Mucoceles are cystic formations characterized by the presence of mucus-secreting epithelial cells, which enlarge when the excretory duct becomes obstructed. Posterior ethmoidal mucoceles are rare conditions that can lead to severe ocular complications requiring immediate intervention. The close anatomical proximity of posterior ethmoidal mucoceles to the optic nerve underscores their significance. In this case report, we present a case of rapidly progressing compressive optic neuropathy secondary to a posterior ethmoidal mucocele. A previously healthy forty-six-year-old woman presented with sudden visual loss in her left eye, preceded by left-sided headache and periorbital pain. Clinical examination and imaging studies revealed an oval-shaped mass within the posterior ethmoid cell compressing the left optic nerve. Emergency surgery was performed to alleviate optic nerve compression, which successfully relieved periocular pain. However, the patient’s visual acuity and visual field defect remained unchanged postoperatively. Thinning of the ganglion cell layer in the macula region was observed during follow-up examinations. The role of corticosteroids and antibiotics in visual rehabilitation and the impact of delayed surgical decompression on visual outcome remain subjects of debate. Additional cases of mucocele-associated optic neuropathy should be published and analyzed to establish optimal treatment approaches. Mucoceles are cystic formations characterized by the presence of mucus-secreting epithelial cells . When thA previously healthy forty-six-year-old woman presented to the emergency department eight hours after experiencing a sudden visual loss in her left eye. She had a 5-day history of worsening left-sided headache, as well as a three-day history of progressive left-sided periorbital and facial pain. An ophthalmological examination was conducted at a primary clinic 10 h prior to her admission to the emergency room due to orbital pain, but no significant findings were observed. Best corrected visual acuity (BCVA) was 20/20 in the right eye and light perception positive in the left eye. Notably, a prominent relative afferent pupillary defect (RAPD) was observed in the left eye, accompanied by periocular pain. The slit-lamp examination revealed no remarkable findings, except for injection of the left nasal conjunctiva. Computed tomography (CT) scans demonstrated a heterogeneous oval-shaped mass located within the posterior ethmoid cell, extending towards the optic nerve at the infero-medial side of the optic canal, where bony dehiscence was observed . The surgery was done by rhinology surgeon, ensuring the absence of iatrogenic optic nerve damage. To approach to posterior ethmoid cell, uncinectomy and partial conchotomy of middle turbinate was done. Anterior ethmoid cell was removed. Content of the posterior ethmoid mucocele was purulent and mucoid. Subsequent microbial culture analysis revealed the growth of Klebsiella aerogenes. Postoperatively, the patient received a regimen of intravenous antibiotics (Ceftriaxone 2000 mg I.V./twice a day) for a duration of three days. Remarkably, immediate alleviation of left periocular pain was unequivocally confirmed. Notably, the patient’s left eye achieved an improved best corrected visual acuity (BCVA) of hand motion (HM) on the day of the surgical intervention. Profound visual field constriction was evident during the left eye’s visual field examination, persisting unaltered even after a two-month follow-up period  and magnetic resonance imaging (MRI), play a crucial role in the diagnosis of mucocele. CT scans can reveal thinning or erosion of the bony wall, as well as outline the expansile homogeneous mass. However, bone destruction is infrequent, and MRI surpasses CT in differentiating mucoceles from other soft tissue lesions, such as neoplasms.Prompt surgical decompression serves as the primary treatment modality for optic neuropathy associated with sinus mucocele . The impOptic neuropathy can occur through three distinct mechanisms. Firstly, the sudden enlargement of a mucocele directly compresses the optic canal, leading to bony dehiscence and subsequent damage to the optic nerve. Secondly, compression can impede the blood supply to the optic nerve. Thirdly, direct spread of mucocele-initiated inflammation into the optic nerve sheath, resulting in optic neuropathy . Yumoto In our case, visual acuity and visual field worsened rapidly. And despite the successful implementation of urgent endoscopic optic nerve decompression surgery, the visual acuity remained unchanged 15 days after the procedure, as did the visual field defect.The following factors might explain the rapid visual loss and visual field loss and the reason for poor visual outcome. First, poor initial visual acuity. Second, optic canal bony dehiscence was identified from CT scan. That may result optic nerve dehiscence. Third, content of the posterior ethmoid mucocele was purulent and mucoid. Direct spread of mucocele-initiated inflammation into the optic nerve sheath might occurred. Fukuda et al. suggested that ischemia and inflammation induce an acute onset or deterioration of ophthalmologic signs and symptoms, which may indicate a poor prognosis .If the patient has optic canal bony dehiscence or purulent content in mucocele, it might be the poor prognostic factor. Furthermore posterior ethmoid cell prevalence in Korean population was revealed 47.3% in the study using computed tomography (CT) . PosteriThe publication and comparative analysis of additional cases of mucocele-associated optic neuropathy are necessary to establish an effective management.


Myeloid sarcoma (MS) is the occurrence of primitive granulocytic precursors in various extramedullary sites. It can occur as an isolated disease, present concomitantly, or during the relapse of various myeloid neoplasms. A high index of clinical suspicion is warranted owing to its varied clinical presentation, rarity of diagnosis, inadequate immunohistochemical techniques, and challenging treatment. The occurrence of myeloid sarcoma of the testis, either as an independent entity or as an initial presentation of acute myeloid leukemia (AML), is exceedingly uncommon, with only a few documented cases in the literature. In this case study, we present a patient who initially presented with testicular swelling, later identified as MS, and subsequently diagnosed as AML through a bone marrow aspirate. This report discusses the diagnostic difficulties encountered and the available therapeutic options for managing MS. Myeloid sarcoma (MS) is a neoplasm manifested by an extramedullary proliferation of immature blasts of the myeloid lineage . They arA 27-year-old male patient presented to the ED with a five-month history of a left testicular mass. Additionally, the patient reported experiencing weight loss, malaise, reduced urine output, and a gradual increase in abdominal pain and distension for three weeks. Initially, the patient had chosen to disregard his symptoms for five months, but he ultimately decided to seek medical assistance when his condition, including abdominal pain, distension, diminished appetite, and weight loss, deteriorated. Upon physical examination, the patient exhibited a distended abdomen with minimal tenderness and an enlarged left testis.Preliminary laboratory analysis revealed biochemical evidence of acute kidney injury, as well as hyperkalemia and hyponatremia. The complete blood count (CBC) displayed mild normocytic anemia and leucocytosis; however, the differential counts and platelet levels were unremarkable. Tumor lysis syndrome was ruled out as the Cairo-Bishop criteria were not met. The levels of serum alpha-fetoprotein, beta human chorionic gonadotropin (beta hCG), and lactate dehydrogenase (LDH) were found to be within the normal range Table .CT scans revealed small bowel obstruction secondary to mesenteric lymphadenopathy, bilateral hydroureteronephrosis due to ureteric compression, minimal ascites, and bilateral testicular masses (left>right) with minimal hydrocoele.The patient was managed for acute intestinal obstruction by emergency laparotomy, jejuno-jejunal bypass, mesenteric lymph node biopsy, and postrenal acute kidney injury (AKI), managed with emergency hemodialysis and percutaneous nephrostomy.After recovery from surgery, a high inguinal orchiectomy was done, and samples were sent for histology and immunohistochemistry.On cross-section, the gray-white firm mass measured 7.5x5x3.2 cm Figure . The hisA biopsy extracted from the mesenteric lymph node was subjected to histopathological examination. The initial findings indicated the presence of an undifferentiated neoplasm. Subsequently, a diagnosis of myeloid sarcoma was established, parallel to the diagnosis of TMS. The confirmation of the diagnosis was achieved through the detection of MPO positivity on the lymph node Figure . DiagnosSo, a bone marrow aspirate was performed, which confirmed AML with 26% blasts that, from flow cytometry, presented an immunophenotype of CD45+, CD13+, CD33+, CD117+, and MPO. Cytogenetic and molecular analyses were not performed due to low resource settings.The patient attained complete remission of bone marrow and lymphadenopathy after standard induction chemotherapy with daunorubicin and cytarabine (ARA-C). The patient experienced Common Terminology Criteria for Adverse Events (CTCAE) grade 3 febrile neutropenia and grade 2 diarrhea following 3+7 induction chemotherapy. However, blood cultures were unremarkable. The patient was treated with broad-spectrum antibiotics for 10 days and subsequently recovered with additional supportive measures. The patient then underwent consolidation chemotherapy with three cycles of high-dose ARA-C and is currently under evaluation for allogeneic bone marrow transplantation.Due to the patient's initial presentation with acute deterioration of symptoms, the evaluation of anemia was not possible as he was being treated for acute small bowel obstruction. In the ED, a peripheral smear was not conducted due to the absence of any indications or suspicions of hematological malignancy. Moreover, the CBC parameters were largely within normal limits, aside from the presence of mild normocytic anemia and leucocytosis. The diagnosis of AML was further complicated by a prolonged recovery period after surgery and the management of AKI. Subsequently, a bone marrow examination was performed only after the orchiectomy, and the lymph node specimen revealed the presence of MS. MS occurs in about 2-8% of AML cases . It is cThe accurate histological diagnosis of MS can often be challenging, particularly in cases with no prior history of malignancies. This difficulty also arises due to the diverse clinical presentation of the disease, its rarity, the presence of minimal myeloid differentiation, variable identification of Auer rods in histopathological specimens, and the lack of available literature on the subject ,11. RetrMS involving the testes is rarely the initial presentation of AML. Our objective in presenting this study is to underscore the importance of keeping MS on the list of differential diagnoses of isolated testicular swelling despite its rarity. Peripheral blood smears are necessary in all cases of testicular swelling. With appropriate use of immunohistochemical techniques, rapid diagnosis can be made, and treatment can be initiated swiftly, regardless of its poor prognosis.


