Schwannomas, originating from Schwann cells surrounding nerve sheaths, tend to be slow-growing. Among these, giant ancient schwannomas are remarkable for their rare occurrence and their capacity for substantial growth and regressive changes. Furthermore, the expansiveness and flexibility of the retroperitoneal space often conceal the symptoms of retroperitoneal schwannomas, leading to delayed diagnosis and allowing these tumors to grow significantly and become large and long-standing before detection.A 24-year-old man presented with left flank pain and a growing abdominal bulge in the left upper quadrant. Computed tomography scan revealed a 15×15×10 cm lytic expansile lesion. Consequently, the encapsulated mass was surgically excised and diagnosed as an ancient retroperitoneal schwannoma through histological and immunohistochemical studies.Comprehensive preoperative planning and a multidisciplinary strategy are imperative for the complete excision of schwannomas. These tumors can present diagnostic complexities, particularly due to nuclear atypia and pleomorphism, which might lead to misinterpretation regarding malignancy. Despite the risks associated with percutaneous biopsies, the low mitotic count is a critical diagnostic factor. Our study underscores the consensus that the definitive diagnosis should rely on postoperative histopathological findings, highlighting the importance of accurate assessment.Rare giant retroperitoneal ancient schwannomas pose diagnostic challenges due to their rarity, lack of distinct symptoms, and atypical locations. This study presents a successful case and management. HighlightsRetroperitoneal schwannomas are rarely encountered tumors, making up around 1–3% of the total cases of schwannomas.The diagnosis of rare giant retroperitoneal ancient schwannomas is complex due to their infrequency, absence of clear symptoms, and uncommon locations.The main approach involves a complete surgical excision to preserve neurological function and reduce postoperative complications.Nuclear changes and pleomorphism in these tumors can lead to the misdiagnosis of malignancy. The low mitotic count is vital for accurate assessment in such cases.A confirmed ancient retroperitoneal schwannoma, measuring 15×15×10 cm, was completely excised from a 24-year-old man.1. These tumors are predominantly benign in nature, but it is worth noting that malignant forms have been documented in up to 60% of individuals with Von Recklinghausen’s disease (Neurofibromatosis type 1)2. Giant solitary schwannomas are uncommon and can vary in size3. They are characterized by their involvement of two or more adjacent spinal levels or their size exceeding 2.5 cm in the largest dimension. Regarding clinical presentation, schwannomas display nonspecific symptoms, with patients experiencing localized pain and pressure-related symptoms in the advanced delayed tumor detection4.Schwannomas, derived from Schwann cells within nerve sheaths, are tumors that grow slowly over time and typically do not exhibit any symptoms5.Ancient schwannomas, a unique tumor subtype, are characterized by their remarkable growth and frequent regressive changes, including fatty degeneration, cyst development, and hemorrhage. These distinctive features differentiate them from other tumor types6.Retroperitoneal schwannomas (RSs) are infrequent. They often go unnoticed due to the expansive and flexible nature of the retroperitoneal space, leading to delayed diagnosis and significant lesion growth8. Due to their rare occurrence, lack of specific manifestations, and involvement of unusual sites, they pose a significant challenge for diagnosis. Therefore, this paper aims to report a rare giant retroperitoneal ancient schwannoma case and detail its successful management. This work has been reported in line with the Surgical CAse REport (SCARE) criteria9.The primary treatment strategy involves surgical removal, which can be achieved through either traditional open procedures or minimally invasive laparoscopy, typically resulting in favorable therapeutic outcomes. This process requires comprehensive preoperative planning and a multidisciplinary approach due to the intricate nature of both diagnosis and treatmentA 24-year-old man was admitted to our hospital with a 1-year history of abdominal bulging in his left upper quadrant and a progressive enlargement over the previous several weeks. The patient reported the bulging as painless and denied other symptoms like nausea, vomiting, or changes in bowel habits, with the exception of occasional flank pain. He had no personal or family history of malignancy. The physical examination showed a pulse of 88 beats per minute, body temperature of 37.2°C, respiration of 20 breaths per minute, and a blood pressure of 110/90 mmHg.Upon palpation, a substantial mass was detected below the patient’s left lower ribs. His laboratory tests were in the normal range except for a slight leukocytosis. Abdominal ultrasonography revealed an irregularly shaped echo, measuring 121×66 mm, located posterior to the left kidney. Color Doppler imaging displayed vascularity associated with the mass. A computed tomography (CT) scan identified a lytic expansile lesion in the vicinity of the left lower ribs, characterized by multiple internal high-density areas   in the tumor cells Fig. .This comprehensive assessment led to the diagnosis of a giant ancient plexiform schwannoma. Notably, after a 2-year follow-up, the patient remained asymptomatic, and no signs of recurrence were observed.10, yet they have the potential for considerable growth. The clinical presentation is unspecific, with masses less than 5 cm often discovered incidentally. Occasionally, they can lead to lower back pain and functional disturbances in adjacent gastrointestinal and urinary organs due to compression of the neighboring organs11.RSs are unusual tumors, accounting for only 1–3% of all schwannomas13. Thus, efficient resource utilization is vital for optimizing surgical outcomes. Table Giant RSs are distinctive due to their rarity and the complexities involved in their management. Their presentation often includes various possible differential diagnoses, such as paraganglioma and pheochromocytoma, alongside conditions like fibrosarcoma, liposarcoma, and ganglioneuroma. The primary treatment encompasses complete surgical removal while preserving neurological function and minimizing postoperative complications. Preoperative evaluation is crucial, including lab and radiological exams. Complex tumor extensions require a multidisciplinary team of experts from diverse medical specialties, including surgeons, pathologists, radiologists, and oncologists, to collaborate and ensure effective case management and coordination20. However, Benign schwannomas can also potentially recur, with reported rates ranging from 5 to 10%. Achieving complete radical resection of RS is challenging due to the risk of bleeding, attributed to their highly vascularized nature, as well as the potential adhesion to retroperitoneal vessels21.Schwannoma recurrences after resection are considered unfavorable. They often occur due to atypical histopathological evidence 18. This unique subtype of schwannoma, known as ʻancient schwannomaʼ, was first described by Ackerman and Taylor. It is characterized by long-standing schwannomas with reduced Antoni A regions and increased hypocellular areas22.Schwannomas are solitary, encapsulated tumors with a firm texture, smooth surface, and gray color. Histologically, these tumors feature elongated spindle cells forming both hypercellular Antoni A areas characterized by twisted nuclei and Verocay bodies, as well as hypocellular Antoni B regions containing inflammatory cells, collagen bundles, xanthomatous changes, and irregular vessels. Ancient schwannomas, although rare, can exhibit degenerative changes like hemorrhage, cyst formation, and hyalinization. The key to their diagnosis is the prominent and widespread staining of S-100 protein in the tumor cells17.Ancient schwannomas have been documented in the literature with various accompanying changes, including hyalinization, calcification, necrosis, hemorrhage, cystic formation, fatty degeneration, and infiltration by siderophages and histiocytes to varying extents. These alterations are believed to result from the tumor’s aging process. Occasionally, nuclear atypia and pleomorphism in these tumors can lead to the misdiagnosis of malignancy. In such cases, the low mitotic count is critical for accurate assessment14.Preoperative identification of RS presents a significant challenge. Conventional imaging methods such as CT, MRI, and ultrasound lack specific features, making the diagnostic process intricate. Among them, abdominal MRI is the preferred choice due to its heightened diagnostic precision compared to ultrasound and CT scans. However, it is worth noting that accurately identifying RS preoperatively remains a challenge, with less than 20% of cases achieving definite diagnoses. Additionally, core needle biopsies may yield inconclusive or misleading results, especially for ancient and cystic schwannomas16.In the patient’s case, the attempt at a definitive diagnosis through an ultrasound-guided biopsy proved unsuccessful due to insufficient tissue for subsequent immunohistochemical analysis. It is imperative to note that percutaneous biopsies carry inherent risks, including the potential for infection, hemorrhage, and the inadvertent seeding of tumor cells. Additionally, the presence of cellular pleomorphism in degenerated regions may sometimes lead to misinterpretation as malignancy. Hence, this study underscores the consensus that the ultimate diagnosis should primarily rely on the findings derived from the postoperative histopathological examinationThis unique case of a giant ancient plexiform retroperitoneal schwannoma highlights the complexity of this rare condition. A careful assessment for mitotic activity is necessary for this benign tumor variant. Our findings contribute to the existing knowledge regarding this distinct tumor entity’s successful treatment and clinical behavior. Further research and reporting will improve diagnostic capabilities and refine management strategies for ancient schwannoma patients.The institutional board review at Guilan University of Medical Sciences granted approval for the study is available upon request from the corresponding author .Written informed consent was obtained from the patient to publish this case report and accompanying images. A copy of written consent is available for review by the Editor-in-Chief of this journal on request.None.All authors contributed equally.The authors declare that they have no competing interests.researchregistry9404.https://www.researchregistry.com/browse-the-registry#home/.Elahe.abbaspourmd@gmail.com Orcid ID: 0000-0002-7387-8223.Elahe Abbaspour, Poursina Hospital, Rasht 41937 13194, Iran. E-mail: The data used to support the findings of this case report are available from the corresponding author upon request. Anonymized and aggregated data that do not compromise patient confidentiality can be made available to researchers for further analysis upon request and appropriate ethical approvals.Not invited.


