We used laparoscopic approach to treat a giant gall stone successfully.•The dexterity and experience of the surgeon is what determines how safe choice of approach is irrespective of the size of the gall bladder.•We widened the epigastric port to retrieve the stone in first case but in the second case we widened the umbilical port. Giant Gallbladder calculus is an uncommon finding among Africans. This condition has paucity of reports in literature. Laparoscopic approach is even a rarer modality of treatment.This is to report two cases of giant gall stone treated laparoscopically.A 32 year old female presented with a history of right hypochondrial pain, on examination, blood pressure was 110/70 mmHg, pulse was 76 beats per minute, and tender right hypochondrum. Abdominal ultrasound showed calculus in gall bladder working diagnosis was Acute Cholecystitis secondary to Cholelithiasis.She had laparoscopic cholecystectomy. The findings were: Giant gallbladder calculus measuring 8.2 cm by 7.5 cm in diameter.The second patient was a 62 year old woman who presented with right hypochonrial pain, on examination, Murphy’s and Moynyham modified Murphy’s were positive. Abdominal and pelvic scan showed multiple gallbladder calculi. She had laparoscopic cholecystectomy and findings were multiple calculi with one measuring 8 cm by 6 cm in widest diameters. Both patients’ follow-up in outpatient clinic were uneventful.Giant gall stone is a rare condition. It is not an absolute indication for open cholecystectomy. Laparoscopy can be a very useful method of treatment in experienced hands. Giant gall bladder stone is very rare ,2. GiantCase Report:A 32 year old female presented with a history of right hypochondrial pain, On examination, blood pressure was 110/70 mmHg, pulse was 76 beats per minute, and tender right hypochondrum. Abdominal ultrasound showed calculus in gall bladder. Working diagnosis was Acute Cholecystitis secondary to Cholelithiasis.She had laparoscopic cholecystectomy. The second patient was a 62 year old woman known diabetic and hypertensive who presented with right hypochondrial pain of three years duration, no fever, jaundice and itching. On examination, Murphy’s and Moynyham modified Murphy’s were positive. Bowel sounds were present and normoactive. Digital rectal examination was unremarkable. Abdominal and pelvic scan showed multiple gall bladder calcuuli. She had laparoscopic cholecystectomy and retrieval of gallbladder was done through the supra-umbilical port , Fig. 5.2A stone formed in gall bladder is termed Gall stone disease. Gall stone disease is a very common clinical condition. This condition is more common in western world than Asia and Africa with females being more commonly affected than men . Giant gThe aetiological factors leading to gall stone formation could be multi-factorial such as infection, Metabolic and stasis or combination of these factors. one of the most common medical complications leading to surgical intervention is attributable to gall stone disease especially in sickle cell disease patients, diabetics, patients who undergone weight reduction surgeries. It could be asymptomatic or sometimes develop to a symptomatic stage  as in ouAcute cholecystitis due to cholelithiasis can be diagnosed clinically. Radiological investigations play a key role prior to surgery. Besides confirming gall stone, it could estimate the size and some complications that may be associated. Ultrasound scan is very sensitive in diagnosing gall stone, it can accurately assess the size of a gallstone and should be done routinely ,10. AbdoThe risk of biliary tract injuries represent the potentially life-threatening complication of laparoscopic cholecystectomy. The risk increases in case of inflammation or anatomical anomaly. Some authors have evaluated the role of preoperative magnetic resonance cholangiopancreatography (MRCP). Preoperative MRCP with a thorough description of biliary tract anatomy might allow safer laparoscopic cholecystectomy procedure ,12.The gall bladder may contain a single large stone as in our first index case or many smaller ones in addition. It may also contain both giant with multiple stones as we saw in our second index patient. This is yet to be reported in literature to the best of our knowledge and literature search. Gallstones with a diameter of over five cm are very rare. Giant gall bladder stones, one measuring four inch in circumference and another six and a half inch long and six inch thick have been reported ,5. Also Patients with large gallstones may be more suited to admission to an inpatient unit as they have a higher risk of conversion to open. The gold standard treatment for symptomatic gall stones currently is Laparoscopic cholecystectomy. Large gallstones may pose technical difficulties when performing a laparoscopic cholecystectomy.laparoscopic cholecystectomy have been reported to be a difficult procedure in presence of giant gall stone due to more severe inflammation and thickening of the gallbladder wall. The large gallstone would make it difficult to grasp the gallbladder with the laparoscopic instruments and expose the anatomy of Calot’s triangle. However this is possible and virtually depends on the skill and experience of the laparoscopic surgeon. In The two cases we did we were able to dissect the gall bladder out. Difficulty with the retrieval of such a large gallstone has also been reported, however we widened the epigastric port to retrieve the stone in first case but in the second case we widened the umbilical port and exchange the optical with epigastric port. This can create mirror image which the surgeon has to anticipate during retrieval while using this approach as we did. Better wound scar was relatively noted with umbilical retrieval. The histology result showed acute cholecystitis in the first case and chronic cholecystitis in second case. Port site metastasis was also our concern but no evidence of malignancy was reported on histology. Strictly speaking, giant gall bladder stone does not pose absolute indications for conversion to open cholecystectomy as seen in our index cases. Therefore, Laparoscopic cholecystectomy is still the procedure of choice in such cases instead of Open cholecystectomy unlike what is reported by some Author . This esThe size of the gall stone has been frequently used as an index for tendency of a conversion from Laparoscopic to open cholecystectomy. Large or giant gallstones would result in more severe inflammation and thickening of the gallbladder wall. Giant gallstone is said to make gall bladder difficult to be grasped with the laparoscopic instruments in other to expose the anatomy of the Calot's triangle . We usedDuring cholecystectomy, even in open or laparoscopic approach, surgeons should not allow the gallbladder to break or rupture. Firstly, to forestall spread stones or spillage of bile in abdomen with high risk of abdominal infections. Secondly, there can be a risk of unknown cancer or metastasis in gallbladder ,17, so sThe actual purpose for conversion to open is inability to expose the anatomy . Althoug3Giant gall stone is rare, it is not an absolute indication for open cholecystectomy. Laparoscopy can be a very useful method of treatment in experienced hands.No conflict of interest.No source of funding.Exemption of ethical approval was given because no identifiable patient’s parts were seen.Written and signed consent to publish as case report was obtained from both patients.PO Igwe; case design and write up.ON Diri; proof read and approve with corrections.Case series.PO Igwe.Not commissioned, externally peer-reviewed.


Proliferative fasciitis (PF) of the hand is a rare condition, which typically occurs in adulthood. To date, only two dozen cases of PF have been reported in children. This benign condition can mimic malignant soft tissue tumors such as soft tissue sarcoma. We present a case of histopathologically confirmed PF of the fifth right finger in a nine-year-old girl, along with the imaging workup. We also provide a review of the previous literature on PF in children. Proliferative fasciitis (PF) is a benign pseudosarcomatous myofibroblastic proliferation of the soft tissues . In mostAn otherwise healthy nine-year-old girl presented to the emergency department with pain and swelling around the fifth right finger metacarpophalangeal (MCP) joint, and a palpable mass. Symptoms had appeared a week before consultation and progressed since then with a rapid increase in size. There was no history of recent trauma or fever in clinical records. At clinical examination, the subcutaneous mass was firm, not adhered to the skin, and tender to palpation. There were no inflammatory signs. The mass was located in the ulnar aspect of the fifth MCP joint. Laboratory findings were unremarkable, with normal inflammatory markers. A plain radiograph of the right hand showed a periosteal reaction in the ulnar aspect of the proximal phalanx of the fifth finger. Ultrasound revealed a 22-mm oval mass located in the palmar aspect of the fifth MCP joint, contiguous to the fifth flexor tendons and surrounded by diffuse soft tissue edema. The lesion presented an echogenic central area, with no visible signal on color Doppler interrogation, and a hypoechoic rim with mild vascularization Figure .The MRI revealed a soft tissue mass, located on the outer surface of the muscular superficial fascia. The mass was homogeneously isointense compared to muscle on T1-weighted images and demonstrated heterogeneous signal on T2-weighted fat-suppressed (FS) images, more intense in the periphery than in its central zone. FS T1-weighted images after contrast administration demonstrated thin rim enhancement, and also enhancement of small regions within the mass, corresponding to microvascular zones with high T2 signal Figure . A ‘waitPF was first described by Chung and Enzinger in 1975 . PF is qThe genetic background of PF is still unknown. A clonal aberration (MYH-USP6 gene fusion) was reported only for NF, suggesting a benign neoplastic origin . This muPF can mimic sarcomas such as RMS and epithelioid sarcoma (ES) because of its rapid growth and histological features. A giant cell tumor of the tendon sheath (GCTTS) could also be included in our differential diagnosis, because of the particular location of the lesion, which is contiguous to the fifth flexor tendon. Early lesions show components of increased cellularity and myxoid change that can mimic the usual findings in NF . HoweverBecause the imaging features of PF are non-specific, diagnosis often relies on pathological findings. The diagnosis of PF must be confirmed histopathologically. Like in NF, it shows a tissue-culture proliferation of spindle myofibroblasts in a variably myxoid and collagenous stroma ,6. The hThe immunohistochemical findings are similar to those of NF and PM. The spindle-shaped cells stain for SMA Figure . ImmunosSMARCB1 deletion or mutations [The classic type of ES can fit in the differential diagnosis of pediatric PF. Like PF, ES has tumor cells with abundant cytoplasm, areas of necrosis or inflammation and spindled cells. Unlike ES, PF is typically negative for cytokeratins and does not show utations . We reported a case of a nine-year-old girl with PF. PF is a rare disease in children. When present in children, it exhibits some similarities and some differences with the adult form. Pediatric PF should be considered in the differential diagnosis when dealing with a superficial soft-tissue mass in children, to avoid misdiagnosis of the malignancy. Imaging can help to narrow the differential diagnosis and to plan the biopsy and surgery, although the differentiation between PF and a malignant soft-tissue mass, such as RMS, requires a histopathological examination.


