 4 and 6 and loss of chromosome 13 , making him at a higher risk of AML.The patient started chemotherapy with the 3+7 protocol, went into complete remission (CR1), and then received two cycles of consolidation chemotherapy with high-dose cytarabine arabinoside (HiDAC). Later, he was seen in a transplant center to prepare him for an allogeneic stem-cell transplant (Allo-SCT) after finishing full consolidation cycles but unfortunately, he was lost to regular follow-up. The family was contacted several times, but they did not come for the scheduled appointments.Two months later, he presented in the emergency room with sudden-onset weakness and numbness involving both lower limbs, preventing him from walking or even standing. The patient stated that these symptoms started a few hours before his arrival at the emergency room but were preceded by a two-week history of upper back pain radiating to the anterior chest wall without a history of back trauma. There was no fever, cough, hemoptysis, shortness of breath, headache, neck pain, neck stiffness, or photophobia. Furthermore, he reported that he did not pass urine for the last 12 hours.On examination, he was fully conscious and oriented to time, place, and person. There were palpable, enlarged, hard, non-tender left anterior and right postauricular cervical lymph nodes around 2 × 2 cm in diameter. There were no other affected lymph nodes. An oral exam showed mild gum hypertrophy. The cranial nerves exam revealed no facial asymmetry, and all cranial nerves were intact. Upper limbs neurological examination was normal, whereas the lower limbs examination revealed a flaccid weakness with a power of 0/5, areflexia, and loss of all sensations up to the nipples bilaterally. No tenderness over the spine could be appreciated on examination. The abdominal examination revealed no palpable liver and spleen, but there was a soft and tender palpable mass in the hypogastric area extending up to the umbilical region, which seemed to be a distended urinary bladder. Foley’s catheter was inserted, immediately draining around 1500 ml of urine. Urgent magnetic resonance imaging (MRI) of the dorsal spine was obtained, showing upper dorsal cord compression extending from T2 to T6 due to posterior extra-medullary epidural/subdural neoplastic mass. The cord was diminished in width (compressed cord) without signs of vascular thrombosis or intramedullary or extra-medullary hemorrhage.An urgent neurosurgical referral was made after starting dexamethasone 8 mg intravenously every eight hours. He was then taken to the operating room for spinal decompression surgery. The soft tissue mass in the epidural space compressing the spinal cord and extending from T2 to T6 was excised and sent for culture and tuberculosis polymerase chain reaction (TB PCR), which later came negative. The histopathology exam showed a mass comprising tumor cells consisting of neoplastic immature myeloid cells and necrosis Figure . The neoThe abrupt onset that occurred within four to six hours of the neurological deficit indicated that the most likely cause of paraplegia was spinal artery occlusion with thrombus or para-spinal hemorrhage; however, MRI of the spine excluded both these causes. Other common causes of paraplegia with a sensory level, such as spinal tuberculosis  or para-spinal abscess, were considered initially given that the patient was immune-compromised and on chemotherapy and was ruled out. The MRI findings are not specific in myeloid sarcoma  while hiChloroma of the spine is usually extra-medullary, mostly located in the epidural space, as in this patient’s case, whereas intramedullary chloroma is extremely rare . Extra-mCertain cytogenetic abnormalities in the malignant myeloid cells are associated with myeloid sarcoma, including inv(16) and t, and some molecular mutations such as FLT3 mutations and MLL rearrangement. Trisomy 8 has been the most common cytogenetic association that may point to extra-medullary involvement in AML .Clinically, the presence of lymphadenopathy, which is uncommon in myeloid malignancies but common in lymphoid malignancy, can be considered myeloid sarcoma of the lymph node with the cervical group of nodes being the most common site of extra-medullary involvement in AML . GingivaA previous case report described an AML accompanied by thoracic epidural myeloid sarcoma in a 59-year-old man who initially presented with sudden-onset paraplegia, which is similar to our case. However, he had a white blood cell count at presentation of 2,300/μL, which is lower than our patient; thus indicating that high leukocyte count at AML presentation is not necessarily associated with developing chloroma . On the Furthermore, the association of AML with intraoral chloroma is extremely rare  and mighUnlike lymphoid leukemia, myeloid leukemic blast cells can form a solid mass that invades different organs and causes sudden disability such as in our case report. Early diagnosis and intervention may decrease morbidity and mortality. Myeloid sarcoma should be predicted in all AML cases, especially if special predictors are present, such as those we emphasized in the discussion of our case report, including morphological, cytogenetic, and immune-histochemical predictors.


