Adrenocortical carcinoma (ACC) with metastasis has a grave prognosis, and adrenalectomy is associated with a high perioperative mortality rate in dogs. A favorable outcome following trilostane treatment in patients with metastatic ACC confirmed by a decreased size of the adrenal tumor and metastatic lesions has not been reported in dogs.A 12-year-old neutered male Maltese dog was diagnosed with a right adrenal tumor and a hepatic mass. Adrenal-dependent hyperadrenocorticism (ADH) was diagnosed based on clinical signs and an adrenocorticotropic hormone stimulation test (ACTHST). In addition, tests for plasma metanephrine and normetanephrine ruled out a pheochromocytoma. Based on cytology and computed tomography, unresectable metastatic ACC was confirmed. The dog was managed with trilostane due to the presence of distant metastasis. Medical management improved the clinical signs and post-ACTHST cortisol concentrations. One year after the first presentation, the clinical signs and ACTHST test showed a favorable outcome. In addition, computed tomography revealed a decreased size of the right adrenal tumor and resolution of the hepatic mass.Trilostane could be considered as a treatment option for unresectable metastatic ACC. A decrease in tumor size following treatment with trilostane has not been reported in dogs. This case report is the first to demonstrate a favorable outcome of metastatic ACC following trilostane mono therapy for >1 year. Primary adrenal tumors account for 0.17 to 0.76% of all neoplasia in dogs . AdrenalTreatment for adrenal tumors may include medical and/or surgical procedures. Treatment methods are often recommended based on whether local invasion or distant metastasis is present. Medical treatment is often favored when the primary tumor appears unresectable . HoweverTrilostane selectively inhibits the enzyme 3β-hydroxysteroid dehydrogenase (HSD3B1) corticoids and sex hormones by blocking the conversion of pregnenolone to progesterone . A recenTo the authors' knowledge, there are no previous reports of successful management of a metastatic adrenocortical tumor with trilostane monotherapy. This case report is the first to demonstrate a favorable outcome of metastatic ACC following trilostane mono therapy for >1 year.A 12-year-old, neutered male, Maltese dog was presented to a local animal hospital with abdominal distension, polyuria, and polydipsia. The abdominal mass was confirmed on ultrasonography, and the patient was referred to our veterinary medical teaching hospital for additional diagnostics and management of the abdominal mass. On physical examination, generalized erythema, scales, alopecia and lichenification were observed. In addition, inguinal hyperpigmentation and abdominal dissension was noted. No abnormal body temperature, heart rate, and respiratory rate was observed. A complete blood count, serum biochemical analysis, and electrolyte and coagulation tests were performed, and elevated alkaline phosphatase , triglycerides , and lactate  were revealed. On urinalysis, proteinuria  and hematuria  were identified. Radiography showed hepatomegaly and calculi in the urinary bladder. Abdominal ultrasonography showed gallbladder sludge, one heterogenous hepatic mass (15 × 5 mm), and a right adrenal tumor (26 × 19 mm) with local invasion of the CVC; the left adrenal gland was within normal limits .Fine-needle aspiration cytology performed by a clinical pathologist on the adrenal tumor and hepatic mass revealed cells with anisocytosis, round nuclei, a basophilic cytoplasm, and cytoplasmic vacuolization; these were suspected to have originated from the adrenal cortex . In addi3) with CVC invasion, a hepatic mass , and >20 soft tissue attenuating solid masses  and ground-glass opacities (GGOs) throughout the lungs, indicating suspected metastasis from ACC  was performed by radiologist using Siemens SOMATOM Emotion eco (16-slice CT scanner) with following scan parameters: 120mAs, 130kVp and 1-mm continuous slices. The contrast of total-body CT scanning was obtained after administration of iohexol . A CT scan showed a right adrenal tumor , the left adrenal gland increased , the hepatic mass resolved completely, and no significant changes occurred in number or appearance of the masses and GGOs in the lungs. In addition, no additional metastasis was observed  and an increased size of the left adrenal gland (5.8 mm). The CT scan revealed the right adrenal gland had decreased . Mitotane significantly decreases the adrenal gland size in dogs with pituitary-dependent hyperadrenocorticism (PDH), and it also is effective in dogs with ADH due to its adrenocorticolysis effect . In contThere are reports that the contralateral adrenal gland may shrink in dogs with ADH, but there was no significant evidence of adrenal cortical atrophy in this case, and the adrenal gland was similar to those of normal dogs based on the ultrasonographic features of size, shape, and parenchymal structure , 23. DurTrilostane has been used to treat cancers  in human medicine. –27. One The definitive evidence for the effectiveness of a treatment for a tumor is the improvement in clinical signs and survival. However, images are generally used to assess therapeutic effects earlier and more objectively . CurrentThis is the first case report of trilostane treatment in a dog with metastatic ACC with a confirmed favorable outcome. The low incidence of side effects of trilostane suggests that trilostane is a highly acceptable alternative to mitotane for medical management of ADH. Studies with a larger number of dogs are necessary to confirm the value of trilostane treatment for ACC with metastasis.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Since this is a case report, ethical review and approval were not required. Written informed consent was obtained from the owners for the participation of their animals in this study.S-WP and KK were involved in case analysis and were responsible for writing the manuscript. O-KK was involved in the draft preparation and case analysis. W-BR and C-ML were involved in the coordination of the case and were responsible for interpretation of results. All authors contributed to the article and approved the submitted version.


Children with acute pancreatitis may experience abdominal pain; the causes of which include anatomical abnormalities and medications. The rare anatomical etiology of duodenal duplication cyst is typically asymptomatic and discovered incidentally. The authors present a unique case of a Whipple-operated duodenal duplication cyst.The authors present the case of a 12-year-old Arab male who was admitted to our hospital with worsening, severe epigastric pain, stabbing in nature, and radiating to the back, suggestive of acute pancreatitis. Serum lipase levels were significantly elevated. The patient received appropriate care. His medical history is notable for multiple bouts of pancreatitis in the last 18 months. Previous investigations at other hospitals were mostly unrevealing. A more extensive workup was performed, revealing a duodenal cystic structure. This led to the diagnosis of a duodenal duplication cyst. The Whipple procedure was decided upon due to his recurrent pancreatitis, which caused fibrotic adhesions and anatomic region distortion. The patient underwent surgery and recovered uneventfully.Acute pancreatitis in children is frequent and can be caused by unrecognized duodenal duplication cysts. When symptomatic, the majority present with vague abdominal pain. Despite using ultrasound as an adjunctive for diagnosis, the cyst might not become apparent until the condition has progressed to an advanced stage. A delayed diagnosis may result in complications necessitating risky surgeries.Children with recurrent pancreatitis should be evaluated for a duodenal duplication cyst. Early use of computed tomography scans may be necessary to identify the cause and spare the patient from risky procedures like Whipple surgery. HighlightsDuodenal duplication cyst is a challenging diagnosis, often incidentally discovered in children below 2 years of age.Ultrasound may not always detect duodenal duplication cysts in children, and a computed tomography scan, although invasive, may be necessary for an accurate diagnosis.Early use of CT scans may be advisable in suspected cases of duodenal duplication cysts to avoid a delayed diagnosis.Delayed diagnosis of duodenal duplication cysts can lead to potentially fatal consequences and impact the quality of life.An endoscopic approach is the usual treatment for duodenal duplication cysts, but the Whipple procedure may be required in certain select cases.1. Acute pancreatitis as a cause of abdominal pain has become a common general pediatric condition in the last two decades, with an increasing incidence2. The causes vary but are frequently drugs, infections, trauma, or anatomic anomalies3. According to the INSPPIRE Group , acute pancreatitis is defined as reversible inflammation of the pancreatic parenchyma when two of the three following criteria are met: abdominal pain compatible with acute pancreatitis, a serum amylase or lipase value three times the upper limit of normal, and imaging findings consistent with acute pancreatitis. Acute recurrent pancreatitis is defined as two distinct episodes of acute pancreatitis (each as defined above), with a return to baseline  or complete normalization of serum pancreatic enzyme levels) in between4.Acute abdominal pain is one of the most common complaints in children, and it presents a diagnostic challenge due to various underlying causes5. Most duodenal duplication cysts are discovered in the first two decades of life and are uncommon, usually asymptomatic, and found incidentally8. This report describes a rare case of a 12-year-old Arab male with recurrent bouts of pancreatitis who received a delayed diagnosis of a duodenal duplication cyst and was operated on by the Whipple procedure. This manuscript complies with the Surgical CAse REport (SCARE) criteria9.A duodenal duplication cyst is a severe but uncommon cause of acute pancreatitis. It makes up just 4% of all gastrointestinal tract duplications and is thought to occur less frequently than once per 100 000 live births2.A 12-year-old male of Arab descent was admitted to our hospital after presenting to the emergency room with worsening, severe, constant epigastric pain of a 1 h duration that was stabbing in nature and radiating to the back. The pain was unbearable and accompanied by nausea and twice vomit. His medical history was significant for multiple bouts of pancreatitis over the past 18 months, which had been managed at other hospitals. Between his first attack and his current presentation, it was noted that his BMI had dropped from 29 to 25 kg/mPrevious investigations during the first few attacks, including ultrasound (US) and blood tests, did not yield conclusive results on a specific underlying cause for pancreatitis. However, during a previous attack, a computed tomography (CT) scan without contrast was performed, which revealed the presence of a cystic structure, as reported by the family. However, no formal report was found, and no treatment was recommended for the cyst at that time. The patient had also experienced intermittent, vague abdominal pain for the past year, which had been attributed to indigestion. His surgical history was unremarkable, and no significant drug or family history was reported. Further questioning revealed no history of recent illnesses, substance use, abdominal