Rectal perforation is a rare cause of acute abdomen. The most common cause of rectal perforation is trauma. Barotrauma due to the injection of compressed air in the rectum is an extremely rare cause of rectal perforation. We report a case of extensive pneumoperitoneum with abdominal compartment syndrome caused by rectal perforation secondary to the forceful injection of compressed air through the perineum. The patient was successfully managed by immediate relief of abdominal compartment syndrome by needle decompression followed by surgical repair of rectal perforation. A blow gun dust cleaner is a commonly used pneumatic tool in the industries . The imp2 [2 . Hence, 2 [2 . Because2 [2 ,6. We reA 40-year-old man presented with sudden onset abdominal pain, distension and per rectal bleeding. He reported that four hours prior, his friend placed air nozzle of compressed air gun near his perineum while they were cleaning out the dust from their body and clothes in a factory. Immediately, after that he developed abdominal distension and pain. The patient had no comorbidities. On clinical examination, the patient was tachypneic and the abdomen was grossly distended, tympanic and tender. On per rectal examination, fresh blood was present in the rectum. No rectal mucosal injury could be appreciated. Abdominal radiograph revealed extensive pneumoperitoneum Figure .Blood investigations were unremarkable. Contrast-enhanced CT revealed gross pneumoperitoneum, air in the perirectal fat tissue and subcutaneous emphysema suggestive of rectal perforation Figure . Urgent abdominal decompression was done using large bore needle to reduce the respiratory distress. On laparotomy, air gushed out of the abdominal cavity and about 100 ml of hemoperitoneum was present. The upper and middle third of the rectum was lacerated with presence of a large 4 x 4 cm full thickness perforation in the anterior wall of the rectum with fecal matter coming out of it Figure . On examination through the perforation, no full thickness injury to the posterior rectal wall was found. The perforation was primarily repaired in two layers by 3-0 polydioxanone sutures, and diverting loop sigmoidostomy was performed. The operative time was 120 minutes and blood loss was 100 ml. Postoperative recovery was uneventful with hospital stay of six days. After two months, the patient underwent colostomy closure. At the last follow-up of six months after colostomy closure, he is symptom free. The reported incidence of rectal trauma is approximately 1%-3% in civilian trauma centers with the most common cause being gunshot injury . Rectal The most common sites of injury in such cases are the rectosigmoid junction and sigmoid colon as seen in the current case ,8. The cIn suspected cases of rectal injury, digital rectal examination and rigid proctoscopy should be performed. These bedside procedures can easily detect injuries in the mid- and lower-third of the rectum. However, for higher injuries, abdominal imaging should be conducted. The large amount of air in the peritoneum can be easily visualized on chest or abdominal radiograph taken in erect position as seen in the index case . In doubDue to the high pressure, large amount of air enters the peritoneum through the perforation leading to severe abdominal distension and respiratory distress . ImmediaColorectal injuries should be suspected in patients exposed to perineal barotrauma. These patients are at high risk for development of intra-abdominal compartment syndrome. Intraperitoneal pneumatic colorectal perforations should be managed by immediate surgery in order to prevent development of fecal peritonitis, pelvic sepsis and septic shock.


Mature cystic teratoma (MCT) with meningioma of the ovary is a very rare benign tumor. There is only 3 reports of this disease until June 2019. The aim of the present study was to describe a ovarian mature cystic teratoma containing meningioma and nests of neuroblasts in a 15-year-old girl.The method used in the present study consists of description of the clinical history, image lab features, and pathological result.The patient complained of a 2-month history of irregular vaginal bleeding. Abdominal computed tomography (CT) showed a large oval cystic-solid mass with septations and fat density shadow, in abdomen pelvic cavity. The cystic part was the main component in the mass. The tumoral solid parts and its internal division could be seen intensified from slight to moderate on contrast-enhanced CT images compared with those on precontrast images, and the solid parts showed heterogeneous enhancement. Neighbouring intestinal tract and the uterus displaced by compression. The pathological examination confirmed the diagnosis.The clinical feature of ovarian mature cystic teratoma with meningioma includes a lack of specificity. Only meticulous recording of the gross features, histopathological examination including immunohistochemistry and supportive clinical and radiological findings to arrive at a correct diagnosis in case of unconventional tumours. If necessary, preoperative puncture can be performed. Mature cystic teratomas are the germ cell tumor deriving from primordial germ cells and composes of tissues arising from endoderm, mesoderm, and ectoderm in terms of histology . MalignaA case report of meningioma and nests of neuroblasts arising from mature cystic teratoma of the ovary in an adolescent female was presented. We searched PubMed, Medline, Google Scholar, Chinese Biomedicine Database, and the China Journal Full Text Database without language restriction. The search terms included (meningioma [MeSH]) AND Ovarian teratoma [MeSH]). The demographic, clinical features and imaging findings of both the newly described and previously reported cases are summarized and discussed.A 15-year-old girl presented with a 2-month history of irregular vaginal bleeding. She complained of abdominal distension and progressive aggravation, occasional abdominal pain. On examination, a large mass was found in abdomen pelvic cavity.9/L, hematocrit count 0.348 L/L, and fibrin degradation products count 18.34 mg/L. No abnormalities were revealed except for cancer antigen 125 (121.20 U/mL) and postmenopausal roman index in (39.50%) the elevated tumor markers.Physical examination revealed the abdominal cavity had giant mass with the upper boundary between the belly button and the xiphoid process. The margin of the mass was clear and the activity was poor. Laboratory blood tests were as follows: platelet count 366 × 10Ultrasonography (US) displayed a huge pelvic cavity solid-cystic mass measuring 250 × 195 × 86 mm with separation, and an echoic nodule in the wall. The solid component measuring 52 × 32 mm. The mass was mainly composed of cystic components, which were poor in sound transmission, and dense light spot echo could be detected. Color Doppler flow imaging (CDFI) showed Punctate blood flow signal in the tumoral nodule, wall and internal division  with septations and fat density shadow in abdomen pelvic cavity. The cystic parts was the main component in the mass and the margin of the solid parts (3.8 × 4.1 × 3.6 cm) was clear (Fig. Laparoscopic left salpingo-oophorectomy and Separation of pelvic adhesions were performed. Surgical exploration revealed a large cystic mass located at the left ovary. Fat, hair, scalp-like tissue could be seen when the tumors were dissected, with dark red and bloody fluid inside, as well as a solid nodule.On gross description, the Pelvic cavity showed a multiloculated cystic mass measuring 20 × 13 × 27 cm in largest dimension, with gray brown solid areas measuring 4 × 4.2 × 3.9 cm. The uterus, bilateral tubes, and right ovary were unremarkable. There was hair-like sample with a diameter of about 1.1 cm. The thickness of the inner wall was 0.4–0.5 cm, and the inner wall was smooth.Microscopic examination of the cystic areas shown sebaceous glands, hair follicle, and squamous epithelium Fig. . SectionIn addition, a few epithelioid cell nests were found on the wall of the cyst, and the cell heterosexuality was obviously accompanied by necrosis. The tumour cells was small with a round or polygonal, darkly staining nucleus with signs of division Fig. a. ImmunoFinal pathological diagnosis of this tumor was a mature ovarian cystic teratoma containing meningioma and nests of neuroblasts.After 4 months of follow-up by ultrasonography, no complication or recurrence was observed.We initially identified 3 relevant items in PubMed, Medline, Google Scholar, Chinese Biomedicine Database, and the China Academic Journals Full-Text Database. Publication dates ranged from 1968 to June 2019. After reviewing each publication, we selected 2 original studies in English. The characteristics of these patients with ovarian teratoma containing meningioma was shown in Table MCTs are common ovarian neoplasms characterized by the presence of elements of the 3 germ layers. They are diverse neoplasms with a wide range of epidemiology, histological characteristics, and biological behavior. A variety of tissue types derived from one or more germ cell layers can be observed microscopically, but the most common elements consist of cartilage, tissue of the central nervous system, and epithelium including respiratory, gastrointestinal, and cutaneous systems –8. TumorTeratomas containing meningiomas have been found only in the ovary and testes –4, 9. InTeratoma with meningioma of the reproductive organs was originally described by Takeshima et al.  in 2004.The mean age of the patients with MCT was 37.5 years. The patient’s age in the present study was only 15 years compared to 52.5 years in the mean age of the two previously published patients . The cliDue to the rarity of this tumor, imaging has not made an accurate diagnosis or even detailed description. Ultrasonography is the most common, economical, and simplest method for clinical diagnosis of ovarian cystic teratomas. Specifically, the US findings of mature cystic teratomas are various. For instance, a cystic lesion with a densely echogenic tubercle projecting into the cyst lumen, or with the sebaceous material and hair in the cyst cavity, it presents as a diffusely or partially echogenic mass with the echogenic area normally showing sound attenuation, or a cyst cavity with multiple thin echogenic bands. However, definite diagnosis may be limited by only assessing the internal structure and echogenicity of ovarian mass. Therefore, this diagnostic option is not appropriate in the present study , 13. In In the present case, the tumor manifested as a multiloculated cystic mass with mild to moderate degree enhancement of solid part and internal division in the cyst, and fat components can be seen, without calcification. The histopathological examination shows that the tumor consists of soft tissue composed of spindle cells and a cystic space, with the thin-walled cystic lesion has connective septa covered by fibrocyte. Moreover, a few epithelioid cell nests are founded in the wall of the cyst. Generally, there is a raised protuberance in the cyst cavity of MCT, just like the soft tissue component in this case, which is called the Rokitansky protuberance . It is iFor all these reasons, we are committed to differentiating secondary benign component from malignant component arising in ovarian cystic teratoma on CT findings.The imaging manifestations of secondary malignant tumors in cystic teratomas have been discussed previously. Imaging findings of the tumor usually presented as: larger than 9.9 cm of the largest diameter, the presence of enhancing soft tissue components, an obtuse angle between the soft tissue components and the inner wall of the cyst, as well as extracapsular tumor growth with extension into adjacent structures or disseminated metastasis . Buy et Ovarian teratoma containing meningioma is a rarely seen tumor. Pure ovarian cysts can be identified by ultrasound alone. Pure ovarian cysts usually have a circular or elliptical clear liquid sound transmission area with clear boundaries and thin, smooth cyst wall with a diameter of 3–8 cm. An acoustic enhancement effect was observed on the back wall and posterior of the cyst. CDFI showed no blood flow in the cyst wall . NeverthOvarian mature cystic teratoma containing both meningioma and neuroblasts components is extremely rare, but preoperative diagnosis is very important because it involves the choice of treatment options and prognosis of patients. It is recommended to determine the pathology through preoperative puncture when fat and enhanced soft tissue components are found in cystic tumors during CT examination. Despite it being a benign disease, there is a possibility of recurrence and malignant transformation. Radical surgical resection is needed to treat this tumor and discreetly follow-up with CT or ultrasound is essential.