Facial cosmetic implants are utilized for definition enhancements in the malar, mandibular, and nasal regions. Though these implants are safe in the majority of patients, notable complications such as implant malpositioning may be seen. More rare but serious complications such as infection, abscess, and intrasinus migration may also occur, such as in this case reported on a 69-year-old female with a history of bilateral malar silicone implants. Imaging findings on this patient, whom initially presented with complaints of erythema and edema in the left malar region, were notable for edema and soft tissue signs of infection around a well-visualized crescent shaped maxillary implant. Penetration of the implant into the left maxillary sinus was also noted. Diagnostic imaging played a key role in determining the cause and severity of this patient’s condition. Thus, the case reported is with an aim to familiarize radiologists with identifying and interpreting the complications of malar cosmetic implants on diagnostic imaging. Malar augmentation consists of adding volume to either the malar or submalar space to elevate the surrounding subcutaneous tissues . CurrentWe present a 62-year-old female with a four-year history of bilateral silicone malar implants that presented with a five-day history of left-sided facial swelling and erythema. The patient reported having bilateral malar implants placed for cosmetic purposes. The patient denied any other past medical history, prior facial trauma, or previous complications with her implants. CT imaging was performed on initial evaluation, displaying a visualized left malar implant penetrating into the ipsilateral maxillary sinus Figures , 2B withThe patient required endoscopic sinus surgery for removal of the offending foreign body. Systemic culture-directed antibiotic therapy was also initiated. The patient’s post-operative course was without complication following endoscopic removal.Silicone implants in the facial region are useful for cosmetic purposes due to their volume enhancing effects. While most of these implants are without post-operative complications, maladies do occur with malpositioning being the most common . InfectiIntrasinus migration of malar implants, such as that reported in this case, is a rare development that complicates the use of the conservative alternatives described. Precedent reports have found foreign body removal as the more appropriate treatment in such cases . AlthougThe use of HRCT and MRI plays a fundamental role in determining the severity of this rare but serious complication. The increasing use of such implants displays the importance in educating radiologists on methods of recognizing and interpreting signs of infection via diagnostic imaging modalities. While the diagnosis of an infected facial silicone implant begins with a thorough history and physical exam, identification of such implants on imaging, along with localized soft tissue changes suggestive of post-implantation infection or implant migration, is of key importance in diagnosing and interpreting the extent of such complications.Silastic shell cosmetic cheek implants may result in complications such as infection, abscess and osteomyelitis, with symptoms including tenderness at the implantation site, swelling, warmth, and erythema. The uses of HRCT and MRI are advantageous imaging modalities that may aid clinicians in determining the severity and extent of malar implant complications.


CT represents the gold standard in the diagnosis of gunshot lesions due to its ability to detect and stage injuries with very high sensitivity and specificity. A standardized protocol for penetrating trauma is still under debate for the use of intravenous contrast only or also rectal and oral contrast. Herein, we report a case of gunshot vaginal trauma in a 43-year-old patient presenting with vaginal bleeding. In our case, the protocol was “patient's tailored,” the intravaginal selective use of air was administered due to symptoms  and CT findings, this 2-step protocol increased diagnostic confidence and allow a correct and challenging diagnosis.Nonobstetric vaginal or vulva trauma is an extremely rare occurrence, with an incidence of < 0.2% of traumas Nonobstetric vaginal or vulva trauma is an extremely rare occurrence, with an incidence of < 0.2% of traumas  with significant vaginal hemorrhage.A 43-year-old woman was referred to our institution in emergency room settings for a gunshot injury with an entry hole in the right gluteal region, the exit wound was not appreciable at physical examination. The patient was hemodynamically stable Multidetector computer tomography of the abdomen and pelvis was performed with and without contrast. Nonenhanced, arterial, portal venous, and delayed phases were acquired.At CT examination, no intra-abdominal free air or hemoperitoneum was appreciable. The gunshot entry hole was detected in the right gluteal region and the retained bullet was localized in the left coxofemoral subcutaneous region with associated fragmented fracture of the left ischiopubic branch with evidence of multiple tiny bone pieces retained within the ipsilateral adductor muscles A–C.Fig. No signs of active bleeding or major vascular injury were appreciable. No penetrating lesions of the rectus, bladder, or uterine were detected.Following the bullet's path through the pelvis , a suspeSubsequently, the bullet retained in the left subcutaneous region was extracted.Penetrating trauma is a significant cause of morbidity and mortality worldwide and is secondary to a violation of the abdominal cavity by any object capable of penetrating the body: it comprises a wide range of mechanisms that can be divided into nonballistic (stab and puncture wounds) and ballistic trauma (gunshot wounds) Hence the importance of the CT study given its ability to detect injuries with very high sensitivity and specificity and to characterize the bullet's trajectory. CT permit to identify the trajectory of the bullet through the body in order to understand where the greatest amount of kinetic energy is transferred. In fact, the deposition of the projectile energy has various effects in different tissues: if the elastic limit of the tissue is exceeded, the soft tissues tear, the bones fracture or can make the projectile ricochet creating another wound tracks for the fragmentation of the bullet. The alterations affecting the tissue encountered by the projectile depend on its mass, on the speed of the impact, on the type of tissue encountered, on the composition and construction of the projectile and on the path of the projectile Gunshot wounds in the pelvis can inflict injuries on multiple organs and vessels simultaneously, making it therefore essential to study the bullet's trajectory in order to estimate the extent of the damage and establish the most appropriate therapeutic approach.Penetrating gluteal trauma is a common cause of admission to trauma centers, although the real incidence is unknown. Lunevicius et al., in an analytical review of 664 cases of penetrating buttock trauma, demonstrated that 95.4% of patients were young males and that bleeding and penetrating lesions of small bowel, colon, or rectum were the commonest lesions ,8. A rectrajectography, this tool is based on the connection of the entry and exit wounds by a placing cross-cursor, and using MPR reconstruction it's possible to cut planes obliquely in orthogonal planes obtaining a double-oblique orientation along bullet's trajectory CT diagnosis of penetrating trauma can be challenging, it's fundamental for the radiologist to be familiar with projectile kinetics in order to identify both subtle and overt injuries. A useful tool in CT interpretation of penetrating trauma is CT In our case, at physical examination, the entry wound was in the right gluteal region with loss of cutaneous and subcutaneous substances. At CT, the entry wound was characterized by edema and hemorrhagic infarction of subcutaneous planes and of the gluteus maximus muscle and by the presence of air bubbles. There was also evidence of hemorrhagic infarction in the right ischio-rectal fossa. The retained bullet was localized in the left coxofemoral subcutaneous with an associated fragmented fracture of the left ischiopubic.Tracing the bullet's path through the pelvis, the suspicion of vaginal laceration was raised due to the evidence of a bloody distended vagina more evident and the thickening of the perivaginal soft tissues. Intravaginal negative contrast (air) was administered and increased diagnostic confidence for the diagnosis of vaginal laceration.Our experience supports what was previously published Nonobstetric vulvovaginal lacerations are underreported and are extremely rare, an isolated gunshot laceration of the vagina represents an exceptional event. Conservative treatment is usually recommended in women with minor injuries but female patients suffering from gunshot wounds to the pelvic area should be always investigated for vaginal, urethral, anal, and bony pelvis injuries ,11. It'sWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.