trauma, or scorpion bite.Upon physical examination, the patient was found to be tachypneic with a temperature of 38.3°C, a heart rate of 100, a blood pressure of 105/67, and an oxygen saturation of 96% on room air. Clinical examination of the abdomen revealed tenderness over the epigastric area with voluntary guarding but was otherwise negative. A complete blood count, amylase, lipase, and other relevant lab tests were obtained, and results are shown in Table As part of routine tests, alpha-fetoprotein, cancer antigen 19-9 (CA 19-9), and carcinoembryonic antigen levels were obtained, and results were within the normal range. The patient was started on total parenteral nutrition, made nil per os, and received intravenous fluids and omeprazole as part of routine management for acute pancreatitis. Further evaluation and management, including consideration of the previously identified cystic structure, were planned to determine the underlying cause of recurrent pancreatitis in this patient.A 4×3 cm cystic structure with a well-defined wall and internal debris seen posteroinferior to the pancreatic head and medial to the concavity of the duodenum was detected by bedside abdominal US. To assist in locating the cyst, a CT scan with and without oral and intravenous fluids contrast was ordered. The pancreatic body and tail appeared bulky with peripancreatic free fluid; however, it showed homogenous enhancement. As shown in Figure Although CT with oral contrast was done, a barium swallow was ordered by another team member. This unnecessarily exposed the patient to more radiation. However, it unsurprisingly showed a filling defect in the medial aspect of the second part of the duodenum forming an acute angle with the duodenal wall. The cyst was then identified using magnetic resonance cholangiopancreatography (MRCP), which revealed a well-defined fluid-filled cystic structure with maximal dimensions of approximately 4.2×3.38×2.97 cm between the head of the pancreas and the second/third duodenal junction as shown in Figure Previous investigations suggested that the most likely diagnosis was a duodenal duplication cyst or choledochal cyst (choledochocele). However, recent MRCP results demonstrated that the cyst and common bile duct are not connected, confirming that the cyst is indeed a duodenal duplication cyst.Considering the recurrent nature of the patient’s pancreatitis, it was initially hypothesized that fibrotic adhesions and anatomical distortion might necessitate the Whipple procedure. The surgical team discussed various surgical and endoscopic options with the family, and together they agreed that converting to the Whipple procedure, instead of simply removing the cyst, may be the ultimate course of action. The patient was admitted to the hospital for elective surgery, and during the procedure, the initial assumptions were confirmed, leading to the decision to proceed with the Whipple procedure.The surgical procedure involved several steps. Firstly, the duodenum was divided and mobilized, followed by the opening of the lesser sac and the division of the inferior border of the duodenum. The greater curvature of the stomach was then mobilized, and the distal part of the stomach was resected using blue GIA 80. A jejunum loop was also resected using blue GIA 60. The superior mesenteric artery was identified, and the pancreas was resected and disconnected from the retroperitoneum using 2/0 silk sutures and then removed en bloc.Next, the pancreas was anastomosed with the posterior wall of the stomach using an umbrella suture. End-to-end hepaticojejunostomy was performed using a continuous 5/0 prolene suture, and the distal jejunal loop was anastomosed end-to-side with the stomach using 4/0 PDS sutures. Entero-enterostomy was performed 80 cm distally to the biliary anastomosis using 4/0 PDS sutures. Two JP-10 drains were left in the abdomen adjacent to the anastomoses to facilitate postoperative drainage.The abdomen was closed using a two-layer technique, with the inner layer closed using continuous 3/0 vicryl sutures, and the external layer closed using interrupted 2/0 vicryl sutures. The skin was closed with a stapler.In summary, the patient underwent the Whipple procedure with distal gastrectomy and duodenectomy with ROUX-EN-Y anastomosis of the stomach to the jejunum Figs.  and 3. TThe patient was transferred to the pediatric ICU for monitoring after the procedure. He was initiated on a total parenteral nutrition formula consisting of 3% amino acid and 3% glycerin injection with electrolytes, as well as receiving ranitidine, somatostatin, and ceftriaxone. After two days, the patient was discharged from the ICU and transferred to the pediatric surgical ward. During his postoperative period, the patient’s recovery was uneventful, with clinical improvement noted in both the physical examination and laboratory tests. The patient was able to tolerate oral feeding, had normal bowel movements, and passed gas. The plan was to discharge the patient on postoperative day seven. Until now, follow-up evaluations, including assessments of surgical site healing, recovery of bowel function, and resolution of postoperative symptoms, were unremarkable. Physical examinations, laboratory tests, and bedside transabdominal US did not reveal any concerning findings.We report an unusual case of a duodenal duplication cyst in a pediatric patient, located in the second part of the duodenum, that was identified after 18 months of recurrent pancreatitis.10. Duodenal duplication cysts, which are congenital disorders associated with pancreatitis, are usually diagnosed in the first two years of life6. However, our case was unique as it was diagnosed at the age of 12, after experiencing multiple episodes of pancreatitis. While imaging is not necessary for diagnosing acute pancreatitis if the other 2 criteria are met, transabdominal US is often used to rule out any obstructive causes4. CT imaging is usually reserved for more severe cases where there is no clinical improvement or worsening10. In our case, despite undergoing imaging and blood tests, it was only 18 months after the initial symptoms began that an abdominal US revealed a cyst near the pancreas. This delay in detection could be attributed to bowel gas interference, small cyst size, or challenges in interpreting results due to the patient’s overweight condition. The patient had experienced intermittent, vague abdominal pain for a year before the diagnosis. This aligns with reports that suggest the most common symptoms of duodenal duplication cysts are nonspecific, such as vague abdominal pain with or without nausea and vomiting11, which can be easily mistaken for other causes like indigestion.Acute pancreatitis is a condition that occurs frequently and presents with a wide range of symptoms. In extreme cases, it can be fatal4.Limited research exists on acute recurrent pancreatitis in children, with an uncertain understanding of its epidemiology and natural history. Furthermore, there is a lack of evidence-based guidelines for diagnosis, prognosis, and treatment in pediatric cases, leading to reliance on adult-derived guidelines by pediatric specialists. This poses challenges as the causes of pancreatitis in children differ significantly from those in adults12. Diagnostic tools such as abdominal US, CT scan, MRI, and MRCP have been commonly employed in reported cases, based on clinical suspicion. Additionally, upper gastrointestinal series and endoscopic retrograde cholangiopancreatography have been utilized for diagnostic purposes. Endoscopic US has also been employed in certain cases as a diagnostic modality5.Due to the variability in presenting symptoms and challenges in diagnostic imaging, duodenal duplication cysts pose a significant risk of morbidity and mortality if not diagnosed and treated promptly13. While endoscopic excision is commonly used in pediatric cases5, our patient underwent a Whipple procedure due to intraoperative findings of fibrotic adhesions and distortion of the anatomic region resulting from recurrent pancreatitis. This approach is similar to a reported case where a 23-year-old patient underwent a Whipple procedure due to the firm adherence of a necrotic and inflammatory mass to the duodenum and pancreatic head14. However, the patient in our case was 12-year-old when the surgery took place. Deciding whether a Whipple procedure should be the first surgical option for pediatric patients with a benign disease like a duodenal duplication cyst requires extensive deliberation. This approach is uncommon, as supported by a previous case series study where only one out of 11 cases underwent the Whipple procedure15.The preferred treatment approach for duodenal duplication cysts is complete excision. However, less invasive methods such as partial resection or internal derivation have also been suggested as alternative approaches. Another successful surgical technique, even when performed endoscopically, is marsupialization16, in low-resource settings like Palestine, where healthcare resources may be scarce and substandard, silk sutures are still commonly employed18. Additionally, a national survey conducted by Brunner et al.19 found that unlike the prolene sutures used in our case for end-to-end hepaticojejunostomy, all hospitals surveyed uniformly used monofilament absorbable sutures. This practice could also be attributed to resource limitations in our facilities.Although it is generally discouraged to utilize silk sutures for closing abdominal incisions20. In our patient, the resected cyst originated from the papilla, and the biopsy results confirmed it was benign.The cyst needs to be surgically removed as it may cause severe symptoms and there’s a potential risk of malignant transformation. Long-term follow-up is necessary to monitor for any potential malignant changes at the site of the duplicationRegardless of the patient’s age, it is crucial to consider the possibility of a duodenal duplication cyst when there is a history of recurrent pancreatitis. Although US is typically the initial diagnostic imaging modality in children, we believe that earlier utilization of CT scans and a comprehensive workup, such as MRCP, may be warranted when US findings are inconclusive, blood tests are negative, and medical history does not suggest an underlying cause for recurrent pancreatitis. Further research is needed to determine the sensitivity of abdominal US in detecting anatomical causes of pancreatitis and to establish a distinct diagnostic approach for recurrent pancreatitis in children compared to adults. Early recognition and management of duodenal duplication cysts could potentially reduce the need for invasive surgeries like the Whipple procedure. Despite the rarity of this type of surgery in children, it should be considered in cases where significant adhesions and distortion of the anatomical region are present, as alternative treatments may not effectively address the patient’s condition.Ethical approval is exempt/waived at our institution.The patient’s parents provided written informed consent to publish this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.NA.S.D., A.S.: study concept and design; F.S., A.A., M.N.: data collection; S.D., H.A.M., A.S.: data analysis and interpretation; S.D., A.S., F.S., A.A., H.A.M., M.N.: writing the paper; Z.Z., Y.D., M.J., A.S.: writing - review and editing.NA.NA.Abdalhakim Shubietah.Available upon the Editor-in-Chief request.Not commissioned, externally peer-reviewed.