The differences among the techniques available for localisation  are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential . Finally, seven frequently asked questions are answered.We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from  Image-guided needle biopsy is a safe and accurate non-surgical method to diagnose suspicious abnormal findings at breast imaging, pivotal for adequate decision-making, including treatment planning.Complete and adequate information must be given to the woman before image-guided breast interventions and informed consent should be obtained from the woman before the procedure.The combination of device for sampling and image modality for guidance is chosen by the radiologist for each individual case.i.e., the check of concordance between cytology/pathology report of the sample and radiological appearance of the lesion, must be performed.Pathological-radiological correlation, Image-guided preoperative localisation is mandatory for guiding surgery of nonpalpable lesions or surgically relevant extension of palpable lesions.image-guided needle biopsy is essential in the management of suspicious breast lesions detected by screening or during the assessment of clinical abnormalities. It is a safe and cost-effective procedure allowing for an accurate diagnosis, pivotal for adequate decision-making, including, when indicated, treatment planning. Percutaneous image-guided breast biopsies have almost entirely replaced diagnostic surgical excisions that were associated with longer hospital stay, higher cost, and possible complications. In 2010, the European Society of Breast Cancer Specialists, EUSOMA, suggested that 90% of all the women with breast cancer  should have a preoperative diagnosis by means of percutaneous biopsy [Percutaneous localisation before surgery. Localisation can also be performed when neoadjuvant therapy is under consideration in order to mark the lesion site for re-evaluation and treatment planning. It is routinely performed using same image guidance techniques used for biopsy and allows for conservative surgical excision of a limited amount of tissue, yielding together an effective treatment and good aesthetic results [Moreover, the increasing rate of nonpalpable breast lesions detected in screening programmes as well as the general goal of reducing the extent of surgical treatment have increased the need for  results , 3.Different modalities are available for image-guided breast biopsy and localisation procedures, each of them with their own strengths and weaknesses –6. The mThis article is the fifth of a series of recommendations for women’s information, all issued by the European Society of Breast Imaging, EUSOBI, the first  and the A search on the PubMed/Medline has been performed for papers published from January 2009 to March 2019, using the terms “breast” AND “biopsy” OR “fine needle” OR “localization” OR “marker” OR “interventional”. Articles with an informative content most suitable for the purpose of these recommendations were selected as references with special regard to predetermined issues: safety/quality, protocols and techniques, test performance (sensitivity and specificity), and clinical indications. Other articles were included when found to be important among the references of the retrieved articles or when suggested by one or more authors. The entire text underwent a double evaluation by the authors, each of them contributing with relevant intellectual content. However, as many different topics are considered, single authors generally agreeing on these recommendations may have different opinions on individual statements.This article summarises the information to be provided to women and referring physicians about percutaneous breast biopsy and presurgical localisation under the guidance of mammography/tomosynthesis, US, and MRI.i.e., mammography and other x-ray techniques (including tomosynthesis and contrast-enhanced mammography), US, and MRI. The reason to perform a percutaneous biopsy is to prevent unnecessary surgery, associated morbity and costs for equivocal findings on imaging with final non-malignant histopathology. In addition, tailored treatment strategies are currently available including chemotherapy and hormonal therapy before or after surgery , surgical options from lumpectomy to mastectomy with immediate reconstruction, whole or partial breast radiation therapy. The choice among all these options is influenced not only by imaging findings  but also by the diagnosis based on percutaneous tissue sampling, in particular when the analysis includes not only basic morphological characteristics but also the molecular pattern of the tumour [Currently, even taking into account recent advances in breast imaging, tissue sampling represents the most accurate method for confirmation or exclusion of malignancy . In facte tumour . Moreovee tumour –14.We will describe here the details of the different technical options for breast tissue sampling—fine-needle sampling (FNS), core needle biopsy (CNB), and vacuum-assisted biopsy (VAB)—and the imaging modalities for guidance.free-hand breast biopsy cannot be recommended whenever image-guided biopsy is available. CNB and VAB devices (under the same imaging guidance) had similar performances; CNB was found to be associated with a lower risk of adverse events and complications than open surgical biopsy, which were sparsely reported . The incidence of adverse events with CNB was found to be 1–1.5% and that of severe complications less than 1% for all needle sampling techniques; VAB appeared to be associated with increased bleeding and haematoma formation; biopsies performed with patients seated upright appeared to be associated with increased risk of vasovagal reactions; CNB obviated the need for surgery procedures in about 75% of women. The authors concluded that the evidence suggests that US-guided and mammography-guided biopsies have sensitivity and specificity close to that of surgical biopsy with fewer adverse events and that non-imaging-guided free-hand procedures have lower sensitivity than image-guided methods. This large literature review clearly explained the reasons for recommending image-guided biopsy instead of surgical biopsy as a general rule of good practice. However, with regard to VAB versus CNB, lesion size and type must be considered and this may have resulted in an underestimation of the potential advantages of VAB over CNB, particularly when using mammography, tomosynthesis, or MRI guidance.We highlight the results of the latest systematic review of the literature and meta-analysis, published in 2014 by the United States Agency for Healthcare Research and Quality . Based olesion with uncertain malignant potential . This occurs in 3 to 9% of cases, with a range of rates turning out to be malignant  [It is important to note that percutaneous needle biopsy may not provide a definitive diagnosis when the histopathological report describes the presence of a r rates) –25. Thesr rates) . Althougr rates) . In addir rates) .Note A.Percutaneous image-guided biopsy has replaced surgical biopsy allowing a minimally invasive safe, accurate, and cost-effective diagnosis of breast lesions, necessary for the definition of treatment planning. In the case of a biopsy resulting in a pathological diagnosis of a high-risk/B3 lesion, discuss with your radiologist and the breast care team the best option for you . After a negative image-guided tissue sampling, imaging follow-up is usually planned, with imaging modalities and time interval to be defined for each individual case.Women should be informed that the radiologist may propose a repeat needle sampling or surgical intervention also in the case of biopsy resulting into normal breast tissues or benign abnormalities. After a negative breast tissue needle sampling, imaging follow-up is usually planned, with imaging modalities and time interval to be defined for each individual case.Different percutaneous image-guided techniques are available to diagnose palpable and nonpalpable breast lesions. In the last decades, they have improved patient management, avoiding unnecessary surgical biopsy for benign lesions . NowadayWhenever the lesion is well identified on US, this technique is preferred due to the easy approach and the short duration of the procedure (implying a more comfortable woman’s experience) as well as a lower cost. If a lesion is not clearly identifiable on US, mammography, tomosynthesis or MRI is used for guidance, typically the former in the case of suspicious calcifications and architectural distortions and the latter in the case of lesions only visible on MRI [e on MRI .Differently from an intuitive reasoning, smaller gauge numbers indicate larger needle diameters. Commonly applied needles have a diameter ranging from 0.4 (27 gauge) to almost 4.6 mm (7 gauge).Needles of different size and length are adopted for percutaneous image-guided biopsies. The diameter is described by gauge numbers. fine-needle aspiration) or simply by manual movement of the needle inside the lesion (fine-needle capillary sampling) for about 10–20 sec. The extracted material is then spread onto slides and placed in formalin for cytological analysis. The procedure is easy, safe, and fast to perform and the associated cost is very low. When the cytopathologist is onsite during the sampling, results may be available very soon after the procedure [i.e., relatively large, masses.As mentioned before, FNS is performed almost only under US guidance. Local anaesthesia can be performed but it is not ubiquitous practice. A fine needle with diameter variable from 27 to 18 gauge (same or similar to those used for intramuscular injections) is inserted very close to the US probe and, once the needle is seen inside the target, a manual multidirectional sampling is performed, through aspiration using a 10-20-mL syringe or a vacuum aspiration system  cannot be obtained from FNS . For thecomplicated cysts , seromas or haematomas, for therapeutic purposes for pain relief from swelling cysts, or in the case of therapy of lactational and non-lactational breast abscesses, as an effective alternative to surgery [complex cysts , CNB is preferred [US-guided fine-needle aspiration is widely accepted for draining  surgery –39. In p surgery . In the referred .e.g., lidocaine), a needle with a size usually varying from 16 to 12 gauge (most commonly 14 gauge), is inserted by the radiologist, often through a small skin incision. Once the needle is confirmed to be on target, a tissue sample (core) is obtained with a needle of variable length (from about 10 to over 20 mm), depending on the used device, and immediately fixed in small formalin containing jars. Since a lesion may be pushed ahead while shooting, the longer samples obtained from longer acquisition chambers are usually preferred. Biopsy devices utilise a spring-loaded needle (or “gun”) that are semiautomatically or automatically fired into the lesion. This fire is accompanied by a noise and the patient should be informed of this to avoid movements during the biopsy. A variable number of cores  are obtained through subsequent samples and needle extractions. Images are acquired to document the correct needle positioning [Ultrasound guidance is the most commonly used approach for CNB. After local anaesthesia is administered through subcutaneous injections of drugs similar to those used by dentists .In 2% of cases  CNB may The most important step to avoid false-negative results after percutaneous breast biopsy is systematic radiologic-pathologic