Molecular genetic testing confirmed a de novo heterozygous pathogenic variant in TCS2. The patient was commenced on everolimus and has had no complications.A 32-year-old man with a known diagnosis of tuberous sclerosis presented with early satiety and abdominal discomfort. Investigations revealed multiple large angiomyolipoma arising from and surrounding both kidneys. Axial and coronal true fast imaging with steady state precession magnetic resonance imaging (MRI) scans  showed tAngiomyolipomas are a common feature of tuberous sclerosis, occurring in 60–80% of patients  and are


Glioblastoma multiforme (GBM) is an aggressive primary brain tumor that primarily affects adults, with cases in children being extremely rare. Gross total resection with subsequent irradiation and temozolomide, currently delivering the greatest overall survival, is the mainstay of therapy for juvenile GBM. Maximal surgical excision of the visible tumor mass has been shown to have a positive prognostic effect, but radiation concerns for growing brains and inconsistent results from different chemotherapy regimens in pediatric GBM make treatment choices for young patients challenging. Here, we report a case of GBM in an 11-year-old female child who presented with a dramatic presentation of neurologic deficits and clinical worsening due to rapid tumor growth. Pediatric central nervous system (CNS) tumors are the most prevalent solid tumors in children and the second most common childhood cancer after leukemias. Tumors of glial origin, such as glioblastoma multiforme (GBM), are more common in older patients, whereas tumors of embryonal origin, such as medulloblastoma, are more common in younger children. Of note, only 3-15% of primary CNS tumors in children are GBMs . NaturalAn initially healthy 11-year-old girl, displaying typical neuro-psychomotor development, was admitted to the hospital due to a sudden onset of hemiparesis and disorientation that had persisted for 15 days. Left-sided hemiparesis was evident with 3/5 power in the left upper and lower limbs. Her other general and systemic examinations were unremarkable. Her laboratory investigations were within normal limits.A skull CT scan revealed an irregularly shaped, deep-seated expansive lesion located on the right side of her brain. The lesion exhibited peripheral contrast enhancement and obstruction to the flow of the cerebrospinal fluid (CSF), as evident in Figure Surprisingly, histopathological examination revealed a pleomorphic neoplasm, accompanied by vascular neoformation, and areas of necrosis. The tumor cells displayed elongated morphology with hyperchromatic, pleomorphic nuclei exhibiting atypia and mitotic figures. Immunohistochemistry analysis Table  demonstrThe parents were informed of their daughter’s initial diagnosis. They did not expect this diagnosis, so they signed the Against Medical Advice (AMA) paper. We suggested surgical resection of the tumor; however, they denied the procedure. After a month, the girl’s symptoms increased and they returned to our center. Again, this time they did not consent to the surgery, but we at least persuaded the parents to proceed with steroid administration. The patient exhibited improved consciousness levels following steroid administration, but her motor function remained compromised. Consequently, she was referred for radiotherapy. However, after 40 days, a significant neurological deterioration occurred, characterized by hemiplegia and fluctuating levels of consciousness. Subsequent skull CT and MRI scans indicated an enlargement of the lesion Figure . After cThe WHO classifies GBM as a grade IV glioma, indicating its aggressive nature and resistance to conventional treatments. In p-GBM, different molecular and outcome behaviors are observed. Though rare in children, GBM is an aggressive CNS tumor with a poor prognosis. The majority of GBM patients do not have any known risk factors or a family history of brain tumors. Rarely, tumor predisposition syndromes such as Li-Fraumeni syndrome, Lynch syndrome, or constitutional mismatch repair-deficiency syndrome develop as glioblastomas . The famThe location of the tumor and its rate of growth determines the neurological signs and symptoms of glioblastomas. Headache, seizures, and focal neurologic symptoms such as memory loss, motor weakness, visual symptoms, language deficiency, and cognitive and personality changes are the most typical presenting symptoms. The presentation can be dramatic with focal neurologic deficits without common features such as headaches and seizures, as observed in our patient. Children with GBM have acute neurological deterioration often due to intratumoral hemorrhage. This is possible in our patient. Significant edema, mass effect, and elevated intracranial pressure may all be attributed to large tumors. It is well-recognized that preoperative neurological impairments have a deleterious impact on postoperative outcomes . InfantsThe majority of p-GBM are supratentorial in location, with cerebral hemispheres accounting for around half of all cases . Some glNeuroimaging is a critical component in GBM diagnosis, therapy, and prognosis. On CT and conventional MRI sequences, these tumors appear as irregular, heterogeneous, contrast-enhancing masses with significant perilesional edema. Necrosis, bleeding, and a garland pattern of enhancement are typically seen in GBMs. The differential diagnosis typically includes disorders such as metastasis, lymphoma, brain abscess, and other illnesses. MRI provides the precise details needed for radiation and surgical planning. For deep-seated cancers that are challenging to biopsy, magnetic resonance spectroscopy frequently reveals a choline peak with reduced N-acetyl aspartate at the tumor site. On diffusion-weighted imaging (DWI), the tumor’s cellular constituents might show constrained diffusion with a low apparent diffusion coefficient. The tumor can frequently be distinguished from a brain abscess using DWI.In patients with a suspected high-grade glioma such as GBM, a tissue diagnosis is crucial. This can be done either during the surgical resection or during a separate biopsy procedure. When resection is not possible, such as in deep tumors, a significant amount of tumor tissue cannot be removed, the patient’s overall clinical condition prevents surgery, or the patient denies surgery, a biopsy alone is used. Maximal safe resection is the preferred initial strategy for both diagnosis and treatment in the remaining cases.The best current therapy for adult GBMs involves complete surgical resection followed by chemotherapy and radiation. The same principle is applied to p-GBM. According to the Children’s Cancer Group study, 945 children with high-grade glioma who received surgery to remove 90% or more of the tumor had progression-free (PFS) survival of 35 ± 7% compared to those who did not and had a five-year PFS of 17 ± 4% . HoweverHigh-dose glucocorticoids are frequently administered in patients with severe symptoms or herniation risk as they efficiently reduce cerebral edema and ameliorate neurologic deficits. As such chemotherapy regimen is not as well established in p-GBM as in adults. Trials on chemotherapeutic agents such as vincristine, carmustine, procarbazine, hydroxyurea, cisplatin, cytosine arabinoside, prednisone, and dimethyl-triazenoimidazole-carboxamide have not shown any benefit in p-GBM . AlthougThe majority of research highlights poor survival rates in p-GBM compared to adult GBM ,17, and This case report highlights the possible dramatic clinical presentation, diagnostic workup, and treatment strategies of a rare p-GBM. p-GBM can exhibit rapid growth and consequent rapid neurological deterioration with grave prognosis. This case strongly recommends prompt gross total resection of the tumor without delay. The patients should be persuaded for the same. Moreover, the report aims to contribute valuable insights into the challenges patients face during hospitalization and their subsequent clinical course, thereby enriching existing literature.Although rare, p-GBM is different from adult GBM and has a dismal prognosis. p-GBM can potentially present dramatically with much rarer symptoms, and rapid growth of such tumors is probable. The rapid growth of the tumor may be attributable to the tangle of tortuous blood vessel invasion by the aggressive tumor. Prompt surgical intervention with gross total resection of the tumor is warranted in such cases to improve long-term survival. Overall, this case report highlights the clinical presentation, diagnostic workup, and treatment strategies of a rare p-GBM.


Primary pancreatic lymphoma is a rare type of cancer, that accounts for 0.1-0.5% of lymphomas and about 0.2% of all primary pancreatic tumors. Diffuse Large B-cell Lymphoma is the most common subtype. The diagnosis is possible if the lymphoma is located in the pancreas, but the differential diagnosis with pancreatic ductal adenocarcinoma is difficult. The diagnostic accuracy of endosonography-guided fine needle aspiration is inadequate, and thus it is common to diagnose these masses only after surgical resection. The endosonography-guided tissue acquisition allows greater accuracy in the pancreatic masses, as it determines optimal access to histological analysis using tissue in paraffin blocks for complementary immunohistochemical, and molecular tests. Thus, this elaborate diagnostic environment allows the adoption of appropriate treatment strategies for patients with this condition. The authors describe four cases of primary pancreatic lymphoma indicated for surgical resection due to suspected pancreatic cancer, with the diagnosis of Diffuse Large B-cell Lymphoma obtained by endosonography-guided tissue acquisition, changing the therapeutic strategy through the adoption of adequate chemotherapy treatment with good progress. Primary pancreatic lymphoma (PPL) is a rare type of cancer, that accounts for 0.1-0.5% of lymphomas and about 0.2% of all primary pancreatic tumors (PPT) . The oveThe accuracy of the biopsy obtained by endosonography-guided fine needle aspiration (EUS-FNA) in PPL is inadequate, requiring several punctures, thus increasing the chance of adverse events . TherefoWe report four cases of DLBL indicated for surgery due to suspected imaging exams of PDA and accurately diagnosed by EUS-TA, allowing chemotherapy treatment with good evolution.Case 1A 59-year-old man with a history of hypertension was admitted to the hospital for umbilical herniorrhaphy. In the preoperative evaluation, the patient was asymptomatic. Physical examination didn’t identify palpable adenopathy and the abdomen was flaccid, painless, and without visceromegaly. The abdominal ultrasonography (US) showed a hypoechoic and irregular perisplenic nodule measuring 42 mm. The abdominal MRI identified a poorly delimited pancreatic infiltrative lesion involving the splenic artery, which extended to the pancreatic tail, measuring 39 x 29 mm, associated with multiple splenic lesions of up to 40 mm. Also, the exam showed an enlarged spleen with infarction areas and retroperitoneal lymph node enlargement on the left, both peri-aortic and intercavoaortic (33 mm). Laboratory tests were normal, including CA 19.9 = 36 U/mL , lactate dehydrogenase (LDH) = 178.3 U/L (nl= 125.00 U/L e 220.00 U/L), and carcinoembryonic antigen (CEA) = 1.8 ng/mL (nl = 3.5 ng/mL). The endoscopic ultrasound (EUS) showed a hypoechoic and heterogeneous area in the tail of the pancreas, Doppler (+), measuring 38 x 29 mm, with involvement of vascular structures. Elastography showed stiffness of the lesion. The area extended to the celiac trunk and showed a 12 mm perilesional lymph node enlargement  of 345 U/L, alanine aminotransferase (ALT) of 278 U/L, LDH = 234 U/L (nl= 125.00 U/L e 220.00 U/L), leukocytosis with a left shift and a fever of 38.1 ºC. The abdominal MRI/MRCP (magnetic resonance cholangiopancreatography) revealed a mass in the head of the pancreas with poorly defined borders and dilation of the common bile duct, associated with peripancreatic lymph node enlargement. Due to the diagnosis of cholangitis, endoscopy was indicated for drainage of the biliary tract. The endoscopic retrograde cholangiopancreatography (ERCP) showed intrapancreatic bile duct stenosis and after papillotomy it was possible to implant a fully covered self-expandable metallic stent (SEMS). Immediately after endoscopic drainage, EUS-TA was performed. The procedure revealed a heterogeneous area in the cephalic portion with imprecise limits, measuring 34 x 22 mm and in close contact with the superior mesenteric vein without invading it Figure , 2f. TheCase 3A 71-year-old woman came to the hospital due to abdominal pain radiating to the back. She underwent clinical treatment but didn’t show improvement. Complementary CT and MRI revealed the presence of a mass in the body of the pancreas measuring approximately 45 x 34 mm. Laboratory tests were normal, including LDH = 136.1 U/L (nl= 125.00 U/L e 220.00 U/L), Ca 19.9 = 27 U/mL (nl = 37 U/mL) and CEA = 0.8 ng/mL (nl = 3.5 ng/mL). EUS was indicated in this case, which showed a poorly delimited solid-cystic lesion in the body/tail transition region with adjacent anechoic areas, Doppler (-), measuring 45 x 34 mm and affecting the splenic artery. Elastography showed stiffness of the lesion , CA 19.9 = 41 U/mL (nl to 37 U/mL) and CEA = 0.5 ng/mL (nl = 3.5 ng/mL). The EUS was also indicated for this patient, which showed a solid-cystic, poorly delimited, bilobed lesion in the body/tail transition region, measuring 41 x 35 mm with adjacent anechoic areas, Doppler negative, and no vascular involvement. Elastography revealed the stiffness of the mass. The EUS-TA was performed with the ProCore 20G needle, obtaining a large amount of MC from the solid areas, about 3 mL of citrine yellow liquid, which was sent for biochemical analysis revealing a CA 19.9 = 8,000 U/mL, CEA = 87 ng/mL, amylase = 167 U/dL and glucose = 89 mg/dL. The immunohistochemical panel showed high-grade nHL (Figure Table PPL is a rare subtype of primary malignancy, consisting of <0.5% of all pancreatic cancers, usually found in men aged 35 to 75 years . Some diPPL is usually associated with nonspecific symptoms, such as jaundice, abdominal pain, and abdominal mass, rather than presenting symptoms like fever and night sweats, typical of DLBL ,14. AnotThe EUS-TA seems to improve diagnostic precision, with one or two passes of the needle through the tumor mass. In addition to being less invasive, it allows for a more accurate characterization of the lesion . In addiAs demonstrated in these cases, the histological samples of pancreatic nodes and peripancreatic lymph nodes were adequate. Consequently, it enables the diagnosis and the appropriate treatment of a PPL instead of performing surgery, which would be the correct treatment for a PDA. The good amount of collected tissue allowed the study of the tumor’s immunohistochemical panel and was also used for the FC, helping in the diagnosis ,17. In tThis diagnosis granted the recommended first-line chemotherapy protocol R-CHOP to be implemented. It consists of the monoclonal antibody rituximab, associated with cyclophosphamide, doxorubicin, vincristine, and prednisone, exhibiting a disease-free survival rate of 50 to 80% ,19. The We conclude that EUS-TA is the least invasive tool with highly effective diagnostic ability. Therefore, it should be considered when the patient presents pancreatic mass with peripancreatic lymph nodes, so that it may be possible to obtain a viable amount of tissue, thus improving the result of the anatomopathological tests. Precise histological examination is essential to distinguish a PPL from other pancreatic masses, since the treatment of PPL is conservative and based on chemotherapy, without the need for surgical resection.