PSMA-guided biopsy confirmed the diagnosis of a clinically-significant PCa. Following ablation of the lesion with high-intensity focused ultrasound (HIFU), the PSMA-avid lesion disappeared and targeted biopsy confirmed a fibrotic scar with no residual cancer. PSMA imaging may have a role in guiding diagnosis, focal ablation, and follow-up of men with PCa.Focal therapy of prostate cancer (PCa) is currently of great interest, but a metric of success. other than biopsy, is not yet available. In a patient with a repeatedly negative MRI and negative systematic biopsies, a scan employing the radioisotope  Candidates for focal therapy are selected on the basis of biopsy guided by magnetic resonance imaging (MRI). However, in some 15%of cases MRI may not reveal the PCa.2Because of a rising serum PSA level, a 75 y.o. Caucasian male underwent an ultrasound-guided prostate biopsy in February 2020. One of the 12 random samples contained a 1.5 mm focus of PCa (GG3). Subsequent to the biopsy a mpMRI of the prostate was performed, revealing no abnormalities (prostate volume = 31 cc). Patient deferred treatment, and PSA level continued to escalate. A second MRI was performed in June 2021; it was also negative. A second systematic biopsy, employing template guidance, was performed in July 2021 (18 cores); it was also negative. PSA continued to escalate, and in November 2021 a third MRI was performed; again, the MRI showed no abnormalities A.Fig. 1PAs part of an ongoing clinical trial evaluating PSMA for biopsy guidance (NCT05160597), patient underwent In December 2021 a PSMA PET/CT scan, revealing a region of PSMA avidity in the left mid-gland (SUV = 5) B. The PSA left PGA using HIFU (Sonablate 5000) was performed in March 2022 . The proFollow-up MRI in October 2022 showed treatment effect and no suspicious regions A. PSMA s368Ga-PSMA-11) was first cleared by the U.S. FDA in December 2020. Six months later a commercially-available agent (18F-PSMA-1007) was also cleared.A PSMA-based imaging agent .Conceptualization ; Data curation ; Formal analysis ; Funding acquisition ; Investigation ; Methodology ; Writing, editing . Corresponding author: Dr. Marks ; and 10.13039/100016206UCLA CTSI, Grant/Award Number: UL1TR000124. PSMA scanning donated by Prof. Johannes Czernin, UCLA Nuclear Medicine Dept.Dr. Marks’ work supported in part by


A myxoma is a benign intramuscular gelatinous tumor that is rarely known to arise from the scrotum. It can be confused both clinically and radiologically with other more common scrotal wall lesions such as a sebaceous cyst or an abscess. We report a case of a 54-year-old patient who presented with a scrotal wall swelling that was initially suspected to be an infected cyst or cold abscess on imaging. The final diagnosis of a myxoma was made after surgical excision and histopathological examination. A benign intramuscular gelatinous tumor called a myxoma commonly manifests as an intramuscular lump. It is a class of mesenchymal tumors mostly composed of extracellular myxoid matrix. Most myxoma patients are in their fifth or sixth decade of life A 54-year-old man with a medical history of hypertension, coronary artery disease requiring previous percutaneous coronary intervention, dyslipidemia, and a history of smoking presented to the clinic with a scrotal wall lesion noticed for a few months, progressively increasing in size. He denied any testicular pain or urinary symptoms. On physical examination, a firm 3 cm lesion arising from the left scrotal wall with a narrow neck was palpated. The testes and epididymis appeared normal. Due to the concerning nature of the lesion, an urgent scrotal ultrasound was ordered for further evaluation.Ultrasound of the scrotum was done, which demonstrated a well-circumscribed abnormality of mixed echotexture at the site of concern in the scrotal wall. It measured around 4 × 2 cm in size. The lesion had an echogenic wall and internal necrotic or turbid components with vascularity noted within the solid-appearing elements. Both testes and epididymis showed normal size, echotexture, and vascularity. No hydrocele was seen . An inflGiven the concerning findings on ultrasound, the patient underwent surgical excision of the scrotal wall lesion under local anesthesia. The excised specimen was sent for histopathological analysis.Histopathology showed a scrotal wall lesion dissecting in between the muscle fibers composed of bland spindle to stellate cells embedded in myxoid stroma. Few associated small blood vessels were noted. Immunohistochemical staining showed that the spindle cells were immunoreactive for smooth muscle actin and calponin, with focal expression of estrogen receptor (ER) and desmin. They were negative for CD34, S100, Cytokeratin AE1/AE3, epithelial membrane antigen (EMA), STAT6, MDM2, and CDK4. The Ki-67 proliferation index was approximately 5% . Based oThe patient's clinical progress and response to treatment have been satisfactory, with no evidence of recurrence or complications noted during the follow-up period.This is a rare case of a myxoma presenting as a scrotal wall lump thus clinically mimicking other scrotal lumps such as a scrotal wall abscess, sebaceous cyst, or sometimes hydrocele or varicocele. Although myxomas may affect any muscle in the body, they most frequently affect the thighs, buttocks, and shoulders. Involvement of the scrotum is exceedingly rare.From a clinical perspective, an intramuscular myxoma often presents as a solitary, discrete, painless, and hard palpable swelling On ultrasound, intramuscular myxomas are usually hypo-echoic with well-defined margins, sometimes containing anechoic cystic foci within. The presence of anechoic cystic internal contents may make them mimic necrotizing infectious or inflammatory processes such as abscesses or infected cysts. CT usually shows a well-defined homogeneous low-density enhancing lesion. On MRI, the lesion usually appears as a well-defined and smooth intramuscular lump that is homogeneously hypointense on T1-weighted images, and extremely hyperintense on T2-weighted images, similar to fluid signal. The presence of a perilesional rind of fat or edema has been suggested as a definite sign to diagnose myxoma on MRI Histologically, myxoma is typically a hypovascular and hypocellular myxoid lesion composed of the bland spindle to stellate-shaped cells. No necrosis or mitotic activity should be present. If the lesion is more cellular and hyper-vascular, another differential diagnosis should be considered like myxofibrosarcoma, myxoid liposarcoma, and low-grade fibro myxoid sarcoma. Careful histological examination and tissue sampling are essential to reach a definitive diagnosis They are treated with surgical resection ensuring clear margins. The likelihood of recurrence is relatively low A myxoma presenting as a scrotal wall lump is exceedingly rare and can mimic more common pathologies such as a cold abscess or an infected sebaceous cyst. A high index of suspicion is required especially when the imaging shows a mixed echogenic mass with internal cystic changes.The article describes a case report. Therefore, no additional permission from our Ethics Committee was required.All data generated or analyzed during this study are included in this published article.Data Collection, Literature Search, Manuscript Preparation : MAH, JJK, NAN, TK, KAM, NSMAll authors read and approved the final manuscript.We obtained written informed consent from the patient to publish this case report by the journal's consent policy.


Extraskeletal myxoid chondrosarcoma is a rare mesenchymal neoplasm of uncertain differentiation, characterized morphologically by abundant myxoid stroma, a multinodular growth pattern, and uniform cells arranged in strands, clusters, and reticular networks. It usually occurs in adults in the fifth decade, most often in the deep soft tissues of the proximal extremities. The molecular hallmark of this tumor, present in over 90% of cases, is the fusion of NR4A3 with EWSR1 at 22q12.2 or TAF15 at 17q12. Many other tumors with uniform tumor cells embedded in a myxoid matrix can mimic Extraskeletal myxoid chondrosarcoma, and the distinction can be difficult, often requiring immunohistochemistry and/or molecular testing. We herein report the case of an Extraskeletal myxoid chondrosarcoma that occurred in a 74-year-old woman who consulted for a slowly enlarging thigh mass, while highlighting the key morphologic, immunohistochemical, and molecular features of this rare type of soft tissue sarcoma, as well as a summary table gathering diagnostic features of relevance to the differential diagnosis. Extraskeletal myxoid chondrosarcoma (EMC) is a rare malignant mesenchymal neoplasm of uncertain differentiation, characterized by abundant myxoid matrix, multilocular architecture, and uniform cells arranged in cords, clusters, and reticular networks . It occuPatient information: a 74-year-old woman with history of diabetes and arterial hypertension, presented with a painless mass on the inner part of the left thigh, evolving for 4 years.Clinical findings: physical examination revealed a painless mass of hard consistency, located in the inner part of the left mid-thigh.Timeline of current episode: on September 2022, an X-ray and MRI of the left thigh were performed. Few days after, a biopsy followed by the resection of the mass were performed. A chest X-ray was also performed.Diagnostic assessment: the X-ray of the thigh showed an oval opacity in the soft parts of the inner face of the left mid-thigh. The Chest X-ray revealed the presence of pulmonary nodules of metastatic appearance  with a slight male predilection. Children and adolescents are exceptionally affected. Clinically, it presents as a slowly growing mass in the deep soft tissues, with a duration ranging from few weeks to several years , often aMacroscopically, most EMCs are well circumscribed, surrounded by a fibrous pseudocapsule. The tumor size is variable ranging from few centimeters to 30 cm, with a median size of 4 to 7cm. On section, the tumor is soft to firm, of grey to tan-brown color, displaying a lobulated appearance comprising gelatinous areas separated by fibrous septa, with possible cystic cavities, hemorrhage, and necrosis. The macroscopic examination in our case was consistent with the macroscopic appearance reported in the literature, with a soft tissue mass measuring 8cm in great axis, encapsulated by a fibrous capsule, dissected by fine fibrous septa delimiting several gelatinous lobules, with hemorrhage foci. Microscopically, a multinodular architecture with a striking myxoid background is usually noticeable at low magnification. The tumor is made of hypocellular nodules with increased cellularity at the periphery, separated by delicate fibrous septa, containing cords, clusters, and delicate strands of uniform interconnected cells. The tumor cells are provided with small, round to oval nuclei, evenly distributed chromatin, inconspicuous nucleoli, and modest amount of deeply eosinophilic to vacuolated cytoplasm, set in an abundant pale blue myxoid matrix composed of sulfated mucopolysaccharides . Other cImmunohistochemically, EMC consistently display strong expression of vimentin. Twenty percent (20%) of cases are positive for PS100 , which iDrawing a clear line of demarcation between EMC and other myxoid or chondroid-like lesions may be challenging on the basis of morphologic appearance alone, and immunohistochemistry or even molecular testing is often required, along with both clinical and radiological correlation. The morphology of EMC is quite characteristic, and the diagnosis is generally easy to make if one is familiar with the entity. However, other soft tissue tumors can be morphologically confusing, and the use of immunohistochemical and molecular studies, along with a correlation with clinical and radiological findings may be necessary.