correlation of all benign and high-risk/B3 histopathological results by the multidisciplinary team including the pathologist and the radiologist.i.e., lesions with uncertain malignant potential) biopsied using CNB will eventually turn out to be malignant [Depending on the underlying histological abnormality, from 10 to 50% of lesions characterised as high-risk/B3  or upright systems  are available, according to experience and resources of the medical centre, both of them being suitable. Dedicated prone tables are more expensive than the upright alternatives but are less frequently associated with vasovagal reactions, partly because interventions occurring below the table cannot be seen by the patient.When VAB is performed under US guidance, the patient is positioned in the same way as diagnostic examinations, e.g., less than 1 cm in size) may be completely removed.For mammography- or MRI-guided procedures, once the lesion has been localised on images, a computer determines the spatial coordinates that define the lesion position. After local anaesthesia is administered, the needle is positioned in place. If an US-guided VAB is used, real-time scanning is used to identify the lesion and to reach the target; in the case of mammography or MRI guidance, images are acquired to document the needle position . MultiplIn the last decade, percutaneous image-guided systems aiming to completely remove small breast lesions have been developed –51, for A marker, typically a metallic clip visible on mammograms , can be placed in the biopsy site at the end of sampling with CNB or VAB to allow for subsequent checking of concordance between the pathological results and imaging appearance, as well as for preoperative localisation. This is especially important for small lesions that can be completely removed with VAB and are no longer visible after biopsy  and alsoe.g., at the time when the biopsy results are discussed. This mammogram is useful for confirming lesion targeting (correct or displaced location of the marker in the biopsy site) and assessing reduction or absence of lesion findings  after biopsy. In addition, it provides a comparison for future follow-up exams.Note B.When a breast abnormality identified on imaging requires a tissue diagnosis, different biopsy options exist to obtain adequate samples. Among FNS, CNB, and VAB, the radiologist will opt for the best method allowing for an accurate diagnosis, depending on lesion appearance, patient characteristics, and local availability of devices. When needed, a metallic marker at the biopsy site is placed. Don’t worry: these markers are not a contraindication for any MRI examination and do not alarm at the airport!For biopsies with marker placement, a post-biopsy mammogram is commonly performed, either immediately following the procedure or later, Image guidance outperforms non-imaging-guided free-hand approaches for breast lesion sampling. The choice among mammography/tomosynthesis, US, or MRI methods is made by the radiologist according to several factors, the most important being the visibility of the lesion to be targeted.If a lesion is visible on US, the best choice is to perform the biopsy under its guidance , 58. US stereotaxis, a term that refers to the need of two oblique projections providing a two-view (stereo) information to the operator [Mammographic guidance is the method of choice for lesions detected by mammography which do not have a clear correlate on US . Most ofoperator , 61. Stei.e.,, the presence of calcifications within the samples. The duration of an uncomplicated stereotactic biopsy itself, excluding patient information before and after the procedure, histopathological correlation and reporting as well as preparation and cleaning of the room, is about 30 min.With dedicated prone systems, vasovagal reactions can be easily managed, but the upright add-on systems allow interventions to be performed in women who cannot lie prone due to orthopaedic problems. All stereotactic biopsies performed for calcifications should be followed by specimen radiography to document adequate sampling, In the last few years, mammography guidance can also be performed using digital tomosynthesis, a technique that provides images of thin slices of the breast , 62, 63.targeted US or second-look US), even if breast US performed before MRI did not detect any abnormalities [MRI-guided VAB is a safe and accurate procedure that is mandatory when suspicious lesions are visible on MRI only , 66–68. malities –71. Impomalities . Thus, tmalities . It has malities . A largemalities  reportede.g., implantation of MRI-unsafe devices) between the previous breast MRI exam and the current MRI-guided procedure to be performed.Of course, any contraindications to MRI and/or gadolinium-based contrast administration must be checked as for any contrast-enhanced breast MRI , taking It is important to note that devices and software for MRI-guided interventions are not ubiquitously available across countries, and women cannot easily access these procedures partly due to diversity in public/insurance coverage and reimbursement policy. A EUSOBI survey among European radiologists  showed tThe patient is placed inside the magnet.Pre-contrast and immediate post-contrast T1-weighed series are acquired for lesion localisation.The patient is moved out of the magnet to percutaneously access the lesion (from the side).The patient is again moved inside the magnet for checking the biopsy device position.The patient is moved out of the magnet to perform the biopsy and deploying the marker.The patient is then finally moved inside the magnet to evaluate marker localisation and possible complications such as bleedingMRI-guided biopsy is performed on the MRI table, with a sequence of movements inside and outside the magnet. The patient is placed in prone position with the targeted breast gently compressed in a dedicated biopsy grid Fig. . A dedicNote C.If a suspicious lesion is visible on US, the best choice is to perform the biopsy under US guidance. If a suspicious lesion is visible only on mammography or tomosynthesis, these methods have to be used for guiding the biopsy. If a suspicious lesion is visible only on MRI, MRI-guided biopsy should be performed; if your centre has no possibility to perform an MRI-guided biopsy, ask your radiologist for a referral to a centre offering this procedure.Of note, additional time is needed for compressing the breast after biopsy  and for cleaning, before the next patient can be examined.Axillary lymph node assessment is an integral part of preoperative staging in patients with newly diagnosed invasive breast cancer . Informaconcordance between the cytological or pathological result and the radiological appearance of the targeted lesion has to be verified. This mandatory task must be performed by the professional who performed the image-guided sampling, usually a breast radiologist, in collaboration with the reporting pathologist [For any combination of guidance methods and needle types, hologist –78.In most cases, the radiologist will consider the cytology or pathology result as concordant with imaging findings, especially when CNB or VAB has been performed. However, in the case of inadequate sampling (more frequent in the case of FNS) or discordance between cytology/pathology and imaging findings, a repeat biopsy using the same or a different biopsy method can be considered, which is often after discussion in the multidisciplinary meeting. In the case of findings highly suspicious for malignancy on US, mammography/tomosynthesis, or MRI with discordant benign findings at FNS/CNB/VAB, it is also possible to go directly for surgical removal, after preoperative image-guided localisation, if the lesion is nonpalpable.Percutaneous breast biopsies are minimally invasive and in general very safe, with severe complications requiring treatment being exceedingly rare , 34. ComSevere bleeding requiring surgical intervention is very rare. Careful screening for bleeding disorders, avoidance of vessels when choosing the needle track (possible only under US guidance using colour-Doppler imaging), and adequate compression after the procedure reduce the probability of severe bleeding.The risk of bleeding will increase with the needle diameter and the amount of sampled tissue . BleedinPseudoaneurysm  of breast vessels is a very rare complication after either CNB or VAB, reported in the literature mainly as case reports. It is due to blood leaking from a breach in the arterial wall, contained by the adventitia or surrounding perivascular soft tissue. An enlarging mass a few days after the procedure, showing blood flow inside, is the commonest presentation. Management options include observation, US-guided focused compression, thrombin injection, open surgical repair, and percutaneous embolisation [lisation .infection does exist, so using sterile packed devices and keeping the environment clean as much as possible is important. The risk of infection after breast biopsies is extremely rare, reported to be 0.1% for US-guided biopsies [As with any percutaneous intervention, a low risk of biopsies . They armechanical displacement of malignant cells along the biopsy tract can very rarely occur and is referred to as neoplastic seeding. The incidence of this event was reported to be 2 of 1644 biopsies [The risk of biopsies  or, morebiopsies , meaningbiopsies . Their bbiopsies  includindistant metastases at long-term follow-up for a cohort of patients who underwent CNB versus FNS. However, the study has relevant limitations, the most important being the retrospective design, the small sample size and the times of cancer diagnosis of the two cohorts . The authors adjusted for the difference in treatment over time. However, the 20-year time difference implies a greater sensitivity for metastases in the CNB cohort as a non-negligible source of bias [A study  reported of bias . In addipneumothorax, especially if an inexperienced examiner uses an improperly steep angle for access [Note D.Percutaneous breast biopsy is a safe procedure, with an extremely low risk of serious complications needing surgery or emergency assistance. Mild complications are also very rare: a certain degree of bleeding is the most common side-effect, usually self-limited; skin or soft-breast tissue infections respond well to oral antibiotics. The probability of neoplastic seeding along the biopsy tract is 2 of 1000 biopsies or lower and considered irrelevant due to the adjuvant radiation and pharmacological treatment in case of breast cancer. All mentioned complications are less frequent than complications under surgical biopsy with or without full anaesthesia.A severe, but extremely rare complication of a free-hand or US-guided breast biopsy is the development of a chest wall injury, for example a r access . A pneume.g., when planning the procedure or 1−2 days before the procedure) or immediately before the procedure [The planned procedure, including the rationale for performing the biopsy/localisation, potential benefits, possible complications, and likely outcomes must be explained in detail to the patient and informed consent should be obtained in advance  treatment does not need to be blocked while clopidogrel may be discontinued some days before and resumed immediately after the procedure [To minimise the risk of bleeding, patients scheduled for percutaneous breast biopsy should be reatment , 89. Deprocedure . SpecifiIn case of pregnancy, mammographic and MRI-guided procedures are possible but the indications should be adequately