Left atrial masses are rare but clinically significant findings, which can present as diverse pathological entities, including primary tumors, thrombi, and metastases. Their diverse pathological entities contribute to a wide range of clinical manifestations, often presenting with nonspecific symptoms that pose challenges for early diagnosis.Within the realm of medicine, unique presentations emphasize the intricate interplay between the size, location, and functional impact of pathological processes. They serve as reminders to healthcare providers to approach each patient as an individual, recognizing that even seemingly minor abnormalities can have significant consequences.To illustrate this, we present two distinct cases of patients with left atrial masses, showcasing the importance of clinical suspicion and a wide knowledge base in identifying and managing these conditions effectively. Left atrial masses encompass a diverse range of pathologies, including both neoplastic and non-neoplastic entities. Primary cardiac tumors are rare, with a reported frequency of 0.02% based on postmortem studies. Approximately 75% of primary tumors are benign, and 50% of benign tumors are myxomas, resulting in 75 cases of myxoma per million autopsies ,2.To accurately diagnose the origin of left atrial masses, various imaging techniques are employed, including echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI). The specific characteristics of the mass, such as its location, shape, and vascularity, along with clinical presentation and patient history, help guide the diagnosis and subsequent management, which may involve surgical removal, medical treatment, or interventions to prevent embolization or complications.We present two patients with incidentally identified left atrial masses and summarize their vastly different clinical courses.Case 1A 68-year-old asymptomatic man underwent routine CT of the abdomen and pelvis Figure  prior toSubsequent two-dimensional transthoracic echocardiogram revealed a 6 cm x 7.3 cm mass in the left atrium, consistent with a left atrial myxoma Figure . AlthougCase 2An 83-year-old female presenting to the emergency room with fatigue was admitted to the hospital for micro-atrioventricular (AV) pacemaker implantation and AV nodal ablation to treat persistent atrial fibrillation. An elective transthoracic echocardiogram  could harbor such different pathologies.Understanding the variability in clinical presentations and the unpredictable nature of disease progression is vital in providing comprehensive medical care. By remaining vigilant to both subtle and apparent manifestations, healthcare professionals can improve patient outcomes by promptly identifying and addressing medical conditions, regardless of their size or symptomatic presentation.The etiology and clinical sequelae of left atrial masses are variable but typically associated with potentially serious and life-threatening adverse events due to embolization. Initiation of surgical intervention is recommended to avoid unpredictable adverse events and improve the patient’s prognosis. Clinical suspicion serves as a crucial guidepost in medicine, prompting healthcare providers to consider potential diagnoses and pursue further investigation, even when initial findings may be ambiguous or nonspecific.Therefore, in the pursuit of providing optimal care, it is imperative to embrace the possibility of rare occurrences, even when they may appear statistically unlikely. By cultivating a mindset of openness, curiosity, and clinical suspicion, healthcare professionals can uphold their commitment to delivering comprehensive and personalized care, ensuring that no significant condition goes unnoticed or undiagnosed.


Eventration of the diaphragm is a cephalad displacement of the diaphragm because of congenital or acquired causes. The diaphragm maintains its anatomical continuity and normal attachments. It may be partial or complete and unilateral or bilateral. Most adult presentations are asymptomatic, but patients may present with respiratory, gastrointestinal, or cardiac symptoms. Surgical repair is indicated in the symptomatic patient with the most common being diaphragmatic plication. We present surgical repair of a symptomatic left diaphragmatic eventration in an octogenarian. Diaphragmatic eventration most commonly manifests in pediatric populations but is reported in adulthood as an incidental finding and because of the presence of symptoms. Diaphragmatic eventration can be described as permanent elevation of the involved diaphragm with preservation of continuity and normal attachments. Eventration can be considered paralytic (acquired) or non-paralytic  with true eventration rarely presenting in adulthood. It occurs unilaterally or bilaterally, involves all or part of the diaphragm, and more commonly involves the left hemidiaphragm with higher incidence reported in males.Surgical repair is reserved for persons with symptomatic presentation and performed via multiple techniques and approaches including thoracic and abdominal repairs. Repair has shown improvement in symptomatology and postoperative pulmonary function. In this report, we present a combined thoracic technique for repair of diaphragmatic eventration in an octogenarian.A 79-year-old male was referred by his general practitioner for consideration for repair of diaphragm eventration. The elevated left hemidiaphragm was noted on chest X-ray approximately a decade before. Referral was prompted by an episode of postprandial shortness of breath and a long-standing inability to belch. Medical history is significant for hypertension and tachyarrhythmia controlled on Flecainide. Clinical examination was remarkable for the presence of bowel sounds in the left chest at the level of the nipple, and apex beat on the right. Chest X-ray showed a markedly elevated left hemidiaphragm with dextrocardia . PulmonaRepair was performed via Video-Assisted Thoracoscopic Surgery with an 8 cm access incision and a 5 mm camera port. The central lax portion of the diaphragm was staple resected using an Ethicon stapler followed by plication of remaining redundant diaphragmatic tissue using 2/0 polypropylene running suture. Postoperative chest X-ray showed acceptable descent of the left hemidiaphragm . HospitaDiaphragmatic eventration is characterized by permanent cephalic displacement of intact diaphragm with retained continuity and attachments to the costal margins. In its congenital form, there is failure of muscular development in part or all the affected hemidiaphragm because of abnormal migration of cervical myotomes to the septum transversum and pleuroperitoneal membrane. This results in structural deficiency of diaphragmatic muscle with numerous fibrous and fibroelastic changes on microscopic examination.et al. [Prior to our index case, the oldest patient reported in the literature to have undergone surgical repair was a 75-year-old by Watanabe et al. . Gastroiet al. . Dyspneaet al. [Management of these patients is dictated by presence of symptoms and etiology. While asymptomatic patients often go untreated, there has been renewed discussion on benefits of surgical repair because of longstanding effects on PFT, chronic alveolar hypoventilation, and hypercapnia. Adults with acquired eventration undergo an observation period depending on severity of presenting symptoms prior to definitive repair because of possible improvement in phrenic nerve function. Treatment options include surgical repair by plication with or without a diaphragmatic patch or resection of the redundant segment with overlapping layered tissue repair. Nonsurgical management involves physiotherapy and pulmonary rehabilitation. Higgs et al.  reported2 insufflation for caudal displacement of intra-abdominal organs, may offer alternatives to proposed laparoscopic advantages [Surgical approaches can be thoracic or abdominal using open or minimally invasive techniques. There is little statistically significant data regarding superiority of thoracic versus abdominal approaches, particularly in adult patients. Pediatric data have shown no statistically significant difference in morbidity and mortality, recurrence, and length of hospital stay between both approaches. Choice of operative technique should be largely based on patient-specific factors. Proposed advantages of laparoscopy include larger working space, reduced risk of visceral injury, and eliminating the need for single-lung ventilation . Relativvantages . In thisProposed complications include pneumonia, pleural effusion such as described in the index case, conversion to open surgical intervention, abdominal visceral injury, pulmonary oedema, chronic pain, and rarely abdominal compartment syndrome .Surgical repair of patients presenting with symptomatic diaphragmatic eventration has shown improvement in symptomatology and pulmonary function . Despite


A 34-year-old female presented to us in the emergency room with acute abdomen since 2 days. Patient had tachycardia, fever, persistent vomiting, and complaint of not being able to pass stool for 2 days and flatus since 1 day. Per abdomen examination revealed a distended, tender abdomen with absent bowel sounds in all quadrants. X-ray erect abdomen was done which revealed multiple air fluid levels (more than 6) confirming the diagnosis of acute intestinal obstruction. Patient underwent an emergency exploratory laparotomy and was found to have a transition point from a mesodiverticular adhesion causing proximal dilatation of small bowel loop. A diagnosis of small bowel obstruction due to Meckel's diverticulum was made. Adhesion band was released, resection of Meckel's diverticulum and functional end-to-end anastomosis was performed. Meckel's diverticulum is a true diverticulum, containing all layers of the small bowel wall. It is failure of the vitelline duct to obliterate completely, which is usually located on the antimesenteric border of the ileum. It occurs in 2% of the general population and majority of patients remain asymptomatic. When it presents symptomatically it causes painless gastrointestinal bleeding. Nevertheless, in rare instances, it can cause acute intestinal obstruction as it did in our case. The average length of a Meckel´s diverticulum is 3 cm, with 90% ranging between 1 cm and 10 cm and the longest being 100 cm. Our case presents a large Meckel’s diverticulum and the size of diverticulum was 4x2cm.