Urinary tract stones are found in many locations, such as in the kidney or ureter, and, less commonly, in the bladder. Bladder stones are solid calculi that are usually composed of calcified material, most commonly uric acid, and typically weigh less than 100 g. There is a higher prevalence of bladder stones in males than in females, which can be explained by the pathophysiology of how these stones are formed. Namely, bladder stones tend to form secondary to urinary stasis, such as in the setting of benign prostatic hyperplasia (BPH). However, bladder stones can form in otherwise healthy individuals without anatomic defects  or urinary tract infections (UTIs). Foley catheters or any foreign bodies in the bladder can predispose to stone formation. Renal calculi, most commonly calcium oxalate or calcium phosphate in composition, can also travel through the ureter and get trapped in the bladder. The most significant risk factors for bladder stones include the presence of BPH and UTIs, both of which favor the development of additional layers of stone material. In exceptionally rare cases, bladder stones measure more than 10 cm in diameter and weigh more than 100 g. These entities have been referred to as giant bladder stones within the limited literature. Minimal data exist on the etiology, epidemiology, composition, and pathophysiology of giant bladder stones. We present the case of a 75-year-old male with a giant bladder stone composed of 100% carbonate apatite, measuring 10 cm × 6 cm and weighing 210 g. Urinary tract stones, also referred to as urolithiasis, can be found in several locations, including the kidneys, ureters, urethra, and bladder . The preThe most common stone composition of bladder calculi is uric acid 50%), with other common compositions including calcium oxalate, calcium phosphate, ammonium urate, cysteine, and struvite. Bladder stones may present asymptomatically, though when symptomatic, they may cause terminal hematuria, suprapubic pain, impaired bladder voiding, and dysuria . Bladder0%, with We report the case of a 75-year-old male patient who presented with complaints of abdominal pain and was found to have severe post-obstructive acute kidney injury. Imaging studies demonstrated a large bladder stone. The patient eventually received an open cystolithotomy because of the massive size of the stone.A 75-year-old male with a past medical history of hypertension and recurrent nephrolithiasis presented to our emergency department due to lower abdominal pain associated with a lack of urinary catheter drainage. Notably, he was admitted to an outside hospital one month prior for a urinary tract infection and bilateral hydronephrosis due to obstructive nephrolithiasis that was managed with antibiotics and urinary catheter placement. The patient reported that his abdominal pain was also associated with back pain, rated 5 out of 10 in severity, and was exacerbated by movement. He denied nausea, vomiting, diarrhea, fevers, chills, night sweats, or gross hematuria. Initial vital signs included a temperature of 97.9°F, blood pressure of 142/82 mmHg, pulse rate of 85 beats/minute, respiratory rate of 15 breaths/minute, and oxygen saturation of 99% on ambient air. Physical examination revealed an ill-appearing male as stated age, bilateral costovertebral angle tenderness, diffuse tenderness to lower abdominal palpation, abdominal distension, and poor dentition. Initial laboratory investigations demonstrated leukocytosis, normocytic anemia, elevated serum creatinine, elevated parathyroid hormone, and decreased vitamin D  post-obstructive acute kidney injury related to bladder stones has seldom been reported in the literature, (2) secondary hyperparathyroidism due to vitamin D deficiency was likely associated with an increased risk of carbonate apatite stone formation, and (3) giant bladder stones are a rare entity in the current body of literature. In our experience, early diagnosis and prompt surgical management of the giant bladder stone led to a swift resolution of the patient’s medical ailments. Future studies should aim to assess the risk factors for developing giant bladder stones and the possibility of endourological interventions for the management of giant bladder stones.Giant bladder stones are a rare entity, and their association with post-obstructive acute kidney injury and bilateral hydronephrosis is even rarer. In this case, a 10 cm × 6 cm carbonate apatite stone was retrieved intact from the patient’s bladder, leading to the resolution of the patient’s acute kidney injury and bladder outlet obstruction. Based on our experience, we recommend prompt urological surgery evaluation in patients presenting with these clinical manifestations, as surgical intervention may be curative. Future studies may evaluate the role of endourological interventions for giant bladder stones and analyze specific risk factors related to the development of giant bladder stones.


Riedel's lobe is a rare anatomical variant of the liver morphology with a downward tongue-like projection of the anterior edge of the right lobe. It is usually detected incidentally with abdominal imaging performed for other indications. We present a case where we found Riedel's lobe incidentally, with invasive adenocarcinoma arising from close proximity. A 64-year-old female came in with encephalopathy and was found to have a distended abdomen with tenderness. Imaging revealed a complex lobular mass in the right hepatic lobe with an elongated extension of the right lobe inferiorly consistent with Riedel's lobe. The differential considered was malignancy versus abscess. CT-guided biopsy revealed invasive adenocarcinoma consistent with intrahepatic cholangiocarcinoma, which was further supported by the presence of portocaval lymph nodes. Various studies have tried to establish an association between Riedel's lobe and the occurrence of cancer arising from the surrounding structures, primarily from liver or metastasis. This case report adds to the current literature when such an association is being studied. Riedel’s liver lobe, the most well-known accessory lobe of the liver, is considered a rare anatomical variant of the liver morphology with a downward tongue-like projection of the anterior edge of the right lobe of the liver involving the segments V and VI ,2. It isA 64-year-old female was brought to the emergency department due to altered mentation and fever. Her medical history includes asthma, hypertension, irritable bowel syndrome, sciatica, and arthritis. Her family history is remarkable for breast cancer in both her mother and sister. Her last breast and colon cancer screening with mammogram and colonoscopy were performed five years and four years ago, respectively, and were unremarkable. She does not have a personal history of cancer or liver conditions.On presentation, she was hypertensive at 140/51, tachycardic at 105, tachypneic at 22, and febrile at 38.5. She was lethargic, oriented to self and location, and had a Glasgow Coma Scale (GCS) of 13. Examination revealed abdominal distension and tenderness in the right upper and lower quadrants without guarding or rigidity. Workup (Table Computed tomography (CT) without contrast of the head was normal. Given the abdominal tenderness, with fever and leukocytosis, she was further evaluated with CT of the abdomen and pelvis with contrast, revealing a lobulated mass within the right lobe of the liver measuring 3.9 cm Figure  in additThe primary site of origin of the adenocarcinoma is suspected to be from the pancreaticobiliary tree, including intrahepatic cholangiocarcinoma based on immunohistochemistry. Alpha-fetoprotein tumor marker was within the reference range with a value of 5.1 ng/mL (<9.0 ng/mL). The patient was treated with supplemental oxygen and dexamethasone initially for COVID-19 infection. Remdesivir was considered as well but deferred following the patient's refusal. She was also empirically treated with piperacillin/tazobactam for concerns of abdominal infection. The patient clinically improved and was weaned off oxygen. She was instructed to follow up with her primary care provider and oncologist for further evaluation and treatment of invasive adenocarcinoma of the liver likely arising from the pancreaticobiliary tree.On follow-up two months later, she is asymptomatic and is following up with an oncologist. She underwent a positron emission tomography (PET) scan, which revealed 5.4 cm metabolically active in the right hepatic lobe mass. Her tumor markers, including carbohydrate antigen (CA 19-9) and carcinoembryonic antigen (CEA), were elevated at 11,876 and 14, respectively. The liver tumor board evaluated her, and given the multiloculated cystic lesion in the segment 4/8 with restricted diffusion or delayed enhancement, 1.3 cm portocaval lymph node, and histopathology finding, the tumor is consistent with intrahepatic cholangiocarcinoma. She is being considered for tumor resection in addition to chemotherapy with gemcitabine and cisplatin.Riedel’s lobe of the liver, also known as the tongue lobe, is a rare anatomical variant described as an elongated extension of the right liver lobe that extends downward . The incIn the majority of cases, Riedel’s lobe is asymptomatic and is often discovered during routine diagnostic and imaging studies. However, when symptoms do occur, patients may experience mild discomfort, abdominal tenderness, nausea, bloating, constipation, or distension, which can be attributed to the elongation of the lobe and the possible compression of nearby structures such as abdominal vasculature, stomach, and kidneys. These symptoms can occasionally mislead physicians to other diagnoses if imaging modalities are not obtained. One of the differential diagnoses of this anatomical variation is hepatomegaly; therefore, awareness of this variation is crucial to prevent the deceptive appearance of hepatomegaly . AlthougIn general, asymptomatic and uncomplicated cases of Riedel’s lobe tend to have a favorable prognosis and do not require any specific management. However, mechanical complications have been reported with Riedel’s lobe, mostly related to the occurrence of torsion and extrinsic compression ,3. Thus,While the association between Riedel’s lobe and hepatic tumors has not yet been clearly identified, the possibility of the chronic inflammation that is postulated to result in the Riedel lobe increasing the chance of cancer arising from the surrounding structure adds to the need for further studies. Our case adds to the limited available literature regarding Riedel’s lobe and concomitant invasive adenocarcinoma of the liver suspected to arise from the pancreaticobiliary tree.Riedel’s lobe is a rare anatomical variant of the liver with a downward projection of the anterior right lobe. It is usually discovered incidentally, has an asymptomatic presentation with a better prognosis than symptomatic patients, and requires no treatment. However, symptomatic and complicated cases will require further management, such as surgical resection of the lobe. The association between Riedel’s lobe and hepatic tumors has not yet been identified; the possibility of the chronic inflammation that is postulated to result in the Riedel’s lobe increasing the chance of cancer arising from the surrounding structure adds to the need for further studies.