reviewed on a case-by-case basis.Patients planned for MRI-guided biopsy should undergo the usual precautions including screening for MRI-unsafe or MRI-conditional implants, prior reactions to contrast agent administration, and renal function impairment, as suggested by the EUSOBI recommendations for breast MRI .Note E.Informed consent is required before a breast biopsy. Management of antiplatelet/anticoagulation therapy may be adopted. Women should be informed of possible adverse events and any allergies to local anaesthetic drugs should be verified. If an MRI-guided biopsy is planned, allergies to intravenous contrast agents as well as contraindications to MRI should be verified. Informed consent also includes communication between the radiologist and the patient (see the next paragraph).The patients do not have to fast on the day of the procedure or discontinue other medications than those related to antiplatelet/anticoagulation therapy, as explained above.The patient should be informed about the reasons for performing a needle biopsy or a localisation procedure.informed consent must be obtained according to national/local regulations.Before the procedure, Patients should be informed about the possible necessity of placing a marker clip in the biopsy site, taking into account that some women may have objections against potentially permanent placed foreign bodies in their breasts. In those cases, precise information on the risks associated with not using these markers has to be provided to the patient, especially the risk of missing a small lesion requiring surgery that may not be visible after the biopsy.Efforts should be made to reduce the patient’s anxiety prior to the procedure, as the anticipated pain strongly correlates with the level of pain experienced by the patient during the procedure, so that communication with patients before biopsy regarding minimal average pain reported during biopsy is a good strategy [strategy . The quastrategy . A studystrategy . We highThe experience of a patient needing a biopsy differs according to the image guidance adopted, as explained in the previous sections. While US-guided is in most cases a straightforward and fast procedure lasting no more than 15 min, mammography/tomosynthesis- and MRI-guided biopsies require preparatory technical measures aiming at the exact lesion localisation, leading to procedural times that can exceed 30 min and increase patient anxiety. Some evidence exists that tomosynthesis guidance can reduce the procedural time in comparison with stereotactic guidance ; one stuWhichever combination of guidance and needle is used, once the patient is positioned and the best and safest needle access route to the lesion has been chosen, the corresponding skin is cleaned and disinfected. Whereas for FNS the use of local anaesthesia is optional , all other types of percutaneous breast biopsy are usually performed under local anaesthesia.For superficial anaesthesia, lidocaine buffered in sodium bicarbonate may be used to reduce the initial stinging sensation of the lidocaine injection , 58. In Note F.Patients’ experience will be different depending on the type of device used for sampling and the imaging guidance adopted. A percutaneous biopsy may last from 15 to 45 min and is generally well tolerated. The position will be the same as the diagnostic examination for US (supine) or MRI-guided biopsy (prone) and may be prone, seated, or in lateral decubitus for mammography/tomosynthesis-guided biopsy, according to the adopted system. Communication between the radiologist and the patient is crucial for anxiety reduction.At the completion of the biopsy, local manual compression, usually for 5 min, as well as cooling, may be applied to the biopsy site to achieve haemostasis and to minimise the amount of bleeding. In addition, the application of a compression bandage can be applied, in particular in the case of moderate or severe bleeding,e.g., swimming) and strenuous exercise for at least 3–5 days following the biopsy.Following the biopsy procedure and after achieving haemostasis with manual compression, wound cleaning, and bandage, the patient is observed for 15–60 min in the radiology suite, depending on the type of procedure and the patient’s profile. Subsequently, she can be discharged with appropriate instructions, including possible pain and bleeding and corresponding remedies, ban of water immersion  should be discussed with the patient in person, usually during the visit after the biopsy. Timing of this visit must strike a balance between minimising the waiting time for the patient and its associated anxiety and the necessity to allow for enough time to have pathology results including, if necessary, additional immune-histological stains. In the cases requiring treatment, the visit after the interventional procedure should include the results from the multidisciplinary conference, at which concordance of imaging and histological findings is assessed and subsequent management is established.Whenever possible, biopsy results as well as recommendations for further management  and a good cosmetic result , 3, 96. e.g., calcifications) or lesions revealed only on MRI, mammography/tomosynthesis or MRI guidance have to be used, respectively. This is why post-interventional marker placement is encouraged: the marker allows a presurgical localisation by US-guided marker identification. The position of the patient is the same in which the biopsy was performed; supine for US-guided methods; upright, prone, or in lateral decubitus for mammography/tomosynthesis-guided methods; and prone for MRI-guided methods.Different localisation methods currently exist and are variably used in different institutions depending on personal choices, skills, and available technologies. The image guidance adopted should be the easiest method whereby the lesion (or the marker left after the biopsy) can be identified with certainty. In case of findings only visible on mammography/tomosynthesis , radioactive seed localisation, and magnetic seed localisation  is about 1 in every 100 procedures [e.g., when a benign diagnosis is obtained with the biopsy), foreign-body giant-cell reactions that may mimic malignancy on mammography and US may occur  [Carbon marking is a long-standing method consisting of injection of sterile charcoal powder diluted with saline solution near to a nonpalpable breast lesion under US or mammographic guidance, depending on how the biopsy was performed , 98. A docedures . In the excised) . The metIt is the commonest method worldwide. A 3–15 cm wire, usually with a terminal hook or pigtail, is inserted through the skin by the radiologist using a co-axial needle introducer and anchored to the lesion or nearby through a 16–21-gauge needle that works as introducer. A variable part of the wire comes out of the skin and is taped or covered until the patient is transferred to the operating room and the surgeon removes it together with a variable amount of breast tissue. Wire localisation is a safe, cost-effective, and standardised technique which may be performed under US, mammography/tomosynthesis, or MRI guidance. It strongly reduces the even low risk of incorrect localisation associated with use of marking fluids (carbon suspension or radioactive tracers) that might distribute along the septa, resulting into imprecision. The main complications are patient discomfort such as vasovagal reactions , reported in up to 7–10% of patients and less frequent for US than for mammography guidance), wire rupture or migration –104. The99mTc) inside the tumour [sentinel node and occult lesion localisation, SNOLL) [ROLL consists in the injection of 0.2–0.3 mL of human serum albumin labelled with radioactive technetium , commonly used for brachytherapy  [For this approach, radioactive seeds are positioned inside the tumour under US, mammography/tomosynthesis, or MRI guidance. These seeds are small titanium radioactive  tumour) . One see tumour)  showed a tumour) . A poten tumour) . ObviousThis recent localisation method uses 5 × 1 mm paramagnetic steel and iron oxide cylindrical seed, readily visible on mammography/tomosynthesis and US, supplied preloaded into an 18-gauge 20-cm needle. The seed is detectable using a dedicated magnetic probe. The first published reports –116 indithe current recommended and most commonly used method is wire localisation. Whether alternative approaches may lead to equivalent or even better results has not been established yet and depends on local experience. In addition, methods using radioactive tracers or seeds have the drawback of radiation exposure even though low doses are used. A meta-analysis from the Cochrane Database published in 2015 [there is no clear evidence to support one guided technique over another. The authors support the continued use of wire localisation as a safe and tested technique that allows for flexibility in selected cases when faced with extensive microcalcifications.We emphasise that  in 2015 , consideNote H.When the pathological result of a biopsied nonpalpable lesion requires surgical excision, a preoperative image-guided localisation is performed by the radiologist. This will allow the surgeon to access the lesion accurately and to remove it. Percutaneous localisation can be performed under US, mammography/tomosynthesis, and MRI guidance, whichever is more suitable and cost-effective for the specific case.Whichever localisation technique is used, additional marking of the skin directly over the nonpalpable breast lesion and measurement of the depth of the lesion in the supine operative position using US (when the lesion is US-detectable) is of great help to the surgeon. Communication between the radiologist and the surgeon is also crucial for choosing the best method for localisation, considering the surgical approach to be used.Image-guided percutaneous needle biopsy represents a fundamental technique to characterise the nature of suspicious breast abnormalities and has almost completely replaced the surgical biopsy for both palpable and nonpalpable lesions. Radiologists play a crucial role in the detection as well as diagnosis and management of breast disease. Depending on the patient profile and lesion characteristics, the radiologist will choose the best available biopsy system from FNS, CNB, or VAB. The choice will also depend on local experience and availability. When a lesion is visible on US, this is the preferred method for biopsy being most accessible, comfortable, and straightforward compared to other techniques. Minor pain and bleeding are possible post-biopsy sequelae, but the risk of severe complications is very low. Radiologic-pathologic correlation is essential for an accurate and successful conclusion of the diagnostic procedure.Preoperative localisation of nonpalpable lesions amenable to surgery is available through US, mammography/tomosynthesis, or MRI guidance, typically by wire insertion.What is the difference between needle biopsy and excisional biopsy?2.What is the difference between FNS, CNB and VAB?Needle biopsies are percutaneous interventional procedures performed with a needle under the guidance of a breast imaging modality; depending on the needle size, local anaesthesia is administered. Excisional biopsy is a surgical operation aiming at removing the entire lesion to be analysed by the pathologist; it may be performed under local or general anaesthesia.3.Is breast needle biopsy a painful procedure?FNS is percutaneous lesion sampling, usually performed under US guidance, using the same fine needles suitable