Infiltration of peripheral or cranial nerves with lymphatic cells is a rare condition that is known as neurolymphomatosis (NL). The involvement could be primary or secondary and mostly occurs in patients with a history of B-cell lymphoma. The most common peripheral nerve involved is the sciatic nerve. Patients may present with painful or painless mononeuropathy or polyneuropathy, and MRI is the perfect modality to evaluate the suspicious clinical findings that may demonstrate enlargement, thickening, and enhancement of the involved nerve or an enhancing mass lesion in the course of the nerve. Biopsy can be safely performed to confirm the diagnosis. Few articles have reported the cases of peripheral nerve involvement by lymphoma as well as MRI features of this diagnosis. In this article, we report a case of NL using MRI, ultrasound, and pathologic features and also present a brief review of relevant literature. Lymphatic infiltration of peripheral nerves, also known as neurolymphomatosis (NL), is an extremely rare condition in patients with known systemic involvement. In fact, the disease may relapse or show recurrence in the nervous tissue In this paper, we report a case of NL. A 69-year-old male who had a history of DLBCL and was in the remission phase following chemotherapy showed a relapse of DLBCL in the distal sciatic nerve and proximal tibial nerve.A 69-year-old man with a history of DLBCL diagnosed in January 2021, presented to the hematology clinic with swelling in the left popliteal fossa, neuropathic pain, and weakness. The first manifestation was a nasopharyngeal mass lesion; chemotherapy began at that time of hospitalization and the patient was treated with Docetaxel (Zytax), vincristine, Adriamycin, dexamethasone as well as intravenous and intrathecal methotrexate. Also, he had a history of scalp squamous cell carcinoma (SCC) 10 years ago. The patient was referred 7 months later in October 2021 with a Left side popliteal palpable mass and neuropathic pain.Ultrasonography of the left popliteal fossa demonstrated a heterogeneous echogenicity mass with internal vascularity in the popliteal fossa and sciatic and tibial nerves as a cable-like edematous structure within the mass . VariousMRI demonstrated a fusiform infiltrating mass lesion measuring 83 × 44 × 35 mm with intermediate signal intensity in T1-weighted, high signal intensity in T2-weighted, and STIR images with heterogeneous predominantly peripheral enhancement in the popliteal fossa. Perilesional edema and encasement of popliteal artery in a part of its pathway were seen. Distal sciatic and proximal tibial nerves were infiltrated by the mass, were enlarged, and passed through the mass, and were involved by it and is described as “Entering and exiting nerve sign” . UltrasoLymphoma is defined as a neoplastic proliferation of lymphoid cells from a secondary lymphoid structure, a lymph node or an extranodal structure. It is well established that extranodal site involvement is present in up to 40% of DLBCLs, and virtually any extranodal location can be a primary site The most common site for involvement is the sciatic nerve but other sites have also been described in the previous case reports such as brachialMRI is the best modality for detecting the spread of the lesion and involved nerves as well as demonstrating the relationship between the mass lesion and peripheral nerves to determine the origin of the mass Another case series published in 2016 reported 5 patients with peripheral and cranial NL during 18 months, all of whom had a history of previous lymphoma diagnosis. Their results showed that enlargement, thickening, and enhancement of nerves were the most frequent appearances of NL in MRI images We reported a case with a known history of DLBL who had a relapse of the disease in the distal sciatic and proximal tibia nerves. It is an uncommon presentation of lymphoma. The diagnosis of neurolymphomatosis should be considered in patients with the same history presenting with a palpable mass lesion and neuropathic pain or radiculopathy. Diagnostic imaging modalities such as MRI could be helpful in detecting a peripheral nerve mass and characterizing the lesion. Biopsy is also safe and confirms the diagnosis when it is uncertain ,2.The authors have obtained written informed consent for publication from the patient.


Lingual foregut duplication cysts are rare developmental anomalies with varied symptoms, and adenocarcinomas may develop from them. Radiological evaluations, including computed tomography and magnetic resonance imaging, can help diagnose these lesions and determine their extent. Abnormal enhancement should raise the suspicion of malignancy of a lingual foregut duplication cyst. Early detection and complete surgical resection of lingual foregut duplication cysts are necessary to prevent malignant transformations. Complete tumor resection with adjuvant radiotherapy or radiochemotherapy is recommended. The teaching point is that mucinous adenocarcinoma can develop from a lingual foregut duplication cyst, and radiological studies may aid in the diagnosis.Adenocarcinomas can develop from lingual foregut duplication cysts, which are rare developmental anomalies, and radiologic studies may aid in the diagnosis. Congenital cystic lesions with foregut-derived epithelial linings, known as foregut duplication cysts, can manifest anywhere from the oral cavity to the anus . LingualA 63-year-old male presented to the outpatient clinic of the otorhinolaryngology department with complaints of the sensation of mouth fullness and dysphagia that had lasted for three months. On physical examination, the tongue showed bulging contour with a normal overlying mucosa.Enhanced neck computed tomography (CT) and magnetic resonance imaging (MRI) revealed a well-circumscribed lobulated cystic mass in the tongue, measuring approximately 6.7 × 5.7 × 5.1 cm. CT images showed a low-attenuation mass with multifocal internal calcifications, and septa-like structures were observed within the mass . On neckThe initial radiologic diagnosis of this mass was a lingual foregut duplication cyst, with differential diagnoses of lymphatic malformation and dermoid cyst. Given the impression of a benign mass, the surgeon proceeded with trans-oral resection surgery. After histopathological analysis of the excised mass, the final diagnosis was mucinous adenocarcinoma , and tumThe patient underwent positron emission tomography/CT scan to exclude the possibility of a metastatic lesion from a primary intestinal malignancy, and there was no evidence of a metabolically active lesion in any location other than the resection margin of the tongue . Upper eAfter a multidisciplinary discussion, total glossectomy was planned as a treatment plan, and adjuvant radiochemotherapy was considered a subsequent treatment regimen.Lingual foregut duplication cysts are uncommon anomalies that occur as a result of remnant heterotopic rests of the foregut-derived epithelium after the first trimester of embryological development . Althoug35Radiologic evaluations can help diagnose these lesions and determine their extent. In our case, enhancements of the peripheral wall and internal septations of the lingual foregut duplication cyst were observed on radiologic images, and these imaging findings may reflect the malignant transformation of foregut duplication cyst.Although no standardized treatment protocol has been established for adenocarcinomas arising from foregut duplication cysts because of their rarity, complete resection with adjuvant radiotherapy or radiochemotherapy is recommended .