Kidney metastasis to the pituitary gland can cause hyperprolactinemia even above 250 ng/mL. Although the treatment of metastasis is palliative, surgical decompression could play a major role in the recovery of symptoms and improve quality of life. Pituitary metastasis should be considered in the evaluation of an unusual pituitary mass.Pituitary tumors are frequently encountered in the neurosurgical setting. Although the majority of them are pituitary adenomas, rare entities encompass pituitary metastasis. They should be differentiated from pituitary adenomas because their management and prognosis are different. We report a 53‐year‐old female who complained of headache and had remarkable hyperprolactinemia (271.1 ng/mL). Having considered macroprolactinoma as the initial diagnosis, medical treatment was initiated with Cabergoline. Subsequently, the patient's vision deteriorated which prompted us to perform endoscopic endonasal transsphenoidal surgery. Histologic examination of the resected tumor revealed metastatic renal cell carcinoma. Main treatment for these subjects is palliative; and unlike the pituitary adenoma, the prognosis is unfortunately poor. Pituitary metastasis should be considered in the evaluation of an unusual pituitary mass associated with hyperprolactinemia.  Systemic metastasis to the pituitary gland occurs in the late stages of the disease, but in 20%–30% of patients, could appear as the first manifestation of malignancy.2A 53‐year‐old woman was referred to our pituitary clinic for evaluation of a giant pituitary mass. The patient complained of a headache 3 months ago that did not respond to medication and was getting worse. She was otherwise normal, except for being in her menopausal stage since 1 year ago, and had not noticed any visual impairment or change in her body weight. She had no complaints of galactorrhea, polyuria, or polydipsia. Physical examination showed mild bitemporal hemianopia with Visual field index (VFI) parameter in perimetry represent 89% and 75% in the right and left eyes respectively, with intact visual acuity that was confirmed by a subsequent perimetry test Figure . The res3Metastatic tumors involving the pituitary gland are uncommon, and symptomatic pituitary metastasis of RCC is very rare.Although hypophysis involvement by systemic cancers is uncommon, it should be considered in the differential diagnosis of a sellar mass, because it can change the management and prognosis of a pituitary tumor especially when the pertinent medical history is present. In 20%–30% of patients, metastasis to the pituitary gland is the first manifestation of a tumor of unknown origin.For the precise evaluation of a pituitary mass, MRI is necessary. Although based on the MRI feature, pituitary metastasis cannot be readily distinguished from a pituitary adenoma or other lesions, some features could be helpful. In comparison with pituitary adenoma thickening of the pituitary stalk, erosion of bony element of sella turcica, loss of normal high signal intensity of posterior pituitary lobe, presence of flow voids in the tumor, and multiple lesions are in favor of pituitary metastasis.The special feature of this case is hyperprolactinemia. In the presence of a pituitary tumor together with hyperprolactinemia, most patients with prolactin levels higher than 250 ng/mL should be considered as cases of prolactinoma.According to the published data, in two historical cases have been reported to have hyperprolactinemia associated with RCC but serum prolactin levels less than 200 ng/mL. In both cases, serum prolactin levels returned to baseline levels after nephrectomy without any imaging of the pituitary region.Interestingly, in our case, the IHC study of the renal mass specimen was positive for the PRL marker same as that for the sellar tumor specimen. So, the renal cell tumor probably was also involved in prolactin secretion.The best management of pituitary metastases has not been clearly determined. Surgical decompression could play a role in symptom palliation and probably improve quality of life. However, achieving gross total resection because of local invasiveness, high tumor vascularization, and cavernous sinus involvement as in our patient might be impossible. Other modalities of treatment include post‐surgical radiotherapy and stereotactic radiosurgery.Unfortunately, the overall survival of these patients despite surgical tumor removal and radiation is poor with a median survival of 6–7 months.4Pituitary metastasis should be considered in the evaluation of an unusual pituitary mass associated with hyperprolactinemia. The paraneoplastic syndrome of certain tumors, such as RCC, can be misleading in the diagnosis and treatment strategy of a pituitary mass. The overall prognosis in this group is generally poor and depends on the treatment of the underlying disease. Surgical treatment may help to improve the symptoms especially visual improvement and the quality of life.Ali Mazar‐Atabaki: Conceptualization; data curation; formal analysis; investigation; project administration; software; validation; writing – original draft. Omid mohamadzadeh: Data curation; methodology; writing – review and editing. Seyed Mousa Sadrehosseini: Conceptualization; supervision. Azin Tabari: Supervision; visualization. Mehdi Zeinalizadeh: Conceptualization; funding acquisition; resources; supervision.There was no source of funding for this study.The authors declare to have no conflicting interest.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal.


Bursitis, though treatable conservatively, very rarely can have ossification and calcification in its substance which requires surgical intervention. The patient should be investigated for any coexisting metabolic bone disorders before proceeding with surgical intervention. The excision biopsy of such a specimen has to be examined histopathologically to rule out any neoplastic etiology. We present an adult male with a painful lump over the tibial tuberosity and its management. Bursae are fluid-filled sacs that are lined by synovium and play their role in protecting tissues like tendons and ligaments from friction against bony surfaces during movements . There aA gentleman of 46 years presented to us with complaints of swelling which was painful to touch over the tibial tuberosity of his right knee. His complaints started two years back insidiously as a small swelling which gradually progressed and attained its present size of 6 cm * 3 cm. The swelling was mobile in both planes and was firm in nature and also tender to touch Figure .He had difficulty kneeling and squatting because of the swelling. The blood investigations showed normal renal and liver function tests with normal serum calcium and phosphorus Table . The radThe MRI images Figure  sagittalHe was operated on under regional anesthesia in a supine position with a tourniquet over the thigh. An S-shaped incision was centered on the swelling over the tibial tuberosity and a hard well-defined mass was identified with a few fibers of the patellar tendon attached to it. The mass was removed in total as a single piece and the few fibers of the patellar tendon that were seen attaching to the mass were repaired to the intact tendon. The wound was closed and the patient was discharged the next day. The excised bursal mass was sent for histopathological examination. The mass was cut open which revealed hypertrophied bursal tissue Figure  and an oHe was started on full weight bearing and isometric quadriceps exercises in the postoperative period. He followed up at two weeks, suture removal was done and knee range of movement exercises were started. At four months follow up he was able to squat and kneel and had no complaints and attained his full range of movement. At 14 months follow up he had no complaints and there was no recurrence.Bursitis can be acute or chronic. Acute bursitis can be due to traumatic etiology (hemorrhagic bursitis) or infective etiology (septic bursitis) ,3. In chOur patient had chronic bursitis involving the superficial infrapatellar bursa also known as a pretibial bursa. The infrapatellar bursa has two parts: one is superficial to the patellar tendon in the subcutaneous plane and one deep to the tendon and anterior to the tuberosity. They both play a role in protecting the tendon during its movement and can develop bursitis due to increased activity -7. RarelHeterotopic ossification has been described as the formation of bone at extraskeletal sites whereas calcification is the deposition of calcium salts in extraskeletal sites . CalcifiIn our patient, the blood workup was within normal limits and not suggestive of any metabolic bone disease. The radiological work including radiographs and MRI was suggestive of an ossified mass in the substance of infrapatellar bursa without any bony scalloping, invasion, or periosteal reactions suggestive of malignant pathologies. This was confirmed by histopathology of the excised tissue which had bone formation in its substance as well as dystrophic calcification. Bursitis though treatable conservatively, very rarely can have ossification and calcification in its substance which requires surgical intervention. The patient should be investigated for any coexisting metabolic problems before proceeding with surgical intervention. The excision biopsy of such a specimen has to be examined histopathologically to rule out any neoplastic etiology. In our patient, it was suggestive of clergyman’s knee, and radiologically showed ossified bursitis. He underwent an excision biopsy of the same and histopathology revealed metaplastic new bone with dystrophic calcification in its substance.


Synovial sarcoma, a malignant mesenchymal tumor, is primarily associated with the extremities. Nevertheless, its appearance within the head and neck region, particularly in the maxillary area, is remarkably rare. This rarity underscores the significance of each case in unraveling the complexities of its behavior and management strategies. The core focus of this research is a detailed case report involving a 6‐year‐old female patient who presented with a conspicuous swelling in the left posterior maxilla. Subsequent incisional biopsy led to microscopic identification of malignant spindle cell proliferation, marked by dysplastic changes, and abundant mitoses. Immunohistochemical (IHC) analysis demonstrated negative reactivity for neural and muscular markers, while positive expression of Vimentin, Bcl‐2, and TLE1. These morphological and IHC findings coalesced to definitively diagnose synovial sarcoma, substantiated by a notable 40% Ki67 proliferative index. The chosen treatment strategy encompassed surgery and radiotherapy, which yielded successful outcomes, with no recurrence observed during the one‐year follow‐up period. Beyond the specific case, this article undertakes a review of existing literature, meticulously analyzing nine similar cases reported in scholarly sources. Microscopic examination with hematoxylin and eosin staining. We aim to shed light on the intricacies of diagnosing and managing this rare condition, emphasizing the importance of early detection and comprehensive surgical intervention for improved patient outcomes.2In September 2021, a 6‐year‐old female patient presented to the Maxillofacial Surgery Department of Mashhad University of Medical Sciences with a complaint of swelling at the left posterior sites of the maxilla. The patient's medical history was unremarkable. Upon clinical examination, a soft, darker‐colored lesion was observed in the buccal and palatal regions, extending from tooth E to approximately the midline. The macroscopic examination revealed a large piece of soft, tumoral tissue along with multiple shapeless soft, and jelly‐like pieces. The largest piece measured 30 × 22 × 8 mm with an irregular surface, while the smaller pieces collectively measured 7 × 22 × 32 mm. An incisional biopsy was performed, and a soft tissue specimen was sent to the pathologist for further evaluation. Microscopic examination of serial sections from the submitted sample revealed a malignant proliferation of dysplastic changes and multiple mitoses of spindle cells. Immunohistochemical (IHC) analysis showed negativity for neural, muscular, plasma cell, and epithelial markers, including Myogenin, SMA, SOX10, CD34, and EMA. However, the tumor exhibited positive expression of Vimentin, Bcl‐2, and particularly TLE1 markers.Based on the morphologic and IHC findings, a diagnosis of synovial sarcoma was established and the diagnosis was further supported by a 40% Ki67 proliferative index. Figure Furthermore, the treatment strategy for synovial sarcoma was meticulously devised. Given the complexity of the tumor's location, a surgical approach was chosen as the primary intervention. The surgical procedure aimed at achieving complete resection with clear margins, thereby minimizing the risk of local recurrence. However, due to the challenging anatomical constraints of the head and neck region, obtaining wide surgical margins can be intricate. To enhance the treatment's effectiveness and address potential residual microscopic disease, a multimodal approach was adopted. This encompassed a combination of surgery and adjuvant radiotherapy. The integration of radiotherapy aimed to target any remaining cancer cells while also acting as a preventive measure against possible recurrence. This comprehensive treatment approach was tailored to not only address the immediate tumor but also to ensure long‐term disease control and optimal patient outcomes.After the completion of treatment, meticulous follow‐up was conducted to monitor the patient's progress. The patient underwent regular clinical assessments and imaging studies. Encouragingly, at the one‐year follow‐up mark, no evidence of disease was observed.3Synovial sarcoma is a rare malignancy primarily affecting the extremities, with its occurrence in the maxillofacial region being exceptionally rare. The unique anatomical location of synovial sarcoma in the maxillofacial region poses significant diagnostic and therapeutic challenges.We meticulously reviewed a collection of nine cases of synovial sarcoma in the maxillary region from the literature,It is important to note that the case we present is a singular case report, and its follow‐up period remains relatively short. Analogous to synovial sarcomas affecting extremities, metastasis or local recurrence can manifest after a certain interval. Consequently, we are closely monitoring the progress of our current patient.From the patient's perspective, undergoing treatment for synovial sarcoma in the maxillary region was a complex journey, particularly given the young age at diagnosis, which was emotionally challenging. However, post‐treatment, the absence of complications following surgery and radiotherapy sessions and the complete disappearance of disease symptoms have brought a sense of relief and optimism. The patient is now in the process of receiving prosthetic treatment, a significant step towards regaining normalcy and overall well‐being.The management of synovial sarcoma involves a multidisciplinary approach due to its aggressive nature and potential for local recurrence and distant metastasis.4Synovial sarcoma in the maxillofacial region is an exceptionally rare entity presenting diagnostic and therapeutic challenges. Our case highlights the importance of considering synovial sarcoma as a differential diagnosis in patients presenting with maxillofacial tumors, even in young children. The accurate diagnosis and optimal management of synovial sarcoma rely on a multidisciplinary approach, incorporating clinical, radiographic, histopathological, and IHC evaluations. Further research and long‐term follow‐up are warranted to improve our understanding of this rare malignancy and refine treatment strategies.Nasrollah Saghravanian: Conceptualization; formal analysis; methodology; project administration; supervision. Amin Rahpeyma: Methodology; supervision; validation. Mahsa Ghorbani: Investigation; visualization; writing – original draft; writing – review and editing. Pooya Saeedi: Investigation; visualization; writing – original draft; writing – review and editing.This study was self‐funded and did not receive any financial assistance from any organizations.The authors declare no conflict of interest.Written informed consent was obtained from the patient's parents to publish this report in accordance with the journal's patient consent policy.