Teaching Point: Subarachnoid hemorrhage is a rare complication of spinal dural arteriovenous fistulas (dAVF) with very characteristic imaging features, knowledge of which is crucial for positive diagnosis and rapid management. We report the case of 45-year-old male without a known history of neurological disease, presenting progressive weakness of lower limbs and tingling-like paresthesia. The evolution of the disease is marked by the onset of thunderclap headache. An endocranial computed tomography (CT) performed in the emergency department showed no particular anomaly. Then, a cerebral magnetic resonance imaging (MRI) was performed showing on axial images hyperintensity in the subarachnoid compatible with a peri mesencephalic subarachnoid hemorrhage space on T2 FLAIR with a normal time of flight (TOF) angiography .Cerebral angiography showed no specific findings.A medullar MRI was then suggested and demonstrated on T2-sagittal MRI  intramedAlso, it showed on axial T2  and postPatient was put under surveillance with symptomatic treatment and showed a recovered partial recovery of his motricity and sensitivity.Spinal dural arteriovenous fistulas (dAVF) are the most common spinal vascular malformations (75 to 80%) and more frequently affect male subjects over 50 years that exhibits arteriovenous shunting at the level of the internal leaflet dura mater, corresponding to an abnormal connection between the arterial supply from the medullary dura mater and the medullary venous system and no exact etiology has been fully elucidated .The clinical presentation of sdAVF is often progressive and non-specific mimicking demyelinating or degenerative diseases of the spine, which explains a frequent delay in diagnosis, resulting in an irreversible damage despite an endovascular or surgical intervention.Hemorrhage is very rare but occasionally encountered and may be a source of unexplained subarachnoid hemorrhage.MRI shows an association of centrally located hyperintense signal on T2-weighted images on TSE sequence, corresponding to chronic hypoxic congestive myelopathy attributable to venous hyper pressure hindering venous circulation, dilated peri medullary vessels, hypointense ‘flow void’ phenomena hypo intense in T2w images, appearing as enlarged and serpiginous veins anteriorly and/or posteriorly to the cord, enhancing after administration of gadolinium The absence of dilated peri medullary vessels do not formally eliminate the diagnosis of Davf. Dynamic MRA (angio-MRI) sequences are more sensitive assets to detect this abnormality.Principal differential diagnosis on imaging includes intramedullary neoplasm, spinal arteriovenous malformation where hemorrhage is common with acute onset, affecting males and females equally.Our case is unique as it depicts the importance of including spinal cord malformations in unexplained cerebral sub arachnoid hemorrhages.


Ovarian cystadenomas are rare neoplastic tumors arising from the ovarian surface epithelium. While commonly observed in adult women, their occurrence in adolescents is exceedingly uncommon. The management of large ovarian cystadenomas in this age group poses unique challenges due to acute presentations and potential complications. We present the case of a 16-year-old girl who presented with sudden, severe abdominal pain and distension. Imaging revealed a 15 cm complex cystic mass originating from the right ovary, consistent with a cystadenoma. Urgent surgical intervention led to the right salpingo-oophorectomy, confirming the benign nature of the tumor. This report highlights the importance of a comprehensive approach to diagnosing and managing rare ovarian neoplasms in adolescents. Timely recognition, appropriate imaging, histopathological evaluation, and surgical intervention are crucial for optimal outcomes and reducing potential complications. Ovarian cystadenomas are neoplastic tumors that arise from the surface epithelium of the ovaries. They represent a common subset of ovarian neoplasms and can be classified into serous, mucinous, endometrioid, or clear cell subtypes . OvarianWe present the case of a 16-year-old adolescent girl who presented to the emergency department with severe abdominal pain and distension. The patient, previously healthy, had no significant medical history or known risk factors. She was not on any medications and had no history of surgical interventions. The patient's menstrual cycles had been regular, and there were no reported gynecological abnormalities or symptoms prior to the current presentation.The patient's symptoms began insidiously one week before presentation, characterized initially by mild lower abdominal discomfort, which gradually progressed to severe, sharp pain. In the preceding 24 hours, she noticed a rapid increase in abdominal girth, leading to significant distension. The pain became excruciating, prompting her parents to seek immediate medical attention.On examination, the patient appeared in acute distress, with a pallor complexion. Her vital signs were within normal limits, except for a slightly elevated heart rate of 100 beats per minute. Abdominal examination revealed a tense, distended abdomen with diffuse tenderness and guarding. A large, firm, and mobile mass was palpated in the lower abdomen, extending above the umbilicus. Bowel sounds were present but diminished.The initial work-up included routine blood tests, which revealed a mild leukocytosis  and an elevated C-reactive protein level of 25 mg/L . Serum levels of tumor markers, including alpha-fetoprotein and beta-human chorionic gonadotropin, were within normal limits. To further evaluate the large ovarian mass and assess its characteristics, a contrast-enhanced computed tomography scan of the abdomen and pelvis was performed urgently.The computed tomography scan revealed a large, well-defined cystic mass originating from the right ovary. The mass measured approximately 15 cm in its greatest dimension and displayed peripheral areas of calcification along with multiple internal septations, enhancing solid components. The findings were consistent with a complex ovarian cystadenoma of the right ovary (Figure Given the patient's acute presentation, the size of the ovarian mass, and the potential for complications such as ovarian torsion or rupture, urgent surgical intervention was deemed necessary. The patient was counseled, and informed consent was obtained from her parents. The gynecological surgical team performed an exploratory laparotomy.Intraoperatively, a large right ovarian cystadenoma was identified, along with evidence of ovarian torsion Figure . Due to Histopathology examination of the excised mass revealed a unilocular cystic structure lined by columnar epithelium with focal areas of papillary projections. The stroma showed mild cellular proliferation and areas of calcification, consistent with the diagnosis of a benign ovarian cystadenoma Figure .Postoperatively, the patient's recovery was uneventful. She received appropriate pain management and was closely monitored in the recovery unit. The patient's condition steadily improved, and she was able to tolerate oral intake without any complications. The patient was discharged on the fourth postoperative day in stable condition. She was provided with detailed instructions for wound care and advised to follow up with the gynecological team for regular check-ups.The patient in this case exhibited an acute presentation with severe abdominal pain and distension, prompting immediate medical attention. The rapid increase in abdominal girth and the presence of a palpable mass raised concerns about a potential ovarian neoplasm . DiffereImaging studies, particularly the contrast-enhanced computed tomography scan, played a crucial role in characterizing the ovarian mass in this case. The computed tomography scan revealed a large, complex cystic mass originating from the right ovary, with internal septations, solid components, and calcification, consistent with a cystadenoma. This information guided the surgical approach and informed the decision for a right salpingo-oophorectomy, which was confirmed by intraoperative frozen section analysis. Histopathology further supported the benign nature of the tumor, guiding the subsequent management and providing crucial information for prognostication .While large ovarian cystadenomas are relatively rare in adolescents, there have been sporadic case reports in the medical literature ,5. The aThe emergent nature of the presentation and the potential for complications necessitated urgent surgical intervention in this case. The decision for a right salpingo-oophorectomy was made due to the evidence of ovarian torsion, compromising blood flow to the affected ovary . The decThe presented case of a large ovarian cystadenoma in an adolescent girl underscores the importance of a systematic and comprehensive approach to the diagnosis and management of rare ovarian neoplasms in this age group. Timely recognition of acute presentations, appropriate imaging studies, histopathological evaluation, and surgical intervention are vital in achieving successful outcomes and minimizing potential complications.