Dermoid cysts are the least commonly occurring developmental cysts in the oral and maxillofacial region. They may be congenital or acquired and are seen as asymptomatic swellings that are slow and progressive. It is very difficult to differentiate plunging ranulas from plunging dermoid cysts as both of them have very similar clinical features. However, since both entities have different treatment strategies, it is important to differentiate one from the other. A 57-year-old male patient reported to the Department of Oral Medicine and Radiology with a large swelling in the submental region. To the best of our knowledge, the present case report is the first one showing such an extensive lesion of plunging dermoid cyst mimicking plunging ranula in an elderly male patient. The report mainly focuses on the diagnostic challenges faced to reach the final diagnosis. Dermoid cysts are developmental pathologies that initiate in the various organs or tissues due to the enclosure of tissues from various bases  formed by a fault in the union of the lateral embryonal mesenchymal tissues  through the fifth week of embryonal growth . It is cPlunging dermoid cysts and lateral dermoid cysts are comparatively rare entities that pose a diagnostic challenge as they usually resemble plunging ranulas in appearance . When thA 57-year-old male presented to the Department of Oral Medicine and Radiology with the chief complaint of difficulty in swallowing and change in voice for two months. The patient also had difficulty in protruding his tongue since then. He had no history of hypertension, diabetes, or cardiological, renal, hepatic, pulmonary, or thyroid problems, and was not on any medications. The family history and past dental history were also non-significant. All teeth in all four quadrants were present. They showed no findings of dental caries, fractures, or abrasion. Generalized attrition was present in almost all the teeth along with mild stains and calculus. The patient had no adverse habits of tobacco, cigarette, areca nut, or alcohol consumption. On extra-oral examination, a solitary diffuse swelling was seen below the chin in the midline Figure . It exteOn intraoral examination, a solitary swelling was seen on the midline region covering the entire floor of the mouth Figure . It had A provisional diagnosis of plunging ranula was given and lymphatic malformation, dermoid cyst, epidermoid cyst, thyroglossal duct cyst, hemangioma, benign salivary gland tumor, and cystic hygroma were considered as differential diagnosis. The patient was advised to undergo ultrasonography (USG) of the submental region to know if the lesion was vascular. In the USG, a well-defined thick-walled (2.1 mm) anechoic cystic lesion of size measuring approximately 38x46x46 mm with thick internal moving echoes and minimal peripheral vascularity was noted in the sublingual space, which was suggestive of a simple infected ranula.As further anatomic detail and connection of the lesion to surrounding structures were lacking, a computed tomography (CT) scan was advised. The CT scan showed a well-defined large hypodense lesion seen in the midline on the floor of the mouth/ root of the tongue, extending inferiorly in the submental region with a contoured bulge measuring 87x48x43 mm. The anterior portion of the lesion showed multiple fat-density areas (sack of marble appearance). The swelling seemed to displace genioglossus laterally and mylohyoid muscles inferno-laterally. The coronal and sagittal views showed a dumbbell-shaped lesion with one bulge projecting into the oral cavity and the other one below the inferior border of the mandible Figure .The axial view showed the inferior bulge as a round-shaped hypodensity with multiple fat densities in the anterior portion Figure . The supFine needle aspiration cytology (FNAC) was done, which showed abundant cyst macrophages along with scattered neutrophils and lymphocytes. The background was hemorrhagic. Occasional nucleate and anucleate squames were also seen. No malignant cells were noted. All these findings were suggestive of a benign cystic lesion.The patient underwent complete blood count, liver function, and blood sugar level  tests before undergoing the surgery. All the values were found to be within the normal limits. Complete excision of the cyst was done under general anesthesia. A mid-line incision was taken along the longitudinal ventral surface of the tongue to the floor of the mouth and by careful dissection, the cyst was separated out Figure . PostopeA single, greyish-white, soft tissue piece measuring approximately 6x3x3 cm showing clay-like pultaceous material was sent for histopathological examination. Under the hematoxylin and eosin stain (10x magnification) multiple sections of the encapsulated lesion were studied and showed soft tissue lined by keratinized stratified squamous epithelium. Underlying connective tissue stroma showed numerous thick-walled blood vessels, chronic inflammatory cells, and muscle cells. Some sections also showed multiple multi-nucleated foreign bodies like giant cells along with adipocytes and sebaceous glands. No atypical or malignant features were seen Figure . All theThe patient was followed up after one week. Reduction in the size of the swelling was noted along with some post-operative edema Figure .Dermoid cysts are typically made up of lipid material with tissue peripherally organized and fluid arranged centrally. They are benign and they rarely tend to rupture . Meyer rTrue dermoid cysts are hollows that are lined with epithelium that show keratinization and with a recognizable covering on the cystic barrier. The lining of the epidermoid cysts is with simple squamous epithelium with a fibrous barrier and no structures devoted. The teratoid cyst’s lining differs from a simple squamous one to a ciliate respiratory epithelium that contains various derivatives of endoderm, mesoderm, or ectoderm. All three histopathological variants have a thick, cheesy, keratinous, and greasy-looking material .The etiology of dermoid cysts can be typically congenital, or acquired, or it may arise from the rest of the totipotent cells that are exiled from the blastomere ,8. It inThe differential diagnoses of sublingual swellings include ranulas, thyroglossal duct cysts, cystic hygroma, lymphatic malformations, dermoid cysts, epidermoid cysts, heterotopic gastrointestinal cysts, and duplication fore-gut cysts . Ranula A similar case of submental swelling was presented by Wadhera et al. in 2019 . HoweverThe submental dermoid cyst is an extremely rare cystic lesion of the oral cavity in an elderly male. It can imitate an enormous plunging ranula in its clinical appearance. Appropriate radiographic and histopathologic evaluation is vital in making the ultimate diagnosis in such situations, as this would help specialists in the precise management of such patients. Initially, the present case was misdiagnosed as a plunging ranula. However, with proper investigations and scans, the diagnosis was confirmed to be a dermoid cyst. The close resemblance of a plunging dermoid cyst to a plunging ranula poses a diagnostic challenge for clinicians. The misdiagnosis of the lesion can lead to inefficient outcomes of the therapy and recurrence of the lesion. Therefore, it is important to carry out all the investigations sequentially to differentiate between the two entities.


Teaching Point: Osteoid osteoma is one of the most frequent benign bone tumors; however, when found in the toes it usually presents atypical clinical and radiological features including soft tissue swelling that can lead to misdiagnosis. A 20-year-old male presented with complaints of progressing swelling and mild disturbance on the tip of the second left toe, without a preceding history of trauma. No involvement of other joints or systemic manifestations were reported. A foot magnetic resonance imaging (MRI) was requested under the suspicion of soft tissue abnormality.Magnetic resonance imaging showed a pseudonodular soft tissue subungual lesion with high signal on FS-PD images and contrast uptake .Associated findings included erosive changes on the terminal tuft and surrounding soft tissue edema . A presuDermatologists performed surgical exploration of the subungual tissue, but no tumoral lesion was identified. Soft tissue samples were obtained without relevant findings.Given the absence of a definitive diagnosis and the progressive development of morphological changes in the toe, it was decided to carry on with an excisional biopsy of the distal phalanx.The patient was treated surgically, and histopathology study of the specimen showed anastomosing trabeculae of woven bone rimmed by plumb osteoblasts consistent with osteoid osteoma .Osteoid osteoma (OO) constitutes 10–12% of all benign bone tumors. It has a male predilection and usually occurs in young subjects. Patients typically present with a distinctive nocturnal pain relieved by non-steroidal anti-inflammatory medication. Radiologically, a particular feature is the presence of a cortical lucent nidus surrounded by sclerotic bony reaction [OO of the toe has a low prevalence, being more frequent on the hallux and distal phalanges. Furthermore, when this lesion is found in the phalanges it is more likely to have an endosteal or periosteal location, which determines the uncommon clinical and radiological findings.MRI studies of similar cases from literature only reported a characteristic nidus in half of them, probably because in small lesions the nidus and surrounding cortex show an indistinguishable signal intensity.Less frequent pain of the lesion can be explained by the periosteal origin and the absence of weight-bearing stress. In addition, cutaneous and vasomotor alterations are directly related to the increased release of prostaglandins from the nidus.All these clinical and radiological aspects derived from the OO in the toe phalanx must be differentiated from a wide range of conditions including infective, rheumatic, traumatic, and neoplastic circumstances . Glomus The main treatment of OO is the removal of the nidus, either with surgical resection or by percutaneous procedures such as radiofrequency ablation.