for intramuscular injections or thinner needles, according to local experience. Once the needle is in the lesion, multiple cells are collected; the biological material is prepared as smears on glass slides and examined by the pathologist for a cytological diagnosis. CNB is a percutaneous procedure that uses a spring-loaded needle for “true cutting” tissue “cores” providing a histological tissue diagnosis. VAB performs a task similar to that of CNB using larger needles, facilitated by a vacuum-generating device that attracts the tissue towards the needle, allowing removal of larger amounts of tissue in comparison to CNB.4.Is local anaesthesia used during a breast biopsy?Minor pain and bruising can occur immediately at the end of the procedure and up to one or two days. If necessary, adequate analgesic support can be taken.5.Is there any risk of dissemination or activation of cancer cells with image-guided interventional procedures?Yes, local anaesthesia is always administered before core needle biopsy (CNB) or vacuum-assisted biopsy (VAB). Before FNS, as the procedure for delivering anaesthesia is not different from collecting cells, local anaesthesia is optional.6.Can needle biopsies provoke infections?The risk of mechanical displacement of malignant cells along the biopsy tract can rarely occur and is referred to as “neoplastic seeding”. It has been reported to happen in less than 2 cases every 1000 biopsies. It is considered oncologically irrelevant due the high probability of lack of viability of the displaced cells and to the possible addition of adjuvant radiation and pharmacological treatment in the case of breast cancer. In fact, preoperative needle biopsy does not increase local recurrence rate in breast cancer patients. In addition, if seeding does occur, it is mostly seen in the skin, which is detected early and easily treated, with low clinical importance.7.How much waiting time to get the result of the needle biopsy?A very low risk of infection accounting for 1 case every 1000 procedures does exist, and adherence to sterile working conditions is important. Infectious complications are limited to skin or soft tissue and respond well to oral antibiotics. The risk of infection may be higher in patients with diabetes or compromised immune systems.e.g., when a pathological-radiological discordance happens, requiring consultation among the specialists and potential re-reading by the pathologist) may need longer time to provide results.In some centres, the result can be available very soon after the procedure. Otherwise, the cytology/pathology report should be available within 1 or 2 weeks after the procedure. However, special cases (


Gorham-Stout disease is a rare bone disorder. Here, we present a case of Gorham-Stout disease diagnosed during follow-up of a patient with cholesteatoma; the disease affected the temporal bone and other sites of the skull. To the best of our knowledge, this is the first report of Gorham-Stout disease diagnosed with recurrent cerebrospinal leakage after surgery to treat cholesteatoma.A 25-year-old male patient re-presented to our department for the first time in 7 years with otorrhea in the right ear and recurrent meningitis. The patient had a history of multiple surgeries for cholesteatoma and suffered from recurrent cerebrospinal fluid leakage, which initially was thought to be caused by recurrence of cholesteatoma. Therefore, skull base reconstruction was planned. However, the underlying cause was identified eventually as defects in the temporal bone caused by massive osteolysis due to Gorham-Stout disease. Skull base reconstruction was abandoned because the osteolysis was considered to be progressive. Conservative treatment with infectious control was implemented as an alternative.This case describes unusual temporal bone osteolysis after cholesteatoma surgery and the importance of considering the possibility of multiple concurrent diseases in such individuals. The distinguishing features of this case are the fact that the temporal bone had disappeared, and deconstruction was complicated by infection and inflammation caused by cholesteatoma, surgical invasion, and Gorham-Stout disease. Appropriate diagnosis saved the patient from ineffective multiple surgeries for cerebrospinal fluid leakage or cholesteatoma, and improved his quality of life. Gorham-Stout disease is a rare bone disorder, the etiology of which is not fully understood . This diHere, we present a case of Gorham-Stout disease significantly affecting the temporal bone and other sites of the skull, in a patient with a history of cholesteatoma and presenting with recurrent cerebrospinal fluid (CSF) leakage and meningitis. To the best of our knowledge, this is the first report of Gorham-Stout disease diagnosed in a patient with recurrent CSF leak after surgery to treat cholesteatoma.A 25-year-old male patient re-presented to our department for the first time in 7 years with otorrhea in the right ear and recurrent meningitis. He had been treated for meningitis in another hospital and had experienced fever and seizures two weeks before visiting our hospital. The patient had a history of multiple surgeries for cholesteatoma and had been treated for severe otitis media at the age of 2 years, at which point right temporal bone osteolysis was identified. He subsequently suffered from recurrent meningitis and underwent several brain abscess drainage procedures. At ten years of age right temporal bone surgery was performed to rebuild the separation between the middle ear and lateral temporal lobe. At 16 years, he was diagnosed with cholesteatoma, and radical mastoidectomy was performed. Further details of these operations, performed at other hospitals, were not available. We were unable to obtain detailed past medical records regarding treatment  of his cholesteatoma, and we could not estimate whether the past intervention of the cholesteatoma was appropriate. When the patient was 17 years old, he visited our department for the first time to undergo assessment for controlling cholesteatoma, recurrent meningitis, and otalgia. First, tympanoplasty was performed to assess the disease and remove residual cholesteatoma from the middle ear; cholesteatoma was diagnosed by histopathological analysis. It was not possible to determine whether the cholesteatoma was a residual congenital cholesteatoma or a secondary cholesteatoma formed as a result of osteolysis of the external auditory canal or middle ear. At that time, we hesitated a more extensive procedure because of his age and limited information about his past surgical interventions. Meningitis and otalgia were subsequently controlled. However, after six months, when he was 18 years old, the patient experienced another episode of meningitis. At that time, he was also suffering from an epidural abscess, which was drained during hospitalization. He attended our department until he was 19 years old, at which point he chose to discontinue the hospital visits.When the patient presented at our department again at the age of 25 years, computed tomography (CT) imaging revealed massive osteolysis of the temporal bone Fig.  a−c. Not?A3B2 twb=.27w?>Pre-operative CT imaging with three-dimensional reconstruction clearly revealed not only temporal bone osteolysis but also spotted osteolysis of other bones of the skull, including the mandibular bone, zygomatic bone, and contralateral temporal bone Fig. f. At thiDuring the first year of follow-up, he suffered a mild headache on one occasion, leading to an unscheduled visit. He was treated with intravenous antibiotics at an outpatient clinic to prevent the development of severe meningitis. At this point, no apparent CSF leakage was observed, no hospitalization was required and his headache had resolved within a few days. After that, there was no need to visit the hospital, except for follow-up once every few months. He was followed every two or 3 months for the next 1 year, during which time there were no signs of CSF or cholesteatoma recurrence.We think that he has little risk of recurrence of the cholesteatoma because there has been no clear evidence of recurrence of cholesteatoma since the age of 18. However, this is an extremely rare case. CT imaging with three-dimensional reconstruction has been taken in every six months to assess the progression of osteolysis of the temporal or other bones of the skull and to watch out recurrent cholesteatoma. He remained well at the time of his last follow up. His quality of life has been maintained.Gorham-Stout disease is a rare condition that is difficult to diagnose, as there is no specific test or procedure. Diagnosis is made by excluding other diseases, particularly lymphadenopathies, bone manifestations of systemic diseases, or other neoplastic lesions . PreviouTo the best of our knowledge, this is the first case of Gorham-Stout disease accompanied by cholesteatoma; in several other cases, cholesteatoma was raised as a differential diagnosis alongside osteoradionecrosis, benign tumors , and malignant and metastatic disease. In this paper, we made a diagnosis of Gorham-Stout disease based on radiological findings after excluding other differential diagnoses. The diagnosis was supported by histological findings. In this case, a characteristic osteolytic lesion was evident in the bones of the skull, including on the contralateral side that had not been affected by previous surgical procedures for cholesteatoma. Differential diagnoses, including neoplastic tumors or infectious diseases, were excluded after histological inspection. We noted the formation of abnormal bone slits in bones that had maintained normal bone remodeling. This histological finding supported our diagnosis as Gorham-Stout disease.Simon et al. have published the largest case series of Gorham-Stout disease to date and reported a mean age at diagnosis of 3.5 years (range: 0–10) . In the Treatment of Gorham-Stout disease includes surgical intervention, medical treatment, and radiation therapy , 7. SurgWhen faced with spontaneous CSF leakage or progressive osteolysis after cholesteatoma surgery, a surgical examination of the temporal bone is usually planned, regardless of the apparent recurrence of cholesteatoma. However, in this case, we found that the symptoms were caused by Gorham-Stout disease, not cholesteatoma. Thus, we concluded that recurrent surgical inspection of the temporal bone was inappropriate in this case.Here, we present an extremely rare case of Gorham-Stout disease, diagnosed with recurrent cerebrospinal leakage after surgery for cholesteatoma. Osteolysis of the temporal bone is associated with several diseases, including cholesteatoma, osteoradionecrosis, benign tumors (such as paragangliomas), and malignant and metastatic disease. Osteolysis of skull bones can also be caused by Gorham-Stout disease. Our case shows that temporal bone deconstruction can occur in the presence of multiple concurrent diseases. The distinguishing feature of this case is the fact that the temporal bone had disappeared, and deconstruction was complicated by infection and inflammation caused by cholesteatoma, surgical invasion, and Gorham-Stout disease. Bony destruction was observed in other bones of the skull, including the contralateral temporal bone, mandibular bone, and zygomatic bones, which had not been affected by previous surgical procedures for cholesteatoma. Thus, an appropriate diagnosis saved the patient from having to undergo multiple ineffective surgeries for CSF leakage or cholesteatoma, thereby improving his quality of life.