A significant percentage of lesions of endodontic origin require surgical management due to the possible diagnosis of odontogenic cysts and tumors in the maxilla and mandible. Ossifying fibroma is a benign fibro-osseous lesion that typically presents as a painless, slow-growing, and expansile lesion that appears as a well-demarcated lesion with a variable degree of internal calcification on radiography. Treatment results in a large osseous defect, utilization of a graft to fill the void accelerates healing and prevents complications that may result from failure to fill by the host response.®) used in regeneration of the osseous defect related to the lesion and resulting surgery.Following endodontic surgery placement of osseous graft material via Guided Tissue Regeneration to fill the defect aids to accelerate fill of the defect on a healthy 26-year-old female patient. A case discussing the one-step treatment of an ossifying fibroma of the anterior part of the mandible following endodontic microsurgery with associated retrograde fill of the apex, then site grating with biphasic calcium sulfate (Bond ApatiteHistologically, the ossifying fibroma is dominated by connective tissue containing cell rich areas with a few fragments of fibrosis. Moreover, in the connective tissue numerous small fragments of spongy and compact bone with areas of partial necrosis present and a significant number of inflammatory cells are observed. Surgical removal of the cyst with thorough curettage of the osseous walls and grafting of the defect provides predictable healing and the desired clinical results sought. Utilization of the biphasic calcium sulfate graft material allows the elimination of the need to overlay the area with a membrane before the flap due to its hard set and the prevention of soft tissue ingrowth into the graft material during the healing phase. Additionally, the hard set of the material allows tenting of the area to maintain the desired volume and ridge contour. Conversion of the graft material depending on the volume placed to host bone occurs over a 3–6 month period.The case report presented, as well as the authors experience mimics the literature on biphasic calcium sulfate in its use as an osseous graft material and is an effective method for the repair of osseous defects that result from the removal of tumors and cysts of the maxilla and mandible. Treatment of an ossifying fibroma is an ideal application of the use of this biphasic calcium sulfate material allowing tenting of the surgical site over the defect created after cyst removal without the need for resorbable collagen membranes. This simplifies its use and decreases material costs that may hamper patient acceptance of treatment without a decrease in expected clinical results. HighlightsA significant percentage of lesions of Endodontic origin require treatment due to the diagnosis of odontogenic cysts and benign tumors requiring surgical treatment.Ultrasonic devices and retrograde filling materials allow for proper apical preparation and backfilling of the canal of the resected tooth.Synthetic graft materials have benefits over available allograft and xenograft materials related to lower cost and have demonstrated comparable clinical results.Biphasic calcium sulfate is a biocompatible, osteoconductive, bioactive, and bacteriostatic material and well suited for filling of the cystic site following enucleation and retro fill of the canal system.1. A recent study over a 30-year period reported among all cystic lesions, 92.9% were OC and only 7.1% were nonodontogenic cysts2. Providing, a strong link to those cysts being of endodontic origin.A significant percentage of patients presenting with lesions of endodontic origin require treatment due to the diagnosis of possible diagnosis of odontogenic cysts (OC) and tumors in the maxilla and mandible. The majority of those cysts and tumors, of various etiologies, require surgical treatment. The most common lesions identified include the germinal cyst, a broadly understood root cyst, as a chronic inflammatory pathological condition, may constitute the highest percentage of recognizable lesions of this type in the maxilla and mandible. Of those reported, 54.6% were radicular cysts, 20.6% were dentigerous cysts and 11.7% were keratocystic odontogenic tumors3. These are slow-growing benign neoplasms found most often in the mandible, but may also be found in the maxilla, that is composed of bone that develops within fibrous connective tissue. Ossifying fibromas are composed of bone that develops within fibrous connective tissue. Some ossifying fibromas consist of cementum-like calcifications, while others contain only bony material; however, a mixture of these calcification types is commonly seen in a single lesion. These are divided into three variants including cement-ossifying fibroma, juvenile psammomatoid ossifying fibroma, and juvenile trabecular ossifying fibroma (JTOF) as identified histologically, but are treated in a similar fashion4. A much more aggressive course has been reported with JTOFs, which are typically observed in patients younger than 15. These rapidly increase in size, and aggressive excision or more aggressive resection with 5 mm margins is recommended depending on if the lesion is recognized early with well-confined borders within the bone. This should not be confused with the common ossifying fibroma5. Ossifying fibroma’s, mainly occur between the age of 20 and 403. These are more frequently located in the mandible, showing a definite female predilection6. Other cranial and facial bones, the periorbital, frontal, ethmoid, sphenoid, and temporal bones are also relatively common sites of this tumor7. Ossifying fibroma’s are a slow-growing lesion that is well-demarcated from the adjacent bone. Some of those lesions may grow to become massive, causing esthetic and functional deformities. Ossifying fibromas, are divided into three types which due to the presence of both bone and cementum-like tissue are described using the terms ossifying fibroma, cemento-ossifying fibroma, and cementifying fibroma11. The consensus, nonetheless is the three terms describe the same underlying type of lesion4. A much more aggressive course has been reported with JTOF and juvenile psammomatoid ossifying fibroma’s15. The treatment of ossifying fibroma’s is surgical enucleation.In addition, benign tumors constitute a smaller percentage of pathological changes in the jawbones. Some of those tumors may appear like cysts radiographically, especially in the early stages of development, as observed with the ossifying fibroma. One type found dentally is the ossifying fibroma, an encapsulated benign neoplasm composed of varying amounts of bone or cementum-like tissue in the fibrous tissue stromaVarious methods are used in the surgical treatment of OC and benign tumors; from savers (sparing) through aggressive to extremely radical treatment approaches. In the group of sparing methods, an interesting alternative to the well-known marsupialization is a two-stage treatment, in which cyst or tumor decompression is utilized first. Interestingly, a one-step method using endodontic microsurgery techniques has been successfully utilized. The development of microsurgical techniques with the use of dedicated microtools and optical instruments, such as operating microscopes make effective treatment in the operating micro area, without the need to remove excessive amounts of osseous tissue and periodontal apparatus. Additionally, ultrasonic devices and new retrograde filling materials allow for proper apical preparation and backfilling of the canal of the resected tooth.endodontic microsurgery16. One study reported that the volume of the periapical lesion had a significant effect on the outcome of endodontic microsurgery, with larger lesions having a negative factor that benefit from osseous grafting of the surgical site following endodontic microsurgery17. Moreover, a wide selection of available osseous graft are available and have been advocated ranging from allografts, to xenografts and synthetic materials.Following flap and visualization of the apical site when treating the cyst, a defect is present in the surrounding osseous area that was occupied by the cyst and resulted in resection of the apical portion of the root. Debate has circulated for many years on the need to fill the osseous surgical site. Some practitioners advocating allowing clot formation in the defect and surrounding host tissue to convert that clot to host bone. Other practitioners advocating placement of osseous graft material (guided bone regeneration) to fill the defect and accelerate fill of the defect with host bone over time. Although guided bone regeneration did not improve the clinical outcome, it did improve the quality of apical bone remodeling following ®  a biphasic calcium sulfate utilized in bone surgery in terms of its physicochemical properties, consisting of fine-grained crystals of biphasic calcium sulfate and macro-grains of synthetic hydroxyapatite. Biphasic calcium sulfate is a biocompatible, osteoconductive, bioactive, and bacteriostatic material with a long history in osseous grafting