In this particular case study, we present a 66-year-old male who was diagnosed with an atrial myxoma eight years after receiving treatment for non-small cell lung cancer. The patient underwent chemo-radiotherapy  in 2012 to address stage III-A adenocarcinoma of the lung. During follow-up imaging in 2020, a left atrial mass displaying characteristic features of a cardiac myxoma was detected. Upon reviewing a computed tomographic (CT) scan from 2017 within the previously irradiated mediastinal region, the cardiac mass was retrospectively identified. The surgical excision of the cardiac mass was performed, and a subsequent pathological examination confirmed the diagnosis of myxoma. To the best of our knowledge, this is the first reported case of a left atrial myxoma in a patient previously treated for adenocarcinoma of the lung and the first instance of an atrial myxoma occurring in a site that had undergone prior radiation therapy. Primary cardiac neoplasms are exceedingly rare, occurring in less than 0.02% of individuals during their lifetime . Among tIn January 2012, a 58-year-old male with a history of type 2 diabetes mellitus and a smoking habit of 35 pack-years within the past 16 years was referred to the emergency room by his primary care physician. The patient presented with symptoms of coughing and shortness of breath. There was no previous history of cardiac or other medical conditions, and there was no family history of cancer. The patient also reported experiencing right-sided chest pain that had been persistent for three months, along with a recent weight loss of 4 kg within the last month.Upon physical examination, decreased breath sounds were noted over the right lung, while the cardiovascular examination, including electrocardiogram and auscultation, appeared normal. Routine laboratory investigations, including a complete blood count and biochemical profile, did not reveal any abnormalities. A chest radiograph displayed a ground-glass opacity in the right upper lung (RUL). As a result, the patient was admitted to the hospital for further evaluation. Subsequent chest CT scan results indicated the presence of a 3 cm mass in the RUL, accompanied by right mediastinal lymphadenopathy characterized by an enlarged node measuring 2 cm in diameter. Positron emission tomography–computed tomography (PET-CT) revealed increased metabolic activity in the RUL, specifically in the 3 cm mass, as well as other areas of uptake in the right mediastinal region and right pulmonary hilum.To ascertain the origin of the mass, a biopsy was performed under CT guidance, which confirmed histopathologic findings consistent with adenocarcinoma originating from the lung. In order to further investigate the possibility of metastatic disease, a magnetic resonance imaging (MRI) of the head was conducted, which showed no evidence of metastasis in that region.Based on clinical findings, the presumptive diagnosis was stage T1b N2 M0 (stage 3-A) non-small cell lung cancer. To address the condition, the patient underwent tumor resection through a right upper lobectomy procedure, which resulted in clear margins. Following the surgery, the recommended primary treatment was a combination of chemotherapy and radiotherapy (CRT).2 on days 1 and 8 every 21 days, along with cisplatin at a dose of 75 mg/m2 on day 1 every 21 days for a total of four cycles. Subsequently, definitive radiotherapy was performed using 3-D CT-guided treatment planning and photon treatment on a linear accelerator. The radiotherapy targeted the mediastinal area, delivering a total dose of 60 Gy in daily fractions of 2 Gy  . Later, According to our patient, eight years prior to the diagnosis of the atrial myxoma, he had undergone concurrent chemo-radiotherapy (the accepted and recommended approach for stage 3 NSCLC ), which The subsequent evaluation for suspected recurrence of lung cancer revealed the presence of an atrial myxoma within the mediastinal field that had previously received radiation treatment. This highlights the unique nature of the case, as the myxoma was detected in an area that had been subjected to prior radiation therapy.Regarding the differential diagnosis, trial myxoma can be challenging to distinguish from mural thrombi with myxoid stroma. These two conditions exhibit similar histopathological features, rendering immunohistochemistry testing ineffective in determining differentiation. However, the application of the calretinin marker, which is specific to myxomas, can aid in distinguishing them from mural myxoid thrombi. It is important to note that other malignant tumors, such as primary sarcoma, primary cardiac lymphoma, and large B-cell lymphoma, can also present as mimics of atrial myxomas .Macroscopically, atrial myxomas typically exhibit a pedunculated growth pattern and have a soft texture. Their diameter can range from 1 to 15 cm, and they may weigh between 15 and 180 g. The surface of the tumor can be smooth, villous, or friable. Villous and friable myxomas are more prone to causing embolic events, while smooth myxomas tend to be larger and present with obstructive symptoms . Atrial Atrial myxomas primarily affect females, and the peak incidence is observed between the fourth and sixth decades of life. The gender distribution is not equal, as studies indicate a female-to-male ratio of approximately 2.05:1 for left atrial myxomas and 0.75:1 for right atrial myxomas. It is worth noting that atrial myxomas are relatively rare in pediatric patients, with only a few reported cases in this age group ,21,22,23While the association between the atrial myxoma and previous radiation in this case may be coincidental, there is some basis for speculation regarding a potential correlation. It is postulated that cardiac myxoma cells could arise from adult developmental remnants that are subjected to mitogenic stimuli. Studies have suggested that radiation exposure during radiofrequency ablation for supraventricular tachycardia could slightly increase the lifetime risk of developing neoplasms . AdditioCT and MRI modalities offer advantages over transthoracic echocardiograms in the diagnosis and investigation of cardiac masses due to their unique imaging characteristics. However, it is important to note that echocardiograms remain readily available and accessible, serving as a valuable tool in the evaluation of cardiac masses ,27.To the best of our knowledge, this case represents the first reported occurrence of an atrial myxoma in a previously irradiated field. It underscores the importance of maintaining vigilance and considering the possibility of a new primary tumor, even if it is a rare occurrence, to prevent misdiagnosis as a recurrence of the original malignant disease. Proper evaluation and accurate diagnosis are essential for appropriate management and treatment decisions in such cases.


Fibrodysplasia ossificans progressiva is a progressively debilitating condition associated with significant morbidity caused by heterotopic ossification. Recognition of the early signs of hallux valgus and painful soft tissue nodules can assist in the early diagnosis of this condition. Periodic radiographic examination is mandatory to monitor the disease progression.Fibrodysplasia ossificans progressiva is a rare condition with an estimated prevalence of one in two million individuals. The condition is characterized by widespread heterotrophic ossification of skeletal muscles and ligaments. We report the case of an 8‐year‐old female patient and show the radiological progression of the condition. Fibrodysplasia ossificans progressiva (FOP) is a rare condition characterized by widespread heterotrophic ossification and is caused by a mutation in the bone morphogenetic protein (BMP) Type 1 receptor, activin receptor 1A/activin‐like kinase 2 (ACVR1/ALK2).2An 8‐year‐old female patient presented to the University of Pretoria Oral Health centre with progressive limb stiffness and loss of mobility. She was referred due to limited mouth opening and trismus. She was diagnosed with fibrodysplasia ossificans progressiva at 2 years with no other members of the family presenting with similar symptoms. Cone‐beam computed tomography (CBCT) examination revealed ossification of the medial pterygoid muscle on the right Figure  as well Previous radiographic examinations at 2 years of age, revealed calcification of muscles involving the left leg Figure , left anDue to a language barrier, limited communication was possible. No lab records of any blood tests could be traced and the patient was lost to follow‐up.3Fibrodysplasia ossificans progressiva is extremely rare with an estimated prevalence of one in two million individuals.In most cases, the clinical and radiological signs are diagnostic for FOP but genetic testing can be performed. An increased alkaline phosphatase level can also be detected.Treatment guidelines have still not been established as biopsy or surgical intervention often leads to the progression in ossification. Non‐interventional treatment consisting of avoidance of trauma, physiotherapy in combination with non‐steroidal anti‐inflammatory or cyclo‐oxygenase inhibitors during flare‐up episodes, has been advocated.Chané Smit: Conceptualization; investigation; methodology; writing – original draft. André Uys: Conceptualization; investigation; methodology; writing – review and editing.This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.The authors declare that they have no conflict of interest.This study was approved by the University of Pretoria, Faculty of Health Sciences Research Ethics Committee (Reference no.: 139/2022). All procedures followed the ethical standards of the Helsinki Declaration of 1975, as revised in 2008.The written patient consent has been signed and collected in accordance with the journal's patient consent policy.