Mature cystic teratomas represent the most prevalent subtype of germ cell tumors affecting the ovaries. Typically, these neoplasms are benign and characterized by a slow growth pattern. Nevertheless, malignant transformation of these tumors is a rare event that may occur. Despite their typically indolent behavior, some cases may exhibit rapid growth rates and give rise to a variety of complications, including rupture and consequent manifestation of a wide range of clinical signs and symptoms. This report details the case of a 49-year-old woman who presented to the hospital with a chief complaint of chest pain. The onset of her symptoms occurred several days prior to admission and was associated with fatigue without shortness of breath. Imaging studies, including computed tomography angiography and magnetic resonance imaging of the chest, revealed a mediastinal mass measuring 5.9 x 7.4 cm in a cross-sectional area that displayed features consistent with a mature cystic teratoma, including the presence of soft tissue, fat, fluid, and areas of calcification. Notably, a prior computed tomography scan of the chest, performed 20 months before her presentation, did not reveal any evidence of masses. The patient subsequently underwent successful robot-assisted resection of the mediastinal mass, with complete resolution of her symptoms. Histopathologic examination of the excised mass confirmed the absence of malignancy. Mature cystic teratomas are the most commonly encountered form of germ cell ovarian tumors, usually exhibiting a benign and indolent clinical course, but malignancy can arise in around 1-3% of cases . Mature A 49-year-old female with a past medical history of coronavirus disease 2019 (COVID-19) infection presented to the hospital with complaints of chest pain. The onset of the symptoms was noted four days before presentation, and the intensity had gradually increased over time. The nature of the pain was described as stabbing, radiating down her right arm, and not exacerbated by movement. On further inquiry regarding the symptoms, the patient reported fatigue but denied experiencing any fevers, chills, shortness of breath, abdominal pain, nausea, or vomiting. In terms of the patient's surgical history, she had undergone a vaginal hysterectomy and bilateral laparoscopic salpingectomy six years prior to the present episode, due to chronic pelvic pain that failed uterine artery embolization and ligation in the past. During the surgical intervention, several leiomyomas were also discovered. Pathology of the cervix specimen revealed a high-grade squamous intraepithelial lesion.Upon presentation, the patient's hemodynamic status was stable. Physical examination did not reveal any notable abnormalities. Table MRI of the chest with and without contrast confirmed the presence of an anterior mediastinal mass measuring 5.9 x 7.4 x 8.5 cm, which appeared to be cystic and solid, with fat components Figure . NotablyFollowing diagnostic evaluation, the patient underwent robot-assisted resection to remove the mediastinal mass. The procedure was well-tolerated, and the patient experienced a resolution of her chest pain symptoms. Subsequent pathology examination of the excised mass showed cystic components consistent with a mature cystic teratoma containing a sebaceous soft material, mixed with hair and tooth. Notably, the excised mass was negative for malignancy.The majority of germ cell tumors are known to develop within the gonads, whereas a smaller proportion of approximately 5-10% occur in other regions of the body, such as the mediastinum and retroperitoneum . In contPatients with teratomas may present with a range of symptoms, including dyspnea, chest pain, fever, weight loss, and fatigue. Although mature teratomas typically exhibit slow growth rates, some cases of rapidly progressing teratomas have been reported. Notably, a prospective study examining the evolution of mature cystic teratomas found that the mean growth rate for teratomas was 1.8 mm per year . Based oRupture is a rare but potentially serious complication of mature teratomas that necessitates prompt surgical intervention. Several reported cases have documented teratomas rupturing into adjacent structures, producing a variety of clinical presentations that may mimic lung malignancy or tuberculosis . TeratomMature cystic teratomas are known to present with various clinical manifestations that can resemble other pathological conditions, such as chest pain, shortness of breath, and hemoptysis, which can pose a challenge to clinicians. Therefore, it is imperative to consider the possibility of teratomas in the differential diagnosis, particularly in premenopausal females. The absence of detectable masses on previous imaging should not dissuade clinicians from considering teratomas as a potential diagnosis since some cases may exhibit an accelerated growth pattern, despite their typical slow growth tendency.