The diagnosis of vertebral sarcoidosis can be challenging. Besides, there is no consensus for the treatment of these lesions. Exceptionally, lesions may show spontaneous regression. To our knowledge, there are only two case reports of spontaneous resolution of vertebral sarcoidosis documented by follow‐up MRI. Herein, we present a third case. The diagnosis of vertebral sarcoidosis can be challenging. Besides, there is no consensus for the treatment of these lesions. Exceptionally, lesions may show spontaneous regression. To our knowledge, there are only two case reports of spontaneous resolution of vertebral sarcoidosis documented by follow‐up MRI. Herein, we present a third case. In rare cases, it can affect the bones. Vertebral sarcoidosis is even rarer. MRI represents a fundamental tool for the assessment of vertebral involvement. However, sarcoidosis‐related bone lesions can be similar to bone metastases, making the diagnosis rather challenging. Therefore, performing a biopsy is important in order to confirm the diagnosis. There is no consensus for the treatment of vertebral sarcoidosis. In very rare cases, lesions may show spontaneous regression on follow‐up images. To our knowledge, there are only two case reports of spontaneous resolution of vertebral sarcoidosis documented by follow‐up MRI.Herein, we present a case of vertebral sarcoidosis mimicking osseous metastases that resolved spontaneously in a 65‐year‐old woman.2In 2018, a 65‐year‐old white woman presented with various symptoms including 2 years of gradually worsening mechanical low back pain and deterioration of the general status.She had hypertension and hypertensive renal disease. She had a known history of stage 2 pulmonary sarcoidosis for 7 years. Evidence supporting the diagnosis of sarcoidosis included erythema nodosum, chronic arthritis lymphopenia, and hilar and mediastinal lymphadenopathy. The disease seemed inactive given that the patient never had sarcoidosis‐related symptoms nor received treatment throughout the years.Physical examination showed no abnormalities except for lower lumbar spinous percussion tenderness. There were no skin lesions nor peripheral lymphadenopathy. Routine laboratory tests showed creatinine clearance of 48.5 ml/min, hypercalcemia of 2.86 mmol/l, normal serum phosphate concentration of 1.19 mmol/l, and normal liver enzymes and an erythrocyte sedimentation rate of 66 mm/h. Protein electrophoresis revealed hypoalbuminemia of 33.9 g/l and polyclonal hypergammaglobulinemia of 22.1 g/L.A lumbar plain radiograph showed a mixed lytic‐sclerotic pattern with a rim of sclerosis around the central osteolysis in the L2 vertebra Figure . MRI demGiven the deterioration of the general status associated with bone lesions, the patient underwent extensive screening for hematologic and solid tumor malignancies including mammogram, neck ultrasound, and CT scans of the chest, abdomen, and pelvis. CT scans showed bilateral lung nodules Figure , parenchThe diagnosis of systemic sarcoidosis with osseous involvement was established, and the patient was prescribed steroid treatment at the dose of 60 mg, however not taken because of the lack of resources.She was lost to follow‐up for 1 year. At that point, she was readmitted to our hospital with a chief complaint of mechanical low back pain. A follow‐up CT scans at 1 year showed the persistence of the pulmonary nodules, the parenchymal condensation, the bilateral mediastinal adenopathy, and the enlarged spleen, in addition to the appearance of hepatic nodules.Repeated MRI revealed almost complete resolution of the areas of marrow signal abnormality and the disappearance of the paravertebral soft‐tissue involvement Figure . FurtherThe patient was prescribed steroids in the form of oral prednisolone given the multisystem involvement.3Sarcoidosis is an inflammatory granulomatous condition occurring more commonly in women and black individuals. The lungs are involved in more than 90% of cases. Abdominal viscera are commonly involved in sarcoidosis, although this involvement is usually asymptomatic. Symptomatic hepatic sarcoidosis occurs in less than 10% of patients.Osseous involvement is much less frequent with a variable prevalence ranging from 3% to 13% depending on the diagnostic modalities.Patients with vertebral lesions usually report mechanical pain or tenderness over the involved area. Clinical presentation is nonspecific, and backache or radicular pain can reveal the disease. In addition to the sarcoidosis‐related bone lesions, our patient had degenerative disk disease. The latter could be responsible for the symptomatology.The lesions can be lytic, sclerotic, or mixed lytic and sclerotic. The posterior elements and intervertebral disks are usually spared. However, an extension to the pedicle as demonstrated in our patient is possible and has been previously reported.On MRI, the lesions can have a variety of appearances. Typical MRI features include multifocal lesions within the vertebrae that have low signal intensity on T1‐weighted images, high signal intensity on T2‐weighted images, and variable enhancement following contrast medium administration depending on the nature of the tissue.In addition, MRI provides detailed information about an extension to soft tissues, as demonstrated in our patient.Before the bone biopsy, many differential diagnoses should be discussed, including tuberculosis, metastasis, multiple myeloma, lymphoma, eosinophilic granuloma, and disseminated echinococcal lesion.The osseous lesions in sarcoidosis generally present without hypercalcemia. However, our patient had abnormal serum calcium level. This finding raised concerns about possible malignancy. Given the possible coexistence of sarcoidosis and metastases,As previously suggested, performing a biopsy is the key to confirm the diagnosis of vertebral sarcoidosis. Noncaseating granuloma is the hallmark of this disease.Besides vertebral lesions, our patient had sacroiliitis. However unusual, the prevalence of sacroiliitis in sarcoidosis varies from 6% to 23.4%.Consistent with the previous studies, our patient had unilateral involvement of sacroiliac joints with typical imaging findings of sclerosis and joint margin irregularities. For reminder, our patient did not present with the typical inflammatory back pain history, and the pain was rather mechanical.Given its rarity, there is no consensus for the treatment of osseous sarcoidosis. While asymptomatic patients do not require treatment, patients with pain and bone destruction should be treated. In our case, and given the multisystem involvement, steroids had been prescribed. Oral corticosteroids are the cornerstone of the treatment. They have been proven successful in reducing both symptoms and radiological changes.The follow‐up MRI showed almost complete regression of bone marrow abnormality. To our knowledge, only two previous studies have reported spontaneous radiological resolution of vertebral sarcoidosis.We also confirmed the absence of radioclinical parallelism as our patient remained symptomatic despite the radiological resolution of the skeletal lesions.Another possible explanation of the low back pain would be the L4‐L5 degenerative disk disease demonstrated on follow‐up MRI.This case highlights the limitations of MRI to distinguish osseous sarcoidosis from metastatic lesions, the importance of considering vertebral involvement in a patient with a history of sarcoidosis, and the need for biopsy to ensure the accurate diagnosis of vertebral lesions.Vertebral sarcoidosis should be kept in mind when exploring osseous pain in patients with documented sarcoidosis. MRI appearance can be similar to that of bone metastases.Spontaneous improvement of radiographic findings is very rare but possible.Our case is unique and instructive for several reasons. The first is the coexistence of pulmonary, splenic, hepatic, vertebral, and sacroiliac involvement in the same patient. The second is the evidence of almost complete spontaneous resolution of widespread osseous documented by follow‐up MRI, which is rarely reported. And lastly, this report emphasizes the utility of follow‐up MR imaging to document treatment response given the lack of radioclinical parallelism.None declared.SR: drafted the manuscript with the help of KM. HF: helped us to make the final diagnosis and participated in writing the text. HR: took the pictures and helped with the diagnosis. LM: was the first doctor who examined the patient, and helped with the final diagnosis. DK: revised the manuscript. WH: approved the final manuscript.Ethical approval for this study was obtained from the Scientific and Ethical Committees of the hospital.


Fibrosarcoma is a very rare tumor that arises from fibrous tissue. Less than 5% of fibrosarcoma originate from the urogenital tract. Penile fibrosarcoma, even more rare, is characterized by pain, enlargement, penile erection and urinary tract obstruction. To our knowledge, this is the second reported case named “fibrosarcoma of the corpus cavernosum”.A 51-year-old male presented with a 1-month history of penis pain during erection. CT scan showed a soft tissue mass arising from the proximal part of the penis. We diagnosed it as penile sarcoma, performing local excision. The postoperative pathological result was moderately differentiated fibrosarcoma. 3 months later, CT scan showed the recurrence of the tumor, and multiple metastases. Although he received chemotherapy, he died 10 months after surgery.Fibrosarcoma of the corpus cavernosum is rare and have poor prognosis. Total penile amputation may be the best treatment. The effects of chemotherapy are limited. No more effective treatment has been found for a disseminated disease to date. Fibrosarcoma is a very rare tumor that arises from fibrous tissue. It generally involves the extremities and the trunk but rarely involves the genital area. There are only very few cases of penile fibrosarcoma in the published literature via a search of PubMed. The age distribution ranges from 2 to 72 years old. The best treatment for fibrosarcoma is complete excision of the tumor and total penile amputation is recommended. However, we report a case of fibrosarcoma of the corpus cavernosum which was treated by local excision, and summarized the current data regarding etiology, diagnosis, and management from literature.2N0M0) with poor prognosis, and recommended him penectomy if the intraoperative frozen section diagnosis was sarcoma or other malignant tumors. Influenced by traditional Chinese male culture, he and his family refused penectomy. Unfortunately, the frozen pathological section indicated sarcoma. So, we recommended penectomy again during the operation, but his family rejected it for the second time. Then we had to perform local excision. We saw a hard tumor on the left side of the corpus cavernosum in the surgery, and had to remove part of the Buck fascia because of the adhesion, then stitched the tunica albuginea  scan of abdomen and pelvis showed the presence of a well-defined, irregular, and heterogeneously enhancing soft tissue mass arising from the proximal part of the penis, and measuring 3.2 cm in width by 7.2 cm in length, no enlarged lymph node was seen in the groin and pelvis (Fig. ea Figs. . We recoea Figs. . When wePenile tumor is rare, and the incidence in developed countries ranges from 0.6 to 1/100,000 patients .According to the tissues from which they originate, the penile sarcoma can be divided into superficial and deep-seated . SuperfiFibrosarcoma of corpus cavernosum is derived from the supporting structure of the corpus cavernosum and classified as the deep-seated sarcoma. Clinical manifestations mainly include subcutaneous mass, penis pain and enlargement, penile erection and urinary tract obstruction. A review of the literature showed that 3 cases of epithelioid sarcoma occurred which were found to be causing pain during erection as in our case –8. MoreoSome features related to penile sarcoma recurrence and metastatic dissemination patterns have been well confirmed. Local recurrence is characteristic of sarcomas , and eveThe treatment of fibrosarcoma of corpus cavernosum includes surgical resection, chemotherapy, and radiotherapy. Total penile amputation has been advised for tumors of deep corporeal origin. In 1932, Evans  reportedRadiotherapy has been used to control the local diseases in patients with unresectable tumors and positive margins, but the role of radiotherapy is limited. There have been contrasting reports of success with radiotherapy versus secondary fibrosarcoma due to radiation-induced neoplasia . In thisWe can predict the biological behavior of penile sarcomas by some previously described prognostic factors . These fIt is concluded that from this case study fibrosarcoma of the corpus cavernosum is rare, usually progressed rapidly, and has a poor prognosis due to the deep-seated lesion. Local excision is inadequate. Total penile amputation with negative margins may be the best treatment. Chemotherapy can be used as adjuvant therapy, but their effects are limited. No more effective treatment has been found for a disseminated disease to date.