We report a case of diverticulum of the buccal mucosa. A 56‐year‐old man had a small pouch‐shaped lesion behind the parotid papilla that caused pain and food impaction. After resection, the lesion was histopathologically diagnosed as diverticulum without buccal muscle tear. There has been no recurrence during 1 year postoperatively. Diverticulum is common in the colon and other areas of the gastrointestinal tract, and is generally cystic in shape, with a portion of the wall of the gastrointestinal tract protruding outward. It is thought to be caused by increased internal pressure and vulnerability of the gastrointestinal tract wall.A 56‐year‐old Japanese man was referred to our hospital with pain in the right buccal mucosa. He had previously been diagnosed with stomatitis at a family dental clinic, which was treated with corticosteroid ointment. However, his symptoms had not improved. Intraoral examination revealed a pouch‐shaped depression about 4 mm in diameter and 6 mm deep behind the right parotid papilla Figure . DiffereDiverticula are classified as congenital or acquired, unilateral or bilateral, and true or pseudo. A true diverticulum involves all layers of the structure, including the muscularis propria and adventitia, whereas a pseudodiverticulum does not involve the muscular layers or adventitia. In this case, considering that there were no findings of rupture of the muscular layer, the diverticulum was considered to be an acquired unilateral pseudodiverticulum.Diverticulum has four possible causes. The first is a defect arising from dysplasia of the buccal muscles; anatomically, the cheek is composed mainly of the buccinator muscle, which consists of three groups of muscle fiber. It has been proposed that a diverticular lesion is caused by a developmental anomaly involving partial dissection along the buccinator muscle fibers.Histopathologically, the epithelial lining of the diverticulum is continuous with the surrounding buccal mucosa and the subepithelial connective tissue is accompanied by variable amounts of inflammatory infiltrate. The muscular tissue below the connective tissue may not be continuously present.Most diverticula of the gastrointestinal tract diverticula do not require intervention if they are asymptomatic. In terms of treatment, surgery has often been performed for an oral diverticulum to address food impaction and the associated inflammation and to perform differential diagnosis.This is a rare report of a case of diverticulum of the buccal mucosa that was confirmed by clinicopathological findings and computed tomography, magnetic resonance imaging and ultrasonography. We hope that this report will assist clinicians in differential diagnosis of lesions in the oral cavity.Kazushige Koike: Conceptualization; formal analysis; investigation; resources; writing – original draft; writing – review and editing. Hinako Mori: Investigation; resources; writing – review and editing. Kazuhiro Ogi: Resources; writing – review and editing. Makiya Jin: Resources; writing – review and editing. Satoshi Ohwada: Resources; writing – review and editing. Takahiro Iwamoto: Resources; writing – review and editing. Shintaro Sugita: Resources; supervision; writing – review and editing. Tadashi Hasegawa: Supervision; writing – review and editing. Akihiro Miyazaki: Conceptualization; supervision; writing – review and editing.The authors received no financial support for the research, authorship, and/or publication of this article.The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.The study was performed in accordance with the principles of the Declaration of Helsinki. The need for ethical approval was waived by institution as this is not required for case reports.The patient provided written informed consent for the publication of this report and use of his image.


Exploratory laparotomy found the presence of a large subhepatic gossypiboma, intimately adherent to the hepatic angle of the colon and omentum and a second one adherent to the sigmoid colon, small intestine, and parietal peritoneum. The particularity of this case is given by the simultaneous presence of two textilomas with inconclusive evolution, which can make the differential diagnosis difficult to achieve. For a better assessment of the risk of occurrence of this pathology and the identification of a correct prevention strategy, we performed an extensive search and a review of all the articles published in the PubMed database, identifying 57 articles. In conclusion, emergency surgery increases the risk of this complication, and, as a result, prevention can be achieved by following existing protocols in the operating room.Gossypiboma or textiloma is a rare medical situation that can complicate the favorable evolution of a surgical case, with repercussions for the patient’s prognosis. The diagnosis can be difficult due to various clinical symptoms, the time elapsed since the surgical intervention, and the imaging often not being precise in detecting textilomas. Due to the medicolegal implications, the reporting of this event is inconsistent. We present a rare case of a 28-year-old woman who presented with vague pain in the left iliac fossa 11 months after an emergency cesarean hysterectomy was performed. The preoperative imaging examination identified the presence of a subhepatic mass with dimensions of 10 × 8 cm The medical terminology related to gossypiboma or textiloma defines the presence of an operating field, cotton compress, or surgical sponge left involuntarily in the peritoneal cavity during surgery . The mosThe diagnosis can be early, a few days after the operation, or sometimes they can be identified after many years, and it can be associated with increased morbidity and sometimes mortality. Clinical manifestations, treatment, and prognosis of gossypibomas can vary depending on the time of diagnosis and the type and intensity of tissue reactions. Thus, early postoperative, acute, exudative, or purulent inflammatory reactions can occur, with the appearance of peritonitis and abscesses, in which the clinical signs of sepsis with fever, abdominal pain, nausea, vomiting, abdominal distention, and fatigue predominate. Late postoperatively, chronic inflammatory reactions, xanthogranulomatous, aseptic fibrosis, and calcifications can be encountered when patients can be asymptomatic or oligosymptomatic with abdominal pain, transit disorders for gases and stool, abdominal distension, or determined by the compression of the respective mass .Imaging diagnosis is based on endovaginal/abdominal ultrasonography, abdominal–pelvic radiological examination, contrast-enhanced computed tomography, and magnetic resonance imaging . The difAlthough we accept that there is a risk of this undesirable medical situation occurring during surgical interventions due to the medicolegal implications, most surgeons (74%) mentioned that they did not inform the patient about the existence of a foreign body, invoking other possible causes of the indication for re-intervention .This article aims to evaluate the magnitude and risk of gossypibomas after cesarean sections, especially emergency ones, to identify the risk factors and reduce their incidence.The 28-year-old patient presented to the Filantropia Obstetrics-Gynecology Clinical Hospital, Bucharest, with chronic lower abdominal pain, especially in the left iliac fossa. The patient had two cesarean sections in another hospital . The last one was performed 16 months ago for uterine rupture prophylaxis, followed by an emergency supracervical hysterectomy due to the formation of a pelvic hematoma.2, increased consistency, and reduced mobility, which was slightly painful. Blood count, liver, and kidney function tests were within normal limits. The ultrasound examination  with dimensions of 9.6 × 5.4 × 4.8 cm3, with hyperechoic areas alternating with anechoic areas, without highlighting a capsule, without Doppler signal. A mass with the same characteristics with dimensions of 8.5 × 4.9 cm2 was identified in the upper right quadrant. The MRI  3.69 ± 6.24 years (range from 0.04 to 29 years), which indicates that in most cases, the clinical manifestations have been asymptomatic or oligosymptomatic. This is also highlighted in the study by Birolini et al., in which asymptomatic and oligosymptomatic clinical manifestations represented 12% and 71% of cases, respectively [Although a series of studies showed an increased rate regarding the time of diagnosis of gossypiboma being within the first two months, the analysis of the articles studied in this review highlighted a rate of 19.29%, with a peak of 47.36% at more than a year after the surgery. This fact is possibly correlated with the intensity of the clinical manifestations, the severe ones being found in only 17% of cases [The clinical manifestations can be varied and atypical, depending on the topography, the size of the textiloma, their number, and the possible complications that may occur, such as subacute intestinal obstruction and peritonitis. In the early detection of gossypiboma, pain is the main symptom, with palpations of abdominal formations, or it can be asymptomatic/oligosymptomatic, being detected later, after a few years ,43. In tIn the natural evolution of foreign objects retained in the abdominal cavity, processes of encapsulation through fibrotic reaction, intraluminal migration at intestinal, vaginal, and urinary bladder levels, and the formation of abscesses or fistulas can be encountered . Thus, iThe initial investigation is ultrasonographic, which describes the character of the formation, dimensions, structure, vascularization, and anatomical relationship with the neighboring structures. Afterward, the evaluation can be performed by using radiological investigations to diagnose an intestinal occlusive process of a modified anatomical topography and less of the formation due to the lack of radiopaque markers. Completing the imaging evaluation using CT and MRI increases the chances of preoperative diagnosis of this pathology ,42 Tabl.The most frequent possible complications described secondary to the presence of gossypiboma were represented by fistulas 19.29%) [.29% 19,,33,37,50The therapeutic strategy of gossypiboma is surgical, being differentiated depending on the diagnosis time and possible complications’ association. Thus, the preoperative evaluation and preparation of these cases are essential, because the association of a fistula, an occlusion, a perforation, an abscess, or an extensive adhesion syndrome involving neighboring organs can be elements that complicate the surgical intervention, and prolong operative time and the duration of hospitalization. The surgical approach can be on the same incision by open, endoscopic, laparoscopic, or robotic surgery.Late diagnosis of gossypiboma due to the intense inflammatory and granulomatous reaction with the textile material forms an important adhesive process. Early diagnosis is associated with peritonitis, requiring a quick approach to remove the textiloma. Depending on the topography of the textiloma, and the complications of its presence , its surgical removal may involve intestinal resections and anastomoses, as well as epiploic, hepatic, gastric, and adnexal resections ,11.The basic prevention related to the occurrence of gossypiboma is achieved by managing the number of pieces of soft textile material and careful exploration by the surgical team of the peritoneal cavity before closing the wound. Using textile material with radiopaque thread or chips can contribute to their rapid identification ,51 Figu.Although it represents a rare postoperative complication, gossypiboma is associated with a morbidity and mortality rate dependent on the initial pathology, the delay in establishing the diagnosis, and the subsequent postoperative evolution with serious ethical and medicolegal implications. The non-specific clinical manifestations, the imaging that is difficult to interpret, the unpredictable evolution burdened with complications, and the multidisciplinary approach are all challenges regarding the therapeutic management of gossypiboma. As a result, prevention is the best treatment for this pathology, achieved by following the surgical and the operating room protocols, managing the operative time appropriate to the surgical intervention’s complexity, and ensuring the training level of the medical staff. In the situation where we encounter this pathology, the surgical solution of the case and the professional deontology in relation to colleagues and patients are elements that contribute to an appropriate approach.