The mesentery is a broad fan-shaped fold of peritoneum that suspends the loops of small intestine from the posterior abdominal wall. Although primary neoplasms arising in the mesentery are rare, the mesentery is a major avenue for the dissemination of tumours, which can spread through hematogenous, lymphatic, direct or peritoneal seeding. Imaging helps in the diagnosis of these tumours and aids in directing appropriate treatment by assessing their size, extent and relationship with adjacent structures. The aim of this article is to describe the spectrum of imaging findings of the various mesenteric lesions using ultrasound and CT.Evaluation of the mesentery is often neglected during routine ultrasound (US) because of inadequate training and unfamiliarity with the common US features encountered with mesenteric disease. CT plays an essential role in the diagnosis of mesenteric disease. Knowledge of imaging characteristics of various mesenteric lesions helps in timely diagnosis and management. The mesentery is a broad, fan-shaped fold of peritoneum that suspends the loops of small intestine from the posterior abdominal wall. Secondary involvement of the mesentery from tumours elsewhere is much more common than primary mesenteric neoplasms such as desmoid tumour, inflammatory myofibroblastic tumour (IMFT), and others. Most patients with mesenteric lesions present with non-specific symptoms of abdominal pain, tenderness, palpable abdominal swelling, abdominal distension and weight loss. These symptoms are shared by pathologies of other abdominal organs and it is therefore very difficult to identify mesenteric lesions clinically.Some mesenteric diseases present with distinctive imaging findings while others have similar findings, thereby complicating their differential diagnosis. Understanding the characteristic radiological patterns on ultrasound (USG) and CT offers valuable insights for differential diagnoses of mesenteric lesions and their treatment.Primary mesenteric solid neoplasms are rare and the majority of them are benign.1 On USG, this tumour appears as a well-defined or ill-defined mass with heterogenous echotexture and internal vascularity. On CT, it appears as a well-defined or ill-defined mass showing heterogenous enhancement usually in the portal venous phase and it may infiltrate the adjacent organs.2 The MRI appearance of desmoid tumours depends on the relative proportion of cellular, myxoid and fibrous components.The most common soft tissue lesion in the mesentery is a desmoid tumour. It usually occurs in patients with familial adenomatous polyposis (FAP) or Gardner syndrome. Trauma or surgery serves as a predisposing factor for the development of desmoid tumours.3 Inflammatory myofibroblastic tumour appears as a hypo or iso-attenuating mass compared with skeletal muscle depending on the amount of myxoid or collagenous stroma, respectively. Dense central calcification may be noticed. They demonstrate various contrast enhancement patterns including early peripheral enhancement because of vascular tissue , associated soft tissue component and thick irregular septations. Liposarcomas are rare malignant tumours of the mesentery. Liposarcomas are divided into five types histopathologically: well-differentiated, myxoid, pleomorphic, round cell and de-differentiated liposarcoma. Well-differentiated liposarcomas have mixed fatty and soft tissue components while de-differentiated liposarcomas have clearly separated soft tissue and fatty components. Myxoid liposarcomas have fluid density on CT with mixed soft tissue and fatty components. Pleomorphic and round cell liposarcomas have soft tissue components only, with no identifiable fatty component on imaging.5Three patterns of mesenteric involvement have been described for Castleman disease, namely a solitary non-invasive mass (most common), a dominant infiltrative mass with associated lymphadenopathy and matted lymphadenopathy without a dominant mass. These tumours show early, homogenous and intense enhancement . Tumours6  is seen as one or more irregular fibrotic soft tissue mesenteric masses10 They show variable attenuation depending on their contents  and may insinuate between the mesenteric vessels  on USG and as a unilocular or multilocular cyst with enhancement of the wall or septations on contrast enhanced CT. vessels .11These appear as thin-walled anechoic unilocular cysts with posterior acoustic enhancement on USG and unilocular fluid attenuation lesions with no discernible wall on CT.2 They occur because of entrapment of fluid (secreted by the ovaries during ovulation) between peritoneal adhesions.7 They are seen as a fluid attenuation multilocular cystic lesion, multiple unilocular thin-walled cysts or unilocular cystic mass on CT with enhancing but non-calcified septa, which often surround the ovaries. On USG, they appear as unilocular or multilocular cystic lesions, which may be anechoic or may display contents of variable echogenicity  and demonstrate homogeneous enhancement following contrast administration . Other findings observed in cases of abdominal tuberculosis include mesenteric nodularity, fat stranding, peritoneal thickening, localised collections, free fluid, clumping of bowel loops, bowel wall thickening and solid organ involvement in the form of hepatomegaly, splenomegaly, liver and splenic granulomas.Tropheryma whipplei. On imaging, small bowel wall thickening associated with enlarged mesenteric lymph nodes demonstrating hypoattenuating centres because of fat deposition can be seen. Diagnosis is made by small intestinal mucosal biopsy.16It is an infectious condition caused by Gram-positive bacterium, Actinomyces israelii is an anaerobic Gram-positive bacterium and is a normal inhabitant of the oral cavity, gastrointestinal tract and female genital tract. It spreads to involve the mesentery when a mucosal breach is present such as inflammation, surgery, trauma or intrauterine contraceptive device (IUCD) use.17 On imaging, an ill-defined heterogeneously enhancing soft tissue mass infiltrating the mesentery and adjacent organs can be seen. Septic embolism leading to hepatic, renal and splenic abscesses can occur.2 Diagnosis is made based on aggressive imaging features and subtle clinical symptoms in predisposed individuals. Biopsy should be performed in indeterminate imaging findings, which reveal sulphur granules representing bacterial colonies.18These usually occur because of intraperitoneal rupture of liver or splenic hydatid cysts . HydatidMesenteric changes in inflammatory bowel disease include mesenteric fibrofatty proliferation, mesenteric lymphadenopathy, fat stranding , abscess19 (Findings in acute mesenteric ischaemia related to superior mesenteric artery (SMA) thrombosis include dilated bowel loops with paper-thin walls, pneumatosis intestinalis, air within mesenteric vessels, mesenteric fat stranding and free fluid on CECT19 .On USG, tangled serpentine vessels can be seen, which show pulsatile waveforms on spectral doppler while on CECT, tangled serpentine vessels can be seen with early opacification of venous channels in the arterial phase. Direct communication between branches of the SMA and superior mesenteric vein (SMV) can be visualised on volume rendering technique (VRT) images.20 Evaluation of lesions is limited on USG because of operator-dependence, obscuration of the mass in the presence of a gaseous abdomen and obese patients, and inadequate visualisation of the extent of large mesenteric lesions. Contrast enhanced CT is the primary workhorse for evaluation of mesenteric lesions. It helps in determining the origin of the lesions, providing thoughtful differential diagnosis of masses, for selecting the site of biopsy, determining the extent of pathology and accessibility for resectability of lesion. CT, however, has several limitations including poor soft tissue contrast resolution, exposure to ionising radiation and contrast reactions. MRI can be used as the next step in characterising mesenteric lesions. It has higher soft tissue contrast resolution and helps in characterising fluid content of cysts as serous, mucinous, chylous or haemorrhagic and the soft tissue component of solid lesions. Fluoro-deoxyglucose (FDG) positron emission tomography (PET) CT is presently used to detect lymph nodes and distant metastases in mesenteric tumours and also for response assessment to chemotherapy.Ultrasound is the primary imaging modality in the evaluation of mesenteric lesions. It helps in characterising mesenteric lesions as solid or cystic. Ultrasound guided percutaneous biopsy offers real time assessment of the needle tract to avoid vascular injury while performing biopsy.21Management of mesenteric lesions depends on symptoms and imaging findings. Mesenteric lesions detected incidentally on imaging need classification as benign or malignant. Definite diagnosis of a few pathologies such as mesenteric panniculitis, lymphoma, desmoid tumour in patients with FAP and benign cystic lesions can be made on imaging. However, lesions with indeterminate imaging findings need to be biopsied to rule out malignancy. Imaging helps in determining the site for percutaneous biopsy in such tumours. Lesions that are inaccessible to percutaneous biopsy or show indeterminate histopathology findings on percutaneous biopsy require surgical biopsy to confirm the diagnosis.Once confirmed by biopsy, management of the mesenteric lesions depends on the histopathology. Lymphomas and desmoid tumours are managed conservatively with chemotherapy and hormonal therapy or imatinib, respectively. Well-circumscribed lesions located in the periphery of the mesentery can be resected completely, without sacrificing significant bowel length or major mesenteric vessels. Infiltrative mesenteric lesions, located in the root of mesentery are usually managed conservatively because of involvement of major vessels and the need for sacrificing a major portion of bowel, which may lead to small bowel syndrome. Well-defined malignant tumours and symptomatic benign tumours are treated surgically. The goal of surgery is R0 resection , while R1 resection followed by adjuvant chemoradiotherapy can also be performed. Well-defined asymptomatic benign lesions can be followed up and resection is performed when they become large or cause symptoms. Symptomatic infiltrative benign or malignant lesions can be managed by debulking surgery to reduce tumour load and prevent complications such as bowel obstruction or mesenteric ischemia.Although histopathology is the gold standard for diagnosis of mesenteric lesions, imaging plays an important role in diagnosis of mesenteric neoplasms, detection of complications and in deciding appropriate treatment options. Ultrasound is inadequate for optimal visualisation of mesenteric neoplasms and in detecting their relation with other structures because of shadowing from bowel gas, calcification or inadequate penetration of sound beams in obese patients. CT is an excellent imaging modality in the characterisation of mesenteric lesions, detecting their extent and relations with surrounding structures, which is useful for surgical planning. However, CT too has several limitations and other imaging modalities such as MRI and FDG-PET can be helpful in further characterisation of mesenteric lesions.


This report aimed to present a case of wrist-tendon rupture and to discuss a rare complication after corticosteroid injection. A 67-year-old woman had difficulty extending her left-thumb interphalangeal joint several weeks after a palpation-guided local corticosteroid injection. Passive motions remained intact without sensory abnormalities. Ultrasound examination showed hyperechoic tissues at the site of the extensor pollicis longus (EPL) tendon at the wrist level and an atrophic EPL muscle stump at the forearm level. Dynamic imaging demonstrated no motion in the EPL muscle during passive thumb flexion/extension. The diagnosis of complete EPL rupture, possibly due to inadvertent intratendinous corticosteroid injection, was therefore confirmed. This report aimed to present a case of wrist-tendon rupture and to discuss a rare complication after corticosteroid injection. A 67-year-old female complained of difficulty in extending the left thumb for several months. The medical history comprised radial wrist pain after a contusion injury one year ago, for which corticosteroid injection under palpation guidance had also been performed, with gradual symptom relief. The physical examination revealed loss of the active extension of the left-thumb interphalangeal joint with normal passive motions . Other fThe posterior interosseous nerve (PIN) remained bilaterally intact based on dynamic tracking from the level of the supinator tunnel to the dorsal wrist . Moving Finger drop can ensue due to neurological and orthopedic causes . In caseStatic ultrasound examination can serve as a helpful tool for scrutinizing tendon injury, whereas dynamic imaging can be employed to validate motion problems. The most common sonographic finding of tendon rupture is loss of fiber continuity with the formation of a retracted stump. The absence of normal tendon gliding during passive motion further confirms the diagnosis . In chroOne of the important etiologies of spontaneous EPL tendon rupture is intratendinous corticosteroid injection. Other causes include distal radial fracture, repetitive friction against metal implants, and contusions . Local cNeedless to say, ultrasound is a preferred tool for guiding the needle, in order to avoid unwanted intratendinous corticosteroid injection ,17. Peri