Supernumerary teeth are an anomaly characterized by the existence of an additional tooth that may grow in the dental arch region, it a rare occurrence and may be confused with other differential diagnosis, it is important treat such case as they can cause considerable morbidity to the patient.We report a case of a 16 years old female, not known case of any medical condition, who presented to the Ear, Nose and Throat clinic complaining of nasal obstruction and rhinorrhea. Physical examination and CT findings revealed a right upper central incisor tooth located in anterior aspect of right inferior meatus. The patient underwent endoscopic teeth extraction under general anesthesia.Supernumerary tooth is a rare condition, often causes significant distress to patients and often misdiagnosed in a clinical setting. A thorough history physical examination including the anterior rhinoscopy and nasal endoscopy needs to be done for all patients. Further radiological investigations such as CT scan of the paranasal can aid and help confirm the diagnosis. The most common treatment is usually trans nasal endoscopic removal of the tooth. It is r2A 16-year-old female presented to the Ear, Nose and Throat clinic complaining of a long standing history of nasal obstruction and rhinorrhea mostly on the right side. She had no history of facial pain, anosmia, epistaxis or headache. The patient was medically free and had no previous diagnosis of any sort of syndrome or had previous ear, nose and throat procedures. Patient had no relevant family or social history.On anterior rhinoscopy, the patient had a right side deviated nasal septum along with mucopurulent discharge. The nasal endoscopy of the right nostril showed white solid nasal mass arising from the floor right nasal cavity covered in excess secretions and discharge. The left side was normal and the nasopharynx was clear as well, examination of throat and neck revealed no abnormalities.The patient then underwent a non-contrast CT paranasal sinus (The decision was then taken to remove the tooth endoscopically in the operating theatre by the consultant while she was under general anesthesia. Intraoperatively the patient was found to have excess muco-purulent discharge around the area of the tooth and the mucosa was friable and indurated. The tooth was found in the area as it was described in the CT scan (The pathology reported it as a fully formed tooth. Morphologically, it is consistent with an unerupted right central incisor structure. The full length of the tooth all the way to the crown was well-displayed. The tooth was also described as quite viable including the pulp cavity .Image 3HThe patient was discharged from the hospital with no complications. She was seen again in the ENT clinic 1 week later. The mucosa of the right side of the nose healed well and there were no signs of recurrence or complications.3As mentioned previously, supernumerary tooth growth in the nasal cavity is a rare occurrence, it tends to be found in males more than females. It can cause a wide range of symptoms including but not limited to pain in the nasal area, nasal discharge nasal obstruction, rhinorrhea, headache, and epistaxis ,4, the eExamination of such patient would usually reveal a unilateral nasal mass in the nasal cavity, the tooth is usually covered by mucosa, nasal secretions and granulation tissues, the differential diagnosis is wide in such patients should include, foreign body, rhinolith, bony sequestration and even neoplasm, so it is important to that these patients are carefully examine ,5,7.The use of radiological investigations can aid us in diagnosis are the ophthantogram and CT paranasal sinuses, such investigation could actually show a radiopaque mass and in some cases can even confirm the diagnosis which was the case with our patient ,3.Prompt treatment is important because the supernumerary tooth may cause considerable pain and discomfort to the patient, it presence in the nasal cavity will lead to inflammation which may possible cause further nasal mucosa injury, epistaxis, sinusitis, septal abscesses and even oro-nasal fistulas .Treatment is extraction of the tooth, it is usually done by endoscopic view trans-nasal, care must be take to remove the tooth completely and carefully as it wise to avoid further mucosal injury, this could be done in the clinic under local anesthesia if the patient is co-operative or in the operating theatre under general anesthesia, other methods of tooth extraction describe in the literature would be the trans-palatal approach but it is not favored due to the fact that the trans nasal approach offer better visualization and causes much less post-operative morbidity ,11,12. O4Supernumerary tooth is a rare condition, often causes significant distress to patients and often misdiagnosed in a clinical setting. A thorough history physical examination including the anterior rhinoscopy and nasal endoscopy needs to be done for all patients. Further radiological investigations such as CT scan of the paranasal can aid and help confirm the diagnosis. The most common treatment is usually trans nasal endoscopic removal of the tooth.5•Intranasal supernumerary tooth is a rare finding which is only present in 0.1% to 3.5% of the population•The symptoms are unspecific and commonly misdiagnosed due to the wide list of differential diagnosis•The use of radiology such as CT and paranormic X-ray is beneficial in diagnosis of supernumerary tooth•Prompt treatment is important due to further complications that can caused by it.•Trans-nasal endoscopic approach is the most common surgical approach to treat supernumerary tooth casesThe authors state that they have no conflicts of interest for this report.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This case report is exempt from ethical approval at our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not Applicable.Professor Hesam Yusuf Ali.Not commissioned, externally peer-reviewed.Ahmed Khalid Ahmed: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Resources. Hasan Alansari: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Abdulrahman Almannai: Conceptualization, Data curation, Formal analysis, Validation, Visualization, Writing - original draft, Writing - review & editing. Hesam Yusuf Ali: Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing.


The Borst–Jadassohn phenomenon is a morphological finding that consists of the presence of well-defined nests of cells located in the spiny stratum of an acanthotic epidermis. One of the neoplasms where this phenomenon is found is hidroacanthoma simplex. This neoplasm is considered the intraepidermal form of the eccrine poroma. Despite its benign nature, malignant transformations are reported. The present article reports a case of hidroacanthoma simplex and discusses the dermoscopy of this phenomenon. The Borst–Jadassohn phenomenon is a morphological finding that consists of the presence of well-defined nests of cells located in the spiny stratum of an acanthotic epidermis. Some neoplasms, whether malignant or benign, may present this phenomenon, like as clonal seborrheic keratosis (SK), clonal Bowen's disease (BD), Paget's disease, porocarcinoma, or hidroacanthoma simplex (HS).The distinction between these entities, both clinically and histopathologically, is sometimes a challenge. This fact can have consequences since the approach of each one is different. The dermatoscopy of the Borst–Jadassohn phenomenon has been little reported, thus it is worthwhile to describe it in HS.An 88-year-old male patient sought the Dermatology Service complaining of an asymptomatic lesion in the right gluteal region, with an unknown time of evolution.At the dermatological examination, a slightly elevated pink plaque with irregular borders was evident, but with a small area of exulceration . DermoscAn incisional biopsy was performed with diagnostic hypotheses of seborrheic keratosis or Bowen's disease. Histopathology showed basaloid clones without atypia, in the middle of spinous cells . PossibiIn the early 20th century, Borst and Jadassohn independently described neoplasms characterized by well-demarcated cell nests located in the epidermis. Believing them to be a specific type of tumor, the name intraepithelial epithelioma of Borst–Jadassohn was coined. From the morphological and immunohistochemical studies, the majority of the authors nowadays believe that this entity represents a morphological phenomenon, rather than being specific to a certain neoplasia. Therefore, it is preferred to designate it as the Borst–Jadassohn phenomenon (BJP). This phenomenon is characterized as the presence of well-defined islands of epithelial cells, typical or atypical, within an acanthotic epidermis, and can be evidenced in some benign or malignant conditions.One of the neoplasms where BJP is found is the hidroacanthoma simplex. This neoplasm is considered the intraepidermal form of the eccrine poroma.Clinically, it is often mistaken for SK. This confusion may persist in histopathology and the initial diagnosis of clonal SK is not infrequent. There is a well-circumscribed intraepithelial proliferation of rounded and basophilic cells, very similar to what occurs in clonal SK that presents BJP. In the immunohistochemistry, the positivity for CEA and EMA in the cases of HS aid in the differentiation.Shiiya C et al. described four cases of HS and discussed the main dermatoscopic changes, with the central aim of distinguishing it from Bowen's disease and SK.In the case reported, dotted vessels distributed in circle around rounded brown structures were observed. They represent, in the correlation of dermatoscopy with histopathology, proliferation of venules near the clonal cell blocks. Dotted vessels, when in non-melanocytic lesions, are non-specific, but the pattern found in the lesion described may be peculiar.Although hematoxylin and eosin staining did not show the presence of pigment, when the Fontana-Masson staining was used, a great amount of melanin was observed in the blocks .Figure 5In conclusion, the present study contributes to review concepts of BJP to describe the dermatoscopic alterations of this phenomenon in HS, one of the main tumors in which it develops.None declared.Bruno de Castro e Souza: Conception and planning of the study; composition of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature.Maria Cláudia Alves Luce: Composition of the manuscript; critical review of the literature.Thais do Amaral Carneiro Cunha: Approval of the final version of the manuscript; conception and planning of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature.Neusa Yuriko Sakai Valente: Participation in the design of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.None declared.