Leiomyomas are benign smooth muscle tumors, and retroperitoneal leiomyomas without coexisting uterine leiomyomas are extremely rare. Mitotically active leiomyomas, which are leiomyomas with increased mitotic activity, are rarely observed in postmenopausal women, except under the influence of exogenous hormones. This report presents a rare case of a retroperitoneal mitotically active leiomyoma in a postmenopausal woman. The patient presented with an abdominal mass and underwent surgical resection of the retroperitoneal tumor. Pathological examination revealed a mitotically active retroperitoneal leiomyoma with 31 mitotic figures per 10 high-power fields. The patient did not experience recurrence during the 2-year follow-up period. This case highlights the need to consider retroperitoneal mitotically active leiomyomas in postmenopausal women and suggests that myomectomy can prevent their recurrence. Leiomyomas are benign smooth muscle tumors that represent the most common gynecological neoplasms ; howeverAn 82-year-old woman with an abdominal mass was referred to our hospital. She had previously undergone ovarian mucinous cystadenoma with bilateral salpingo-oophorectomy 3 years prior, and had uterine leiomyoma. Abdominal contrast-enhanced computed tomography revealed a well-defined heterogeneously enhanced mass near the left ovarian artery and ureter . No signDuring surgery, we observed a retroperitoneal tumor with a smooth surface at the back of the sigmoid mesentery . The tumPathological reports revealed a smooth muscle tumor with 31 mitotic figures per 10 high-power fields, but lacking cytologic atypia and tumor cell necrosis . Based oThe patient was doing well at the outpatient follow-up at 2 years, with no recurrence.The lessons learned from this case are as follows: (i) retroperitoneal mitotically active leiomyomas can occur in postmenopausal women and (ii) myomectomy does not result in tumor recurrence.Retroperitoneal mitotically active leiomyomas can be observed in postmenopausal women. Leiomyomas are non-cancerous monoclonal tumors that arise from smooth muscle cells and fibroblasts that can exhibit various types of smooth muscle differentiation. Although various atypical localizations of leiomyomas have been reported, growth in the retroperitoneum is extremely rare . AdditioEven after myomectomy of the retroperitoneal mitotically active leiomyoma, no recurrence or metastasis was observed during follow-up. In general, classic leiomyomas have the following features: mitotic index of <5 mitotic figures per 10 high-power fields, mild cytologic atypia and no tumor cell necrosis, whereas a diagnosis of leiomyosarcoma requires at least two of the following three features; mitotic index of ≥10 mitotic figures per 10 high-power fields, moderate to severe cytologic atypia or presence of tumor cell necrosis . SeveralIn conclusion, this case report indicated that mitotically active leiomyomas can occur after menopause and are curable by myomectomy without the need for postoperative chemotherapy or pelvic radiotherapy. Further studies are required to determine the optimal treatment for mitotically active retroperitoneal leiomyomas.


The presence of isolated intraperitoneal free fluid (IFIPF) indicates the presence of mesenteric, organ, or bowel injury, which necessitates surgical exploration. The advances in computerized tomographic scanning (CT scan) allow even smaller amounts of IFIPF being detected. However, the clinical significance of IFIPF following blunt abdominal trauma remains not well-studied. Moreover, IFIPF is an unexpected condition in healthy male in the absence of mesenteric or organ injury on abdominal imaging. Herein, we presented two cases with IFIPF detected by CT scan in two healthy football male players during the World Cup 2022. The two players were managed conservatively and rejoined safely their football team during the same competition. The World Cup 2022 was one of the most impressive tournaments. One of Qatar’s expanded healthcare investments in the emergency services, such as a unique Trauma & Emergency specialized center, a dedicated trauma surgery team, emergency medical and paramedical teams, as well as prehospital medical services. These provisions aimed to ensure optimal healthcare the visitors of Qatar, athletes, as well as the citizens and country residents.Trauma surgery at Hamad Medical Corporation is a specialized field of medicine that focuses on treating all trauma patients through a team of highly qualified professionals, including surgeons, nurses, and other medical staff. Trauma Surgery, under normal circumstances, receives 250–300 patients per month in the Trauma Resuscitation Unit (TRU) at Hamad General Hospital.The presence of free intraperitoneal fluid in trauma patients, especially males, without detectable solid organ/mesenteric injury poses challenges for radiologists and trauma surgeons regarding interpretation and management . EnhanceDuring the tournament period (1 month), 434 patients were managed in the TRU; 71 of them were visitors and players. Of the 71 patients, 38 were trauma cases. Ten of the trauma cases had traumatic brain injuries, 21 had skeletal and extremity injuries, and seven had torso trauma. Football players with isolated extremity injuries were treated outside the trauma center, in a specialized sports hospital (Aspetar).Regarding these seven torso trauma cases, two cases were chest trauma. The first one was a football player treated conservatively and discharged on the next day. The second one was a visitor who experienced multiple rib fractures accompanied by pneumothorax and hemothorax, and treated with tube thoracostomy, pain control, and pulmonary physiotherapy, and was discharged after 1 week. Both patients were discharged in good condition with no reported complications.Five patients suffered blunt abdominal trauma. Among the football players with suspected abdominal trauma, we had three admissions. One of them had a pancreatic trans-section with free fluid based on imaging studies. The other two cases exhibited interesting finding of isolated free intraperitoneal fluid without any injuries of solid organs, bowel, or mesentery.A 25-year-old football player who fell and landed on his abdomen and left hip while playing, and claimed to have heard a crackling sound above his left hip as depicted in He presented to the TRU complaining of abdominal pain. He had mild tenderness in the left iliac fossa and left flank on assessment and a stable pelvis with full-range movement of the left hip.Abdominal CT with intravenous (IV) contrast  and B reNo solid abdominal organ injuries.Mild free fluid was noted in the pelvis.No abnormal bowel enhancement or bowel dilatation.No free air in the abdomen.The bones were intact.The player was admitted for one day for monitoring and pain control. He did not develop any complication and was discharged to his camp after 24 h. He was back on the field in his team on the following match.A 24-year-old soccer player was kicked by another player’s knee in his abdomen during a match  and B. HHe presented to us with lower abdominal pain. On examination, there was mild tenderness in the suprapubic area. He was voiding freely normal color urine.CT scan of abdomen and pelvis with IV contrast was performed  and B.Mild free fluid in the pelvis.No intra-abdominal solid organ injury.No free air.No bony injuries.The patient was admitted for monitoring, but the relevant medical team decided to take over the patient’s care and monitor him at the camp’s medical unit/clinic.The patient did well. Four days later, he participated in his team’s subsequent match in good physical condition with no reported surgical intervention in the camp medical facility.Football is one of the common sports with high injury rate . The abdIn nearly all athletic events, injury to the abdomen is a potential hazard, and recognizing the signs of serious damage is imperative. However, with the proper education and training, these injuries can be efficiently treated both on and off the field .The presence of free intraperitoneal fluid in blunt trauma raises concerns of abdominal organ or mesentery injury. However, the clinical significance of isolated free fluid following blunt abdominal trauma remains unclear . Isolateet al. [Advances in imaging technology have made MDCT scan the modality of choice for evaluating blunt abdominal trauma, and its sensitivity to detect small amounts of free intraperitoneal fluid is progressively increasing . Isolateet al. , reporteet al. [Drasin et al. , conductet al. [et al. [On the significance of detecting intra-abdominal free fluid without solid organ injury on computed tomography in hemodynamically stable patients with blunt abdominal trauma, Mahmood et al.  conducte [et al.  in theirIsolated free intra-abdominal fluid on MDCT scan in previously healthy male patients with blunt trauma and no solid organ, bowel, and/or mesenteric injury may be of no clinical significance. However, further studies are needed to explain and support this finding.All authors have made a substantial contribution to the concept, design of the work; and interpretation of data, drafted the article and revised it critically for important intellectual content, and approved the version to be published.The Medical Research Center of Hamad Medical Corporation has granted permission for this case report to be published on condition that no patient-identifiable data (including patient name and photograph) are included (MRC-04-23-432).None declared.None declared.Data used to support the findings of this case are included within the article.


Currently, there is no consensus on the optimal management of nonmetastatic Ewing's sarcoma of the mobile spine. However, associated to chemotherapy, aggressive surgery with en bloc wide resection seems to improve local control and survival.Primary Ewing's sarcoma (EWS) of non‐sacral spine is extremely rare, especially in middle‐age. Therapeutic strategy aims: to large tumor resection, to provide spine stability and to avoid recurrence through chemo and radiotherapy. We report a case of thoracic spine EWS in an adult treated by combined approach en bloc vertebrectomy. It accounts for only 3.5%–14.9% of all primary bone sarcomas.2A 30‐year‐old man presented with a one‐year history of a progressive, worsening back pain associated to a right intercostal neuralgia, no motor weakness or sphincter disturbance were found. There was no history of fever or trauma. Blood tests were normal and the X‐ray rechecks after making the diagnosis showed an unobvious suspect image at the level of the right pedicle of the 12th thoracic vertebra (T12) with disappearance of its normal contours Figure . MagnetiAfter receiving neoadjuvant chemotherapy based on The EUROpean Ewing tumor Working Initiative of National Groups 1999 (EURO‐E.W.I.N.G. 99) protocol including six courses of Vincristine, Ifosfamide, Doxorubicin, and Etoposide (VIDE), a new MRI showed vertebral and paravertebral soft tissue mass regression with longest axial diameters diminution of over 50% Figure . AccordiWe performed an en bloc vertebrectomy through a double approach surgery: firstly a posterior approach with pedicle screw insertion (two levels above and two levels below), remove of the healthy part of the posterior arch which allow to release the spinal cord from the tumor pseudocapsule, ligation and section of T12 roots Figure . SecondlHistopathological examination of the resected specimen confirmed classical EWS with clear resection margins and good response to chemotherapy with 97% tumor necrosis rate.Postoperative course was uneventful. After 6 weeks of the surgery, the patient started adjuvant chemotherapy and completed treatment with no evidence of disease on reevaluation at the end of therapy. Three years after surgery, the patient is surviving without neurologic deficit, X‐rays revealed consolidation Figure  and with3EWS remains an enigmatic and particular malignant tumor 100 years after its discovery. Spinal involvement most commonly results from metastasis in advanced stages of the disease, while EWS originating from the spine is rare and extremely rare if the sacrum is excluded.Definitive diagnosis requires cytological, immunohistochemical (CD99), and cytogenetic analysis of a pathologic specimen. The translocation involving chromosome 22 is identified in more than 90% of cases, and it is the landmark to differentiate EWS from other small, round blue cell tumors.Currently, early diagnosis and multimodal treatment combining surgery, chemotherapy, and local radiation therapy increases the chance of a successful outcome.Initial chemotherapy and local radiotherapy might be administered before surgery with the aim to shrink bulky and unresectable tumors, to eradicate micrometastases and for acute relief of epidural compression, but it should be noted that there is a variable sensitivity to radiation and chemotherapy due to biological heterogenecity.Although, local radiotherapy had a considerable place in the management of locally extended or unresectable spine EWS especially with epidural compression or with poor chemotherapy response, many authors emphasized the local control superiority of wide surgical resection R0 in patients with good response following induction chemotherapy. In the other hand, safe margins tumor resection, when technically achievable, allows to avoid epidural and local skin and soft tissues potential complications of radiotherapy.In fact, during the last two decades, the outcome in patients with localized disease has improved through an aggressive surgery known as en bloc vertebrectomy by combining anterior and posterior approach or from a single posterior approach as described by Tomita and al.Boriani et alHowever, en bloc resection is a highly demanding procedure that must be carefully planned and the greater surgical risk can be accepted only if it offers a safer result and is performed by specialized surgical and anesthesiology teams.Among the difficulties to be considered is the release of the spinal cord if the tumor is expanding to layer D according to WBB staging system. In this case theoretical safe margin should include the dura in the resection specimen but the cost‐to‐benefit ratio of such procedure should be carefully evaluated. Boriani and his collaborators have shown that a simple release of the dura without resection can be accepted and without proven consequence on the risk of recurrence.Compared to cases where only decompression or lesionectomy was done, patients who underwent en bloc spondylectomy had a lower recurrence rate.4Primary EWS of the thoracic spine is an extremely rare tumor. It is a challenging disease not only to treat but also to diagnosis. A high index of suspicion is needed in patients who present with few or nonspecific symptoms. Early diagnosis is essential to obtain better results and improve prognosis. In localized forms of the tumor, multi modal treatment involving neoadjuvant chemotherapy, wide en bloc vertebrectomy with solid reconstruction and adjuvant radiotherapy and chemotherapy is required for patient outcome and satisfactory quality of life.Mohamed Amine Gharbi: Data curation; formal analysis; investigation; methodology; software; writing – original draft. Houssem Eddine Chahed: Resources; software. Sana Ben Slama: Resources; software. Anis Teborbi: Supervision; validation; visualization. Ramzi Bouzidi: Project administration; supervision; validation; visualization. Mouadh Nefiss: Conceptualization; investigation; methodology; software; writing – review and editing.The author(s) received no financial support for the research, authorship and/or publication of this article.The authors declare having no conflicts of interest regarding this article.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Granular cell tumors (GCTs) are rare, typically benign, solitary neoplasms that can arise throughout the body, with reports of cases in the tongue, esophagus, colon, skin, vulva, and skeletal muscle, among others. Although GCTs are usually asymptomatic, esophageal GCTs can grow large enough to cause dysphagia. When developing the differential diagnosis for dysphagia, a broad consideration includes routine etiologies such as esophageal strictures, eosinophilic esophagitis, carcinoma, webs and rings, achalasia, and motility disorders, but GCTs may not readily come to mind. Due to their scarcity, this case report is presented to raise awareness of esophageal GCTs and emphasize key goals for diagnosing and managing this uncommon yet treatable cause of dysphagia. This case report details the clinical course of a patient presenting with a chief complaint of difficulty swallowing that was found to be caused by a subepithelial esophageal tumor discovered with esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS). Histopathological studies paired with immunohistochemical investigations of a tissue biopsy confirmed the etiology of the offending esophageal mass to be a GCT. The patient’s dysphagia resolved after endoscopic mucosal resection of the GCT, and follow-up evaluations have remained negative for recurrence. This case highlights the esophageal GCT as an uncommon source of dysphagia and the need for EGD and EUS evaluations of subepithelial esophageal lesions accompanied by histopathological analysis for a definitive diagnosis of GCT. The origin of the name of the neoplasm known as a granular cell tumor (GCT) becomes evident when microscopic tissue studies of a GCT reveal ample coarse, eosinophilic granules populating the cytoplasms of disorganized sheets of tumor cells. The borders of GCTs are often irregular and may be so poorly defined as to suggest an invasive nature . HoweverGenerally, GCTs are asymptomatic regardless of location. However, GCTs emerging near or within the esophagus can increase in size to form a bulge that blocks the esophageal lumen leading to dysphagia . Here, wA 68-year-old male with a past medical history of gastroesophageal reflux disease, erosive esophagitis, ulcerative colitis, and diverticulosis presented to the clinic complaining of a 10-month history of intermittent dysphagia to both solids and liquids but an absence of odynophagia. Physical exam findings and routine laboratory values were unremarkable. Before further evaluation could be achieved with EGD, the patient failed to attend scheduled medical appointments and lost contact with his medical providers; however, he returned to the clinic two years later with persistent difficulty swallowing. At this time, EGD revealed a smooth, round sessile nodule measuring 12 mm along its greatest dimension that projected into the lumen of the middle third of the esophagus, as shown in Figure Histopathological evaluation of a tissue biopsy stained with hematoxylin and eosin (H&E) revealed an unordered tangle of cellular ribbons intermixed with fibrous bands. Cytological features were marked by pleomorphic cell size and shape ranging from ovoid to spindle with cytoplasms dotted by plentiful eosinophilic granules, as seen in Figure The patient elected to have his esophageal GCT removed with endoscopic mucosal resection. A repeat EGD at nine months post-treatment was negative for new growth. First described in a tongue neoplasm by Abrikossoff in 1926, GCTs, also referred to as Abrikossoff tumors, are uncommon lesions known to arise almost anywhere in the body, including the oral mucosa, breast, vulva, skin, larynx, bronchus, biliary system, and esophagus . EsophagDysphagia describes the subjective sensation experienced by the patient whereby they find it difficult to swallow. This is distinct from odynophagia, which signifies pain with swallowing. Rapid onset dysphagia raises the suspicion of a foreign body lodged in the esophagus, with the most common etiology being food impaction. Conversely, when a patient complains of chronic dysphagia, a wide differential diagnosis must be narrowed with a focused history, physical exam, and diagnostic workup. An EGD can often rule out a structural abnormality, winnowing the differential diagnosis toward entities such as a motility disorder that should be investigated with esophageal manometry or gastroesophageal reflux disease. If a structural abnormality is present, the EGD may be able to stratify which type of mechanical aberration is present such as a stricture, web, ring, leiomyoma, hemangioma, gastrointestinal stromal tumor, rhabdomyoma, schwannoma, etc.When esophageal subepithelial masses are discovered with EGD, it is essential to localize the origin of the lesion further to guide management. However, due to obfuscation by mucosa, EGD alone cannot distinguish between the possible subepithelial lesions nor even differentiate between an intramural versus extramural etiology . The difEUS is typically the next step after EGD in the workup of a subepithelial mass of the esophagus -17. EUS Analysis of tissue biopsies of GCTs is key to arriving at an ultimate diagnosis because they are associated with a characteristic pathological scheme. Staining of GCTs with H&E shows ill-defined masses consisting of large polygonal to round cells with abundant cytoplasmic granules . The borAlthough malignant behavior is rare for GCTs, their treatment mainly consists of removing the mass because of the underlying potential for malignancy and the danger of metastasis to vital organs that comes with malignant neoplasms . EndoscoIn our patient, a 68-year-old male with worsening dysphagia occurring mostly to solids but also to liquids, a single 12 mm intramural nodule was uncovered with EGD. Follow-up studies with EUS, mucosal biopsy, and histopathology revealed a mass of neoplastic cells containing eosinophilic granules, which stained positive for S-100 and CD56. All findings are consistent with a benign esophageal GCT. The subepithelial mass was successfully removed with endoscopic mucosal resection, and the patient has reported a total absence of dysphagia following treatment with no recurrence on repeat EGD. Two atypical features of this case are that (1) we present the case of a GCT in a male, whereas GCTs more commonly arise in women, and (2) this esophageal GCT was found in the middle third of the esophagus, but they typically form in the distal esophagus.GCTs are uncommon, typically benign neoplasms of Schwann cell origin most frequently found in the gastrointestinal tract, skin, and respiratory tract. Esophageal GCTs are rare, but they are normally found in the distal esophagus when they do arise. Given the broad differential diagnosis for dysphagia, EGD followed by EUS to determine lesion size, location, and to obtain image-guided tissue biopsies is needed to arrive at a final diagnosis. Pathological analysis is required for diagnosis where H&E staining will show nests of large round or oval cells with copious cytoplasmic granules. Immunohistochemical studies will aid diagnosis, as all GCTs will stain positive for S-100, CD68, CD56, SOX10, neuron-specific enolase, PGP9.5, and vimentin. The preferred treatment is removal via endoscopic mucosal resection or surgical resection. Although the potential for a malignant GCT is small, GCT removal is the recommended treatment in all cases so long as the patient is healthy enough to tolerate excision. Given the rare etiology but otherwise common presenting symptom of dysphagia as seen in our patient, GCT should not be missed as a differential in evaluating patients with difficulty swallowing.