Gastrointestinal neuroendocrine tumors, although relatively rare, are one of the most common appendiceal neoplasms. Patient symptoms can range from asymptomatic to acute appendicitis, and these tumors are often diagnosed after histopathological evaluation. This case series describes five separate cases of appendiceal neuroendocrine tumors diagnosed by histopathological review following incidental appendectomy during benign gynecologic laparoscopic surgeries at a single multispecialty group. Each case had a preoperative diagnosis of chronic pelvic pain. Intraoperatively, the appendix appeared scarred, adhered, or nodular. Two patients required a right laparoscopic hemicolectomy for the management of the appendiceal neuroendocrine tumor. As a result of these findings, it is recommended that the appendix be routinely evaluated during gynecologic surgeries and, if abnormal in appearance, appendectomy should be performed. Additionally, laparoscopic gynecologic surgeons should receive appendectomy training to aid with the early diagnosis and treatment of appendiceal neuroendocrine tumors. Gastrointestinal neuroendocrine (carcinoid) tumors are relatively uncommon. However, neuroendocrine tumors are one of the most common neoplasms of the appendix with an incidence ranging from 0.3% to 0.9% . AppendiThis case series describes five separate cases of appendiceal neuroendocrine tumors diagnosed by histopathological review following incidental appendectomy during benign gynecologic laparoscopic surgeries. This retrospective chart review was conducted between January 2011 and January 2022 at a large multispecialty group  with four minimally invasive gynecologic surgeons (MIGS) certified to perform appendectomies. This article was previously presented as a meeting abstract at the Society for Gynecologic Surgeons Annual Scientific Meeting in Tucson, AZ from March 19-22, 2023.Case 1A 32-year-old nulliparous Caucasian female with chronic pelvic pain (CPP) and endometriosis was managed by benign gynecology for over ten years for dysmenorrhea, bowel and bladder discomfort, and dull pelvic pain. She had a history of sexual abuse, post-traumatic stress disorder (PTSD), and asthma. For her CPP, she tried non-steroidal anti-inflammatory drugs (NSAIDs), oral contraceptive pills (OCPs), an etonogestrel/ethinyl estradiol vaginal ring, oral tetrahydrocannabinol (THC), topical cannabidiol (CBD), physical therapy, hydromorphone, eye movement desensitization and reprocessing (EMDR) trauma therapy, and leuprolide acetate. Preoperative transvaginal ultrasound detailed a normal uterus and ovaries bilaterally, and an abdominal and pelvic computerized tomography (CT) scan showed a normal appendix. She was offered surgical management for her CPP and underwent a total laparoscopic hysterectomy, bilateral salpingectomy, endometriosis excision, and concurrent appendectomy due to an erythematous and irritated scar at the appendiceal base. Intraoperative findings were notable for endometrial implants along the peritoneum and left ovary, nodular scarring in the posterior cul-de-sac, and a globular uterus. Pathology was remarkable for endometriosis and a well-differentiated appendiceal neuroendocrine carcinoma measuring 0.3 centimeters (cm) that invaded the submucosa with negative margins. The ANET was assigned Stage I (pT1) and there was no indication for further appendiceal surveillance. She remained on OCPs for Stage II endometriosis suppression and had no postoperative complications.Case 2A 29-year-old nulliparous Caucasian female with CPP and a suspected right ovarian mature teratoma developed right lower quadrant dull aching and cramping following abdominal trauma at work. She denied dyspareunia and urinary or bowel symptoms. She was previously diagnosed with papillary thyroid cancer and had resultant post-thyroidectomy hypothyroidism. She also used tobacco products daily. She did not attempt medical treatments prior to surgery. A preoperative transvaginal ultrasound and an abdominal and pelvic CT scan demonstrated a six-centimeter circumferential suspected mature teratoma and normal appendix Figure . She proCase 3A 21-year-old nulliparous Caucasian female was managed by benign gynecology for three years of generalized CPP, right lower quadrant pain, heavy menstrual bleeding, dysmenorrhea, and abdominal bloating. She denied dyspareunia and urinary or bowel symptoms. Her history was remarkable for iron-deficiency anemia, asthma, and low back pain. For the management of her CPP, she had previously tried NSAIDs, OCPs, Naproxen, THC, and pelvic floor physical therapy. Preoperative abdominal and pelvic CT detailed a normal appendix. She underwent an uncomplicated diagnostic laparoscopy, radical peritonectomy, bilateral uterosacral ligament excision, levonorgestrel intrauterine device insertion, and incidental laparoscopic appendectomy due to a scarred appendix. Intraoperative findings included endometrial implants along the peritoneum, right ovary, and uterosacral ligaments consistent with Stage III endometriosis, sigmoid colon adherent to the left pelvic sidewall, and normal-appearing uterus. Pathology was remarkable for endometriosis and a well-differentiated appendiceal neuroendocrine carcinoma measuring 0.4 cm that invaded the muscular wall of the appendix with negative margins. The ANET was assigned Stage I (pT1a) and there was no indication for further appendiceal surveillance. She had an uncomplicated postoperative recovery.Case 4A 41-year-old Caucasian Gravida 3 Para 2012 (G3P2012) female was managed by benign gynecology for dysmenorrhea, heavy menstrual bleeding despite megestrol and OCPs, and suspected endometriosis. She denied dyspareunia and bowel or bladder symptoms. Her history was remarkable for a major depressive disorder, alcohol dependence, pancreatitis, fatty liver, and a thyroid nodule. Preoperative transvaginal ultrasound showed a retroflexed uterus with normal bilateral ovaries and physiologic free fluid. She underwent an uncomplicated total laparoscopic hysterectomy, bilateral salpingectomy, bilateral ureterolysis, cystoscopy, and incidental laparoscopic appendectomy via the vaginal orifice for a nodular appendix with thickened and indurated areas (Figure Case 5A 23-year-old African American G1P1 female was managed by benign gynecology for five years of CPP and dysmenorrhea for which she had tried OCPs. She denied dyspareunia and urinary or bowel symptoms. She also had a history of chlamydia infection, migraines, and major depressive disorder. Preoperative transvaginal ultrasound detailed a normal uterus with a two-centimeter suspected hemorrhagic ovarian cyst. She underwent a diagnostic laparoscopy, excision of endometriosis, lysis of adhesions, and incidental laparoscopic appendectomy for an appendix with endometrial implants and adhesions from the distal tip to the cecal mesentery. Intraoperative findings were notable for endometrial implants along the left anterior broad ligament, uterosacral ligaments, and right pelvic sidewall consistent with Stage II endometriosis, with otherwise normal-appearing reproductive organs. Pathology was remarkable for endometriosis and a well-differentiated appendiceal neuroendocrine carcinoma measuring 1.6 centimeters that invaded the muscularis propria and had an indeterminate proximal margin with possible lymphovascular extension. The tumor was assigned pT1b and staging was inconclusive due to uncertainty regarding lymphovascular spread along the proximal appendiceal margin. As a result, general surgery performed a laparoscopic right hemicolectomy and lymphadenectomy six weeks later. The right colon and terminal ileum were negative for residual malignancy and 45 lymph nodes were negative, which concluded a Stage I ANET. She was placed on leuprolide acetate for endometriosis suppression and had an uncomplicated recovery from both procedures.During gynecologic procedures for the management of endometriosis or chronic pelvic pain, appendectomies have become more common. Endometriosis implants have been identified on the appendix during a histopathologic review, and studies have suggested that the appendix may contribute to chronic pelvic pain ,5. CoexiEach of the five cases presented had a preoperative diagnosis of chronic pelvic pain. Four patients had a postoperative diagnosis of endometriosis after a histopathologic review, and one patient was confirmed to have a mature cystic teratoma. The patients ranged from 21 to 41 years old. Following the staging of the ANETs, two patients required a right hemicolectomy. In each of the five cases, the appendix appeared nodular, scarred, or adhered to adjacent structures. In order to preserve a minimally invasive technique with five-millimeter trocars following total laparoscopic hysterectomy, the endoscopic stapler was deployed via the vaginal orifice, and the appendix was removed vaginally using an endoscopic specimen bag.Laparoscopic gynecologic surgeons, particularly those routinely managing endometriosis and chronic pelvic pain, should receive appendectomy training to aid with the early diagnosis of appendiceal neuroendocrine tumors. Training for appendectomies and management of associated complications should become a required component in obstetrics and gynecology residency programs to adequately prepare gynecologic surgeons.


Duplication cyst (DC) of the digestive tract is a rare embryological anomaly, presenting as a cystic formation that could be attached to any part of the digestive tract, it is a thin-walled structure made of two layers, an inner layer that is frequently lined by an alimentary epithelium, surrounded by a smooth muscle layer often shared with the adjacent digestive segment. DCs are most commonly located in the distal ileum; sometimes, they are associated with other visceral or skeletal anomalies. They are frequently discovered during childhood, following a bowel obstruction or abdominal pain.Here we report a rare case of an ileal DC lined by a pseudostratified and ciliated epithelium, discovered in an adult patient following intestinal obstruction syndrome. Digestive DC is a rare finding in adult population, especially those lined by a respiratory epithelium, it is characterized by a variable clinical presentation. Sometimes associated with other digestive or extra-digestive defects. Most DCs are discovered during infancy, they rarely stay asymptomatic during childhood and do not manifest until adulthood . DCs couHere we report a case of a 47-year-old male, with no medical history, who was admitted to the hospital, due to a presentation marked by abdominal pain and swelling, and reported that he had not passed gas or had a bowel movement for four days. Otherwise, he didn't mention any similar episodes in the past, or any other digestive or general symptoms. Abdominal CT scan revealed a large cystic mass measuring 93×71×51 mm, attached to the ileal segment with evident mass effect on the adjacent segment, responsible for an ileal obstruction Figures , 1b.No contrast enhancement was observed and no genitourinary or vertebral anomalies were noted. During surgical procedure, the patient underwent a complete resection of the mass along with the attached ileal segment, followed by an ileal anastomosis; there were no signs of associated intestinal atresia or perforation.Gross examination of the resected segment showed a 10 cm, thin-walled cystic mass filled with mucinous fluid closely attached to a 15 cm long intestinal segment; macroscopic examination of both cystic wall and the normal ileal segment didn’t reveal any signs of perforation, atresia or communication between the cyst and the ileal lumen.Histological examination of the cyst wall shows a pseudostratified, ciliated columnar epithelium surrounded by a smooth-muscle layer fused and hardly distinguishable from the ileal muscularis propria. No seromucinous glands or cartilage were seen Figures , 3. The Intestinal DCs are rare cystic congenital malformations that communicate rarely with the intestinal lumen . They deDuplication cysts are subdivided into tubular and cystic types, the latter is more frequently encountered in the small intestine. They can be communicating or non-communicating with the adjacent intestinal segment . SkeletaHistologically, the cyst wall is lined, most commonly, by an alimentary epithelium similar to the adjacent digestive segment or rarely a heterotopic lining that differs from the adjacent segment, and exceptionally an extra digestive lining, such as a respiratory epithelium, as in our case; it is also possible to come across an ectopic pancreatic tissue within the cyst wall . The resMany theories have been proposed to explain digestive DCs including aberrant recanalization and partial twinning, which explain the presence of DCs in both esophageal and anorectal locations and their association to genitourinary tract anomalies. Persistent diverticula theory explains small intestine DCs. The split notochord theory explains associated spinal anomalies with enteric DCs . Lastly,Most DCs with a respiratory lining are located in the foregut  , the preOnly three cases of respiratory lined DCs of the ileum were reported, two belonged to pediatric population and only one case was an adult patient which contained an admixture of squamous, intestinal, and respiratory lining ,12. The Digestive DCs are rare developmental abnormalities, affecting the pediatric population more frequently, they are most commonly located in the distal intestine and usually lined by an alimentary epithelium; the presence of a respiratory lining is exceptional, especially in distal locations. The present case highlights both the delayed onset of digestive symptoms and also the presence of non-alimentary epithelium in intestinal DCs.