orthopedically and dentally. Those two biomaterials with a similar chemical composition with first use of biphasic calcium sulfate dates back to 189218. This material after mixing sets hard allowing tenting of the area when needed and is fully replaced with host bone over time. This material encourages cells proliferation and angiogenesis while preventing infiltration of epithelial-connective cells into the grafted area eliminating the need for an overlying membrane.Synthetic graft materials have benefits over available allograft and xenograft materials related to lower cost and have demonstrated comparable clinical results. One of those materials is Bond Apatite21. A case discussing the one-step treatment of an ossifying fibroma of the anterior part of the mandible following endodontic microsurgery with associated retrograde fill of the apex, followed by grafting with Bond Apatite was used in the regeneration of the osseous defect related to the lesion and resulting surgery.However, the innovation of Bond Apatite is a simple technique for its use. The material is contained in a disposable sterile syringe with a capacity of 1 cm. After activation of the syringes plunger, physiological saline solution is introduced into the solid components within the syringe to activate the material. After such activation, a strong chemical reaction takes place between the saline and calcium sulfate within a few minutes, hydrating the material. The resulting reaction causes the material to take a consistency of hardening cement, without the release of thermal energy permitting the practitioner to place it into the desired site prior to its setting. A barrier membrane is not required in most clinical circumstances, simplifying the procedure, that also reduces the risk of inflammatory complications related to the exposure of the augmentation after suture separation or soft tissue shrinkage. The manufacturer states a gap of up to 5 mm between the flap edges, which is important, for example, in ‘socket preservation’ procedures, does not require membrane usage and can be exposed to the oral environment and soft tissue will migrate to cover the material over a short period of time22.A 26-year-old female patient, presented with pain in the lower right mandibular anterior area on the lateral incisor. No caries was noted via clinical examination or evidence of periodontal disease and pulpal inflammation (pulpitis) was suspected. The patient reported no prior history of inflammatory symptoms and several months prior endodontic treatment had been performed on the right mandibular lateral incisor. A panoramic radiograph was taken to evaluate the tooth and surrounding area and a large periapical area was noted on the tooth Fig. . A periaInformed consent was reviewed with the patient and the form was signed. Local anesthesia  was administered via infiltration into the buccal vestibule. A trapezoidal surgical flap was reflected with vertical releasing incisions between the lateral incisor and canine and also lateral incisor and central incisor with a coronal incision 3 mm below the attached gingival sparing the papillae’s. A full thickness flap was elevated to expose the site. No significant damage was noted upon flap elevation to the facial plates external lamina. A 6 mm wide trephination hole was created over the apical aspect of the tooth to access the underlying lesion Fig. .The graft material was mixed in the syringe according to the manufacturers instructions and expressed from the syringe into the surgical site to fill the defect and compressed with dry gauze to remove any residual moisture on the material Fig. . The flaThe operative biopsy was fixed in 10% formalin and placed in a paraffin block. Slicing of the biopsy was performed on a standard microtome . Each 4 mm section was then subjected to a paraffin removal process in a 60°C incubator for 3 h. The samples were then stained with hematoxylin and eosin   a few particles may remain of the hydroxyapatite granules but are encased in host bone21.Although the resulting defect following surgical enucleation will heal without the placement of osseous graft material, when a significant sized defect is present graft placement may be advisable. This prevents collapse of the buccal aspect of the ridge during the healing phase while accelerating osseous fill of the defect and conversion to host bone compared to allowing a clot to organize. Various osseous graft materials have been advocated and supported in the literature including allografts and xenograft materialsThe case report presented, as well as the authors experience mimics the literature on Bond Apatite in its use as an osseous graft material and is an effective method for the repair of osseous defects that result from the removal of tumors and cysts of the maxilla and mandible. Treatment of an ossifying fibroma is an ideal application of the use of this biphasic calcium sulfate material allowing tenting of the surgical site over the defect created after cyst removal without the need for resorbable collagen membranes. This simplifies its use and decreases material costs that may hamper patient acceptance of treatment without a decrease in expected clinical results. Furthermore, following soft tissue flap elevation and manipulation is not necessary to get complete primary wound closure without compromise to the expected clinical results. Biphasic Calcium Sulfate is comparable with other osseous graft materials, at the 6 month follow-up, a high clinical effectiveness was observed.This was not a research study, but the case was treated in private practice and the authors are reporting the case to treatment completion.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.No funding was received for this.D.D.: treated and documented the case; O.W.: did the histological analysis; E.R.-W.: reviewed and edited the draft; G.M.K.: wrote the draft and did the literature search.No conflict of interests by any of the authors.Dr Kurtzman is corresponding author.Not applicable as this is a case report of a single clinical treatment performed in a clinical dental practice and follow-up not a research study.Not applicable.Not commissioned, externally peer-reviewed.


Cutaneous lesions are derived from the epidermis, dermis and cutaneous appendages. Whilst imaging may occasionally be performed to evaluate such lesions, they may be undiagnosed and demonstrated for the first time on head and neck imaging studies. Although usually amenable to clinical examination and biopsy, CT or MRI studies may also demonstrate characteristic imaging features which aid the radiological differential diagnosis. In addition, imaging studies define the extent and staging of malignant lesions, as well as the complications of benign lesions. It is important for the radiologist to understanding the clinical significance and associations of these cutaneous conditions. This pictorial review will describe and depict the imaging appearances of benign, malignant, overgrowth, blistering, appendage and syndromic cutaneous lesions. An increasing awareness of the imaging characteristics of cutaneous lesions and related conditions will help the framing of a clinically relevant report. The skin is the largest organ of the human body and has a complex multilayered structure. Cutaneous and cutaneous appendages lesions are diverse, but since they are usually amenable to clinical examination and biopsy, they have received little attention in the imaging literature. CT or MRI studies of the head and neck may be used to delineate and stage skin tumours but may also demonstrate previously undiagnosed lesions. It is therefore important for the radiologist to understand the relevant imaging features, associations and significance of these cutaneous conditions.The skin comprises of the epidermis and dermis . The epi It may be primary or secondary to other conditions .CVG is a rare condition resulting in skin overgrowth on the scalp resulting in ridges and furrows resembling the gyriform appearance of the brain .1 It mImaging usually demonstrates symmetric longitudinal ridges but they may be asymmetric or localised in secondary disease. Radiologists should interrogate the pituitary fossa and adjacent scalp for an underlying tumour. Keloids are generally T2 hypointense. Enhancement is variable and the degree of vascularity may indicate proliferative activity .Haemangioma is a benign vascular tumour consisting of a hamartomatous growth of capillaries . They are.g. orbit) are affected. Differential diagnosis includes congenital vascular malformations, and more aggressive vascular tumours such as Kaposiform haemangioendothelioma or angiosarcoma.Diagnosis is based on clinical assessment with imaging being potentially useful in cases of diagnostic uncertainty or to prompt treatment, when deep structures  which are keratin-filled lesions  are common cutaneous lesions. They are usually well-defined oval or spherical masses which demonstrate fluid density on CT, whilst T1 hypointensity, T2 hyperintensity and increased diffusion-weighted imaging (DWI) signal on MRI , however lesions  derived  The diagnosis is clinical but short tau inversion recovery