Intestinal obstruction rarely occurs after uncomplicated vaginal deliveries. Here, we present a case of a multiparous woman with a history of prior appendectomy presenting with generalized, nonspecific abdominal pain that was out of proportion to exam findings. Initial abdominal X-ray was nonspecific, and subsequent computed tomography (CT) abdomen showed closed small bowel obstruction requiring surgical repair. We present a case of intestinal obstruction occurring within 24 hours of uncomplicated vaginal delivery with a risk factor of a prior appendectomy surgery and the use of CT abdomen and pelvis to expedite diagnose. Intestinal obstruction is rarely observed after an uncomplicated vaginal delivery with an incidence of 1 in 3000 and a high mortality rate of 18–25% . Specifiμg of misoprostol for uterine atony during delivery with total blood loss of 400 mL. On postpartum day 1, she tolerated a full breakfast without nausea or vomiting, urinated spontaneously, and was ambulatory. About 11 hours after delivery, she had new onset generalized abdominal pain described as cramping and severe. Her vitals were as follows: heart rate 80 bpm, blood pressure 147/80 mm Hg, oxygen saturation 100% on room air, respiratory rate 18 breaths per minute, and blood glucose 98 mg/dL. She had a relatively mild abdominal examination with moderate tenderness in all quadrants without rebound or guarding. Bedside, abdominal ultrasound showed thin endometrial stripe, uterus well-contracted, and without abdominal free fluid. Her hemoglobin was 11.7 g/dL. She was initially given a mixture of aluminum–magnesium hydroxide, calcium carbonate, soft diet, and pain medications with symptomatic improvement. However, the next day, she developed oral intolerance with persistent abdominal pain. Her electrolytes, l iver function tests, amylase, lipase were within normal limits. Her white blood cell count was 15.2 × 109/L. Abdominal X-ray showed mildly distended dilated gas-filled large bowel without gas in the rectum possibly due to ileus or early obstruction (This patient is a 41-year-old multiparous female who presented with painful contractions with 2 cm cervical dilation and admitted for augmentation of labor. Her medical history was uncomplicated. Her surgical history was significant for open appendectomy at age 12 years and a dilation and curettage at age 27 years for a molar pregnancy. She has had five previous spontaneous vaginal deliveries and no Cesarean sections. She had an uncomplicated vaginal delivery 17 hours after admission with no lacerations. She received 0.2 mg of methylergonovine and 800 truction . Subsequtruction . The disWe present a rare case of intestinal obstruction within 24 hours of vaginal delivery. Intestinal obstruction has been reported in a few case reports in the 1960s following vaginal deliveries , 13 withIt is best to have high index of suspicion for obstruction if the patient has risk factors, such as uterine fibroid seen on ultrasound during pregnancy  or otherThe best modern imaging diagnostic technique in the postpartum period in the context of a challenging diagnosis is CT of the abdomen and pelvis. Relying other imaging may delay care, such as in another case report of a postpartum small bowel obstruction diagnosed 17 days postpartum following insidious onset from postpartum day 1 . In thatIn conclusion, we present a case of closed-loop small bowel obstruction that manifested after a vaginal delivery. Given the diagnostic challenges of non-specific severe abdominal pain after a vaginal delivery, a CT was critical in the diagnosis, which led to a timely surgical treatment. The obstruction was successfully relieved surgically without the need for bowel resection. Therefore, a high index of suspicion should be maintained for severe acute abdominal pain after vaginal delivery especially if the patient has had any abdominal surgery.


With the advancement of imaging and pathological diagnostic methods, it is not uncommon to see synchronous gastrointestinal stromal tumors (GIST) and other primary cancers, the most common of which are synchronous gastric cancer and gastric GIST. However, synchronous advanced rectal cancer and high-risk GIST in the terminal ileum are extremely rare, and they are easily misdiagnosed as rectal cancer with pelvic metastases due to their special location near iliac vessels. Herein, we report a 55-year-old Chinese woman with rectal cancer. Preoperative imaging revealed a middle and lower rectal lesion with a right pelvic mass . Through multidisciplinary discussions, we suspected the possibility of rectal cancer synchronous with a GIST in the terminal ileum. Intraoperative exploration by laparoscopy revealed a terminal ileal mass with pelvic adhesion, a rectal mass with plasma membrane depression, and no abdominal or liver metastases. Laparoscopic radical proctectomy (DIXON) plus partial small bowel resection plus prophylactic loop ileostomy was performed, and the pathological report confirmed the coexistence of advanced rectal cancer and a high-risk ileal GIST. The patient was treated with the chemotherapy (CAPEOX regimen) plus targeted therapy(imatinib) after surgery, and no abnormalities were observed on the follow-up examination. Synchronous rectal cancer and ileal GIST are rare and easily misdiagnosed as a rectal cancer with pelvic metastases, and careful preoperative imaging analysis and prompt laparoscopic exploration are required to determine the diagnosis and prolong patient survival. Multiple synchronous primary malignancies are defined as two or more primary tumors that are each diagnosed at an interval of less than 6 months apart . Among pHerein, we report an extremely rare case of advanced rectal cancer synchronous with a high-risk GIST of the terminal ileum that was diagnosed and treated by preoperative and intraoperative assessments.A 55-year-old Chinese woman had blood in her stool without any obvious cause since 1 month prior. The patient had no abdominal pain or distension, no chills or fever, no anal pain, a normal diet and sleep, normal urine, and no significant weight loss during the course of the disease. The patient was diagnosed with rectal cancer by colonoscopy, and the pathology results suggested adenocarcinoma. The patient had a history of hysterectomy for uterine fibroids and decompression for traumatic brain injury. The patient had no history of familial cancer.9/l, and the stool was positive for occult blood. Other parameters were normal.No enlarged lymph nodes were found on palpation of the clavicle and groin, the abdomen was flat and soft, and no abnormal masses were palpable. A cauliflower-like hard mass was palpable on the anterior wall of the rectum approximately 4 cm from the anus, in a 1/2 circle around the rectal cavity; the finger could pass but did not touch the upper edge of the mass, and the finger sleeve was blood-stained. The patient’s preoperative hemoglobin level was 100 g/l, her platelet level was 80 × 10On March 23, 2022, computed tomography (CT) showed a soft tissue mass on the right side of the pelvis with poorly defined borders and uneven enhancement, and no obvious enlarged lymph nodes were found in the pelvis. The wall of the middle and lower rectum was thickened, and the lumen of the lesion was narrowed, with mild enhancement  showed a mass next to the right iliac vessels, which appeared with isointensity on T1-weighted imaging, slight hyperintensity on T2-weighted imaging, and hyperintensity on T2-weighted fat-suppressed imaging and diffusion-weighted imaging . Apparent diffusion coefficient (ADC) imaging showed a low signal, and the size of the lesion was determined to be approximately 5.4 cm × 4.9 cm; the boundary was still clear (considering the possibility of metastasis)  showed a significantly hyperintense signal, with predominantly intraluminal growth of the lesion (We suggested positron emission tomography-computed tomography (PET-CT) to help improve the accuracy of diagnosis for adequate preoperative evaluation, but the patient refused PET-CT due to financial reasons. Through multidisciplinary discussions, we suspected the possibility of rectal cancer synchronous with a GIST in the terminal ileum, and the final preoperative clinical stage was cT3N0M0.2 insufflation of abdominal space (pressures of 12 mmHg) was performed. We found no ascites in the abdominal cavity and no metastatic nodules in the peritoneum, greater omentum, or liver. At a distance of 80 cm from the ileocecal valve, a small intestinal mass of approximately 6 cm in size was observed with an uneven epidermis and a rich blood supply, which was adherent to the pelvic cavity  were dissected under laparoscopy, and the central lymph nodes were cleared , moderately differentiated adenocarcinoma with no lymph node involvement (0/28) , CD34 (+), Des (-), DOG-1 (+), Ki-67 (1%+), S-100 (-), ALK (-), SMA (-). Genetic testing showed a c-KIT (exon 9) mutation.Postoperative pathological examination of the small bowel showed a spindle cell-type stromal tumor 6 cm × 5 cm × 3.5 cm in size  and a half year of targeted therapy (imatinib 400 mg/day), and was suggested to continue targeted therapy for 2.5 years. The patient refused postoperative radiotherapy due to a fear of radiation-related complications. No widespread metastasis or local progression was found in the latest follow-up Figure 4Synchronous advanced rectal cancer and high-risk ileal GIST have not been reported in detail before. Yan-Jun Liu et al. reported only one case of synchronous colorectal cancer and an intestinal GIST among 6,530 cases of colorectal cancer; however, the study did not specify whether it was rectal cancer .In this case, the patient received a clear diagnosis, and treatment was successful. If the patient had been misdiagnosed with rectal cancer and pelvic metastasis and did not promptly undergo laparoscopic exploration and resection, and preoperative neoadjuvant therapy had been performed with a disastrous effect, then the small intestinal GIST would have inevitably progressed. Patients may experience obstruction, bleeding, or even tumor rupture and extensive abdominal metastasis, which significantly reduces patient survival –13.Analyzing the case, possible reasons for the misdiagnosis of this patient are as follows: (1) while the coexistence of rectal cancer and terminal ileal GIST is rare, the diagnosis of advanced rectal cancer in this case was clear, so we might easily suspect that the malignant abdominal lesion may be an metastasis from the rectum; (2) the lesion was located next to the right iliac vessels and had a rich blood supply, so it was not difficult to suppose the possibility of rectal cancer with pelvic metastasis .The key point in the diagnosis of this case was the differentiation between GIST and pelvic metastases from rectal cancer, and imaging examinations including CT or MRI were often performed. First of all, GIST had a round shape, rich blood supply, and clear boundary. Because GIST were often accompanied by intratumor bleeding and central necrosis, they were revealed uneven enhancement . SecondlIn this successful case, laparoscopic exploration was promptly performed to determine the diagnosis. This case is enlightening due to the following: (1) When the patients were in normal physical condition, laparoscopic exploration could be used to determine the diagnosis in controversial cases. (2) Through careful review of the imaging findings, we found that the blood supply of the tumor originated from the branches of the superior mesenteric artery (SMA), so the tumor was considered to originate from the small bowel , 19.In conclusion, the coexistence of advanced rectal cancer and a high-risk ileal GIST is extremely rare and easily misdiagnosed as a rectal cancer with pelvic metastases. Careful preoperative imaging analysis and prompt surgery can prolong the survival of patients.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Written informed consent was obtained from the participant/patient for the publication of this case report.All authors read and approved the final manuscript. JM wrote and edited the original draft. JZ and SY contributed to data collection and analysis. SD and CZ reviewed the literature. Y-MZ reviewed the final manuscript. All authors contributed to the article and approved the submitted version.