sequences may be useful to evaluate the deep extent of abnormality and delineate abscesses  and syndromes. CT demonstrates well-circumscribed superficial enhancing masses with calcification (>80%) and variable enhancement  and hamartomas (Cowdens).Cylindromas are appendage tumours of uncertain histogenesis but with a folliculosebaceous distribution. Whilst usually small, there may be large coalescing (turban tumours) of the scalp and forehead. Multiple cylindromas occur in Brooke-Spiegler syndrome, where multiple scalp nodules may be demonstrated on imaging .7 OtheNodular hidradenoma is a benign dermal-based skin appendageal neoplasm most commonly occurring in the scalp and face. It presents as a slow growing solitary solid or cystic lesion, with no overlying connection to the epidermis. Imaging appearances are non-specific with CT and MRI demonstrating solid enhancing and cystic components  with posMalignant cutaneous lesions will be diagnosed clinically and by biopsy. Imaging may be used to evaluate the depth of the carcinoma, adjacent structures involvement, metastatic involvement and recurrent lesions. Occasionally, there may be a primarily exophytic lesion with a keratin horn  (65%), followed by B-cell lymphoma (BCL) (25%).The initial patch, plaque or erythroderma stages are difficult to discern on imaging, however, there is subsequently a “thorny” extension to the subcutis due to lymphatic infiltration. On CT/MRI, cutaneous TCL may show diffuse skin thickening, nodularity and ulceration. Whilst more typically occurring on the trunk, they may occur in the head and neck. Cutaneous BCL often presents as an isolated nodule/mass , and are They typically demonstrate avid contrast enhancement and may appear heterogenous due to haemorrhage. Kaposi’s sarcoma is a further low-grade sarcoma which may be AIDS-related. It rarely involves the face but is characterised by marked enhancement.Dermatofibrosarcoma is a rare, slow growing cutaneous sarcoma which develops in the dermis and typically protrudes superficially. Deeper infiltration is described involving the subcutis, and muscle . The heaEpidermolysis bullosa (EB) is a rare genetic blistering disorder characterised by epithelial fragility, resulting in blistering  after miSWS is a rare, sporadic neurocutaneous syndrome characterised by eye, skin and meningeal angiomatosis, as well as a facial cutaneous capillary malformation (port wine stain) in an ophthalmic division of V1 nerve distribution.Imaging plays a crucial role in diagnosis and establishing intracranial ancillary features. Imaging findings  include NF1 is a multisystem genetic neurocutaneous disorder. Cutaneous neurofibromas may be limited to the skin. Plexiform neurofibromas are deeper lesions, however, cutaneous/subcutaneous involvement is common. Plexiform neurofibromas  are moreWhilst cutaneous lesions are usually diagnosed clinically or after biopsy, imaging plays a key role in assessing disease extent and associated complications. Although some imaging appearances are non-specific, those characteristics features of cutaneous lesions listed in


Peritoneal carcinomatosis (PC) refers to metastatic spread of tumor into the peritoneal cavity. Earlier, PC was thought to be associated with grave clinical outcome. However, various advances in treatment options including cytoreductive surgery and heated intraperitoneal chemotherapy or early post-operative chemotherapy can prolong survival of patients with peritoneal carcinomatosis. These treatment options are associated with high morbidity and mortality. The purpose of this article is to acquaint the radiologist about various appearances of peritoneal carcinomatosis in order to help clinicians in selecting candidates for surgery and avoid unnecessary potentially debilitating surgeries in patients with unresectable PC. Peritoneal carcinomatosis refers to spread of malignancy along peritoneal lining. Earlier peritoneal carcinomatosis was considered to carry grave clinical prognosis with short survival life post diagnosis. Nowadays, many therapies like cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) or early post-operative chemotherapy (EPIC) are available for treatment of PC. However, these surgeries are associated with high mortality and morbidity and hence should be done only in patients who are appropriate candidates for surgery in whom surgery is expected to increase survival. Patients with unfavourable sites of involvement by PC should be identified so that potentially debilitating surgeries can be avoided in these patients.The peritoneum is the largest serous membrane covering the abdominal cavity. It consists of two layers, the outer parietal layer, which lines the abdominal cavity and pelvis, and the inner visceral layer, which covers intraperitoneal visceral organs. Several folds of visceral peritoneum suspend the visceral organs in abdominal cavity and divide the abdomen into various compartments.The abdominal cavity is divided into supra and inframesocolic compartments  by trans1The left supramesocolic compartment consists of perihepatic and subphrenic spaces. Perihepatic space is divided into anterior (between diaphragm anterosuperiorly and left lobe of liver posteriorly) and posterior (posterior to left lobe of liver and anterior to stomach and gastrohepatic ligament) compartments. The left subphrenic space is divided into anterior part  and posterior (perisplenic) compartments .It is divided into right and left parts by mesentery which extends from ligament of Treitz to ileo-cecal junction. Inframesocolic compartment consists of right and left paracolic gutters  and mesentery. The right paracolic gutter is wider and communicates freely with the right SM compartment while the left paracolic gutter is shallow and separated from the left SM compartment by phrenicocolic ligament . In maleThe potential space between parietal and visceral layers of peritoneum is called the peritoneal cavity and is filled with a small amount of peritoneal fluid, which allows frictionless movement of visceral organs within the abdominal cavity.There is a distinct pattern of flow of peritoneal fluid in abdomen  2]. In . In 2]. 8Direct spread: Tumours can spread by direct invasion of peritoneum and mesentery. GI tract and pancreatic malignancies spread by this route [is route .Hematogenous spread: Lung, breast cancer, and melanomas can spread by this route. The metastatic deposits are usually located along antimesenteric border of small bowel in the case of hematogenous seeding.Lymphatic spread: Lymphomas and various malignancies can spread through lymphatics with resultant enlarged lymph nodes/lymph nodal masses.Peritoneal seedingMDCT of the thorax and abdomen following oral positive and intravenously administered contrast in the current modality of choice for suspected peritoneal carcinomatosis. Oral positive contrast helps in detection of hypodense serosal deposits on the bowel surface, but calcified deposits and subtle enhancing bowel wall thickening can be missed . A scan The various sites and patterns that must be looked for in CT scan in suspected case of PC are as follows:1) Extraperitoneal disease – including pleural effusion, pleural thickening, nodules, lung metastases, and retroperitoneal lymph nodes/masses (s/masses . Presenc2) Surface deposits – on solid organ  surface. They appear as nodules/plaques/biconvex masses with or without scalloping of liver surface ( surface .3) Intraparenchymal deposits – in visceral organs can appear as well-/ill-defined hypodense nodules with or without peripheral enhancement on arterial phase which become homogenously hypodense on venous phase (us phase . Deposit4) Peritoneal ligaments – deposits appear as enhancing nodules/plaques/masses at sites of ligaments.The various peritoneal ligaments and fissures, which can serve as sites for lodgement of metastatic deposits, include:a) Perihepatic fissures/ligaments (igaments  includinb) Lesser omentum (gastrohepatic ligament): It connects the left lobe of the liver with lesser curvature of stomach. Gastric cancer can spread along the liver surface by this route. It is also connected to the hepatoduodenal ligament, which serves as transport medium for pancreatic cancer along liver surface, porta hepatis, and stomach ( stomach .c) Hepatoduodenal ligament: It connects the porta hepatis to the duodenum and contains the main portal vein, common bile duct, and hepatic artery. It serves as conduit for the spread of pancreatic cancer (c cancer .d) Greater omentum ( omentum : It conne) Gastrosplenic ligament (ligament  and 3c: 5) Serosal deposits  Mesentery (esentery : Mesente7) Pelvis  Pelvis : Metasta8) Peritoneal lining: Usually the peritoneal lining is not visible or seen as a discontinuous line on CT. In PC, peritoneal involvement appears as continuous peritoneal thickening, irregularity, and enhancement, nodules, or masses. Ascites can be seen.9) Sites of stasis of peritoneal fluid  deposits and deposits in specific sites such as the right subphrenic space, lesser sac or mesenteric root, and serosal deposits 15161718.151617MRI is usually used in cases where CT is inadequate/doubtful for presence of metastases 2122. MRI21However, MRI is not routinely used to due to cost issues and prolonged scan time.USG can detect intraparenchymal deposits, surface deposits, ascites, and larges deposits in mesentery; however, complete evaluation of abdominal cavity is often inadequate. Nowadays, USG is reserved for percutaneous biopsy of lesions on real-time imaging 15.FDG PET-CT is more accurate than FDG-PET or CT alone and gives functional as well as anatomic information. Lesions not well delineated on CT are better assessed on PET-CT, which shows FDG-uptake due to increased glucose metabolism in malignant tissues. Metabolic tumor burden measures derived from PET-CT, namely metabolic tumour volume (MTV) and total lesion glycolysis (TLG) offer prognostic information in peritoneal carcinomatosis. However, diffuse extensive peritoneal deposits show mild uptake on PET-CT, an inherent limitation of PET-CT in peritoneal malignancies 26. False262728Earlier, peritoneal carcinomatosis was managed by palliative chemotherapy. Various advancements in treatment strategy of PC have been developed over years which include peritonectomy and visceral resections. In a study conducted by Elias et al., median survival was observed to be 23.9 months in the standard group receiving systemic chemotherapy versus 62.7 months in the patients who underwent CRS and HIPEC . The var34353734An important criteria to be mentioned in the radiological report is the peritoneal carcinomatosis index (PCI). This index was given by Sugarbacker et al. and is a measure of evaluation of volume and extent of peritoneal carcinomatosis 43. It is33LS0- No intraperitoneal diseaseLS1- Lesion size < 0.5 cmLS2- Lesion size between 0.5 to 5 cmLS3- Lesion size > 5 cm, confluent mass/cakingScores in 13 parts of the peritoneal cavity is summed up to give PCI, which ranges from 0 to 39. A PCI score greater than 20 generally precludes complete cytoreduction. Moreover, involvement of jejunal regions 9 and 10 has more unfavorable prognosis than involvement of ileal regions 11 and 12 48. In a While planning for CRS, the tumor entity should also be taken into account, along with PCI. For example, patients with peritoneal carcinomatosis of colonic origin with a PCI ≤ 20 qualify for CRS and HIPEC while the PCI in patients with gastric cancer should be < 10 or ≤15 52.In patients with pseudomyxoma peritonei arising from mucinous neoplasms PCI > 20 is no absolute exclusion criteria since these patients have good prognosis despite high tumour load. In these patients, tumour grading, extent of mesenteric invasion, liver metastasis, and age play an important role in conjunction with PCI . For patPresence of extraperitoneal disease Presence of intraparenchymal depositsPresence of hepatic or splenic hilar depositsNumber, site, and size of peritoneal deposits Presence of ascites, peritoneal thickening, enhancement, and irregularityPresence of deposits > 5 cm in longest dimensionPresence of bowel wall thickening with or without obstructionPresence of ureteric involvement Presence of deposits adjacent to IVC, aorta, or other major vesselsPresence of deposits in mesenteric root/involving proximal aspect of celiac trunk, SMA, SMV, and IMA. Presence of extensive mesenteric involvement in the form of stellate mesentery/diffuse nodularity/root involvement.Abdominal/pelvic wall involvementCalculation of CT-PCIFinal comment if the disease is resectable/resectable with increased surgical complexity/unresectableRecommendation of additional imaging (MRI/PET-CT) when in doubt.In the early 1990s, Sugarbaker et al. introduced cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as a new innovative therapeutic option for selected patients with peritoneal carcinomatosis 55.CRS consists of numerous surgical procedures depending on the extent of peritoneal tumour manifestation. Surgery may include parietal and visceral peritonectomy, greater omentectomy, splenectomy, cholecystectomy, resection of liver capsule, small bowel resection, colonic and rectal resection,  gastrectomy, lesser omentectomy, pancreatic resection, hysterectomy, cholecystectomy, ovariectomy, urinary bladder resection, and Hudson procedure . In patients with mucinous tumours and infiltration of the umbilicus, an omphalectomy is necessary 57.The residual disease is classified intraoperatively using the completeness of cytoreduction (CCR) score.CCR-0 indicates no visible residual tumor and CCR-1 residual tumor nodules ≤ 2.5 mm. CCR-2 and CCR-3 indicate residual tumor nodules between 2.5 mm and 2.5 cm and > 2.5 cm, respectively .In vitro studies could show that hyperthermia may potentiate the cytostatic effects. Moreover, hyperthermia leads to direct cytotoxic effects such as protein denaturation, induction of apoptosis and inhibition of angiogenesis . For theRecent developments include the use of CO2 recirculation and laparoscopy assisted HIPEC.In a systematic review of 24 studies (2787 patients) performed in 2009 by Chua et al. , the oveSmall bowel perforations and anastomotic leaks are the most common and clinically significant GI complications after CRS and HIPEC. Preventive measures such as preservation of the gastroepiploic arcade and prophylactic suture of the greater gastric curvature can reduce the risk of gastric perforation .Other complications include surgery related complications like intra-peritoneal abscesses, pancreatic fistulas, biliary fistulas, chyle leak, prolonged ileus, gastric stasis, venous thromboembolism, urinary tract and vascular access infections, pleural effusion, pneumonia and chemotherapy related complications like neutropenia, anemia, thrombocytopenia, heart, liver, and renal toxicity .Ozone possesses direct cytotoxic activity on tumour cells and also activates immune system to kill cancer cells along with activation and up-regulation of antioxidant enzymes. Intraperitoneal ozone therapy results in local oxidant activity without multi-organ toxicity. In a study conducted by Bocci et al., patients with advanced-stage peritoneal carcinomatosis who underwent intraperitoneal ozone therapy showed prolonged survival .In photodynamic diagnosis, photosensitizers like 5-aminolevulinic acid and its derivatives are used. 5-ALA is taken up specifically by cancer cells which express β-amino acid transporter. 5-ALA is converted into protoporphyrin IX which on exposure to light exhibits fluorescence. These fluorescent properties are highly useful for the identification of cancer tissues during surgery and facilitate the accurate and more comprehensive fluorescence-guided resection of cancer tissues. PDD has been proved to be more sensitive in detecting metastases in gastric  and pancRIT offers parenteral administration of therapeutic radiation with highly specific anti-tumour antibodies, making it well-suited for treatment of PC . In RIT,In their study, single-cycle treatment significantly prolonged median survival approximately two-fold in comparison with controls (P = 0.007). With three-cycle therapy, 75% survived long-term (MS > 183 d).2). In a study undertaken by Drecoll et al. [Alpha-particles kill cells due to induction of double strand breaks in DNA with a high relative biological effectiveness. As the range of the particles is only 28-100 mm in mammalian tissues, the development of carriers mediating specific uptake into the nucleus of tumour- or tumour endothelial cells is important to optimize therapeutic efficacy. Due to its high linear energy transfer, short half-life, and uncomplicated use, 213Bi is promising for medical applications which release alpha particles. F3 (vascular tumour homing peptide F3) is internalized into the nucleus of tumour cells and tumour endothelial cells in vitro and in vivo . DTPA chl et al. , the meaPseudomyxoma peritonei is characterised by spread of thick mucinous material within the peritoneal cavity due to rupture of mucinous neoplasms . It mostMost peritoneal lymphomatosis are non-Hodgkin Lymphoma type. Peritoneum is mostly secondarily involved by pre-existing lymphoma elsewhere with primary peritoneal lymphomatosis a rare occurrence . On CT, 71Malignant mesothelioma is an uncommon neoplasm originating from mesothelial cells or mesenchymal cells of pleura, peritoneum, or pericardium . Radiolo74This condition is characterised by presence of multiple leiomyomas within peritoneal cavity. It usually occurs in female with history of Cesarean section/hysterectomy or myomectomy . RadioloSpread of tuberculous infection into the peritoneal cavity can occur via hematogenous, lymphatic or direct spread . TubercuIn the wet type, ascites along with peritoneal thickening, necrotic mesenteric lymphadenopathy is seen. Fibrotic fixed type is characterised by large omental masses with matted and tethered bowel loops and while in dry type, caseous nodules, fibrotic peritoneal reaction and adhesions are seen with no ascites.Management of peritoneal carcinomatosis has evolved significantly in recent years. Radiologists play a pivotal role in the selection of patients who can benefit from CRS with HIPEC/EPIC, which prolong survival in these patients. Incorrect selection of patients for surgery can result in increased morbidity and mortality in unsuitable candidates.


Introduction: Hand masses are fairly common. While most of these masses are either ganglion cysts or benign tumors, masses in the first web space are not rare, and they may in fact represent a variety of lesions. These include both benign and malignant tumors, metastases, or congenital and anomalous structures, and may involve nerves, vascular structures, connective tissue, and joints.Methods: In this retrospective case series, data on 12 cases of first dorsal web space hand mass treated at our center over a period of five years were collected and analyzed.Results: Twelve consecutive patients presenting with a first dorsal web space hand mass over a period of five years were reviewed. This represented a group of nine females and three males, with a mean age of 53 years (range = 16-70 years). Seven patients had a mass on the right side and five on the left side. The surgical approach to resect the mass in all 12 patients was dorsal. The most common diagnosis was ganglion cyst (50%), followed by lipoma (25%) and aneurysm (16.6%). There was one case of eccrine spiradenoma.Conclusion: First dorsal web space hand masses can encompass multiple different pathologies, and the first web space has an intricate anatomy. Both of these factors mandate a careful approach that includes meticulous preoperative planning with appropriate advanced imaging studies, which helps to make the surgical procedure more efficient and accurate. Clinical anatomyRadial Artery and Radial Sensory NerveAn artery to the dorsal ridge of the scaphoid is a direct branch from the radial artery in 75% of cases and it originates from the radiocarpal or intercarpal artery in 25% of cases . NumerouTendons, Muscles, and JointsVariations of the extensor tendons of the hand are common, and the vast majority of those variations are asymptomatic throughout the life of the individual. However, they may present as a dorsal mass. These anomalous muscles are closely related to the extensor indicis proprius tendon and may overlie the first web space . VariatiThe purpose of this article is to present 12 cases of first dorsal web space hand masses collected over a period of five years from our practice and to discuss a diagnostic approach to include preoperative history, physical examination, and appropriate imaging studies in conjunction with an anatomical understanding of this area.Study designTwelve consecutive patients presenting to the University of New Mexico Hospital with a first dorsal web space hand mass over a period of five years were reviewed to formulate this retrospective case series.Inclusion and exclusion criteriaPatients presenting with a first dorsal web space hand mass were included in the study. Any other hand masses were excluded.Data collectionPatient information obtained from the charts included clinical symptoms and signs, imaging studies, preoperative and postoperative diagnosis, surgical findings, pathology report, and follow-up data regarding the recurrence of the lesion and patient outcomes.Twelve consecutive patients presenting with a first dorsal web space hand mass over a period of five years were reviewed. This represented a group of nine females and three males, with a mean age of 53 years (range = 16 to 70). Seven patients had a mass on the right side and five on the left side. The surgical approach to resect the mass in all 12 patients was dorsal. The most common diagnosis was ganglion cyst (50%), followed by lipoma (25%) and aneurysm (16.6%). There was one case of eccrine spiradenoma.Four out of six patients presenting with ganglions complained of a painful mass, and the remaining patients reported no pain. All the ganglions were transilluminated and the diagnosis was made on clinical grounds. MRI was performed on three of those patients and was useful in determining the origin of the ganglion. During surgery, it was observed that the most common origin of the ganglion was from the second metacarpal-trapezoid joint (3/6), followed by the first carpometacarpal joint (2/6) Figure , and theOne of the patients presenting with the first carpometacarpal joint ganglion had X-ray findings of osteoarthritis in that joint. None of the patients whose diagnosis was a lipoma complained of pain. However, one of them (1/3) complained of paresthesia along the median nerve distribution. The MRI was diagnostic in all those patients Figure .The two patients diagnosed with radial artery aneurysms presented with a painless pulsatile mass. One of them had a history of penetrating injury (pseudo aneurysm) Figures , 4, and The patient diagnosed with eccrine spiradenoma had a history of a hand mass resection four years previously. At that time, no pathologic studies were performed. The recurrent hand mass was painless. MRI was performed and was nonspecific. Our preoperative diagnosis was a giant cell tumor. The MRI, although nondiagnostic due to the nonspecific appearance of the lesion, excluded a vascular origin, a ganglion, or a fatty lesion (lipoma), and pointed to the fact that the lesion did not appear to originate from the adjacent tendon sheath.The mean follow-up of these patients was one year and nine months. There was no local recurrence of the mass in any of the patients at the latest follow-up.The differential diagnosis of a first dorsal web space mass may be extensive and our cases may be unrepresentative of the true occurrence of each of these lesions. We did a literature review and found that there are case reports describing one or two cases of first dorsal web space masses, which makes our case series the largest on this subject to our knowledge -11.A good history and physical examination complemented by imaging studies that may include both routine plain radiographs and MRI studies are usually conducive to the correct diagnoses ,13. We fGanglion cysts are the most common hand masses and corresponded to half the cases in our series. The ganglion may, however, originate from multiple sites, including the radioscaphoid and scapholunate interval, scaphotrapezial joint, and first and second carpometacarpal joints ,14. GangLipomas were the second most common tumors that we encountered in this group of patients, although they occur infrequently in the hand and wrist area . They usIn this series of patients, we encountered two cases of radial artery aneurysms. The diagnosis is usually straightforward when a pulsatile mass over an artery is found. It is important to differentiate a true aneurysm from a false aneurysm (pseudoaneurysm) .False aneurysms can occur secondary to penetrating trauma of the vessel wall with subsequent hemorrhage (case 11). The lumen of the false vessel is in continuity with the true vessel; however, it is devoid of an endothelial lining. True aneurysms occur after injury to the vessel that permits gradual dilatation of the vessel. Whereas false aneurysms usually occur after penetrating injuries, true aneurysms are the result of blunt or repetitive trauma. Atherosclerotic arterial disease is a predisposing factor for aneurysms, since it weakens the vessel wall, allowing gradual vessel dilation to occur, especially in the setting of high blood pressure (case 12). The natural history of both is characterized by slow progression, leading to thrombosis or embolism . MRI witThe occurrence of one case of eccrine spiradenoma emphasizes the fact that virtually any tumor can occur in this area. This tumor of sweat gland derivation most commonly occurs in the trunk and head. It is considered a rare tumor in the hand with only a few cases reported in the English literature ,19. The In conclusion, first dorsal web space hand masses can encompass multiple different pathologies, and the first web space has an intricate anatomy. Both of these factors mandate a careful approach that includes meticulous preoperative planning with appropriate advanced imaging studies, which helps to make the surgical procedure more efficient and accurate. If there is a question regarding the diagnosis prior to surgery, a fine needle aspiration biopsy can be considered. Other diagnostic studies that can be considered include an ultrasound.


We present a rare clinical case of a 64-year-old patient with a pigmented lesion localized in the left buccal mucosa. Subjective complaints of slight pain and discomfort in the process of eating and increased sensitivity when consuming hot food were reported. According to the information provided by the patient, the lesion had progressively increased in size. A history of previous dental manipulations was reported, namely, the extraction of teeth with amalgam obturations in the left half of the maxilla as per relevant indications. During the intraoral examination, a flat, black-colored lesion, 0.4 cm in diameter, with well-defined borders was observed in the buccal mucosa. Teeth 25, 26, and 27 were previously extracted five to seven years ago. An orthopantomography was performed as a routine procedure. It did not show any presence of X-ray contrast areas that could explain the symptoms of the patient. The symptomatic nature of the lesion as well as the negative radiological findings prompted surgical treatment and excisional biopsy with subsequent histological evaluation to rule out oral malignancy. An excision was performed. During the follow-up examination in the next eight days, all the symptoms of the patient were gone. The conclusion of the pathology report was "histological findings and clinical data consistent with amalgam tattoo". The amalgam tattoo is the most frequent iatrogenic pigmented lesion of the oral mucosa, which results from the implantation of amalgam particles in the soft tissues and it is usually asymptomatic. In this case, no surgical treatment is needed. However, in some rare cases, like the one we are presenting, some symptoms can occur and complicate the diagnostic process. In these cases, the complete excision of the lesion is to be performed with subsequent histological evaluation. The atraumatic intervention of teeth, obturated with definitive amalgam fillings, is a main factor for preventing this kind of pigmentation of the oral mucosa. The term “pigmentation of the oral mucosa” covers a wide range of conditions or lesions related to the change of the color of the oral tissues. In their research from 2008, Meleti et al. classified the pigmentations into endogenous and exogenous according to their etiology. Endogenous pigmentations include melanin, hemoglobin, hemosiderin, and carotene, which are deposited in the soft tissues in various ways. Exogenous pigmentations are most often related to the implantation of foreign bodies in the oral mucosa .The amalgam tattoo is one of the most frequent reasons for intraoral exogenous pigmentations. According to different research, the incidence of amalgam tattoos in pigmented oral lesions can vary greatly, between 0.4% and 0.9% for the adult population in the USA and 8% in Sweden . This tyThe amalgam pigmentation is most frequently localized on the gingiva and alveolar mucosa, but the lesions could also be found on the buccal mucosa, on the floor of the oral cavity, on the palate, and/or on the tongue. The usual clinical finding is of a localized, flat, gray and blue lesion with greatly variable size 2-19 mm). Usually, there are no signs of inflammation on the lesions’ periphery. In some cases, if the amalgam particles are sufficiently big, they can be found with the use of an X-ray. In this case, the diagnosis of amalgam tattoo will be based on the clinical and X-ray findings. In case of doubt, in order to confirm the diagnosis, an excisional biopsy is done 9 mm. Usu-7.A 64-year-old female patient without concomitant diseases visited the Department of Oral Surgery, DDM - Varna. She had noticed a discoloration on the buccal mucosa about a month ago - a pigmented lesion in the area of the left buccal mucosa, and had subjective complaints of slight pain and discomfort while eating and increased sensitivity when consuming hot food. According to the information provided by the patient, the formation has progressively changed in size. A history of previous dental manipulations was reported, namely, the extraction of teeth with amalgam obturations in the left half of the maxilla as per relevant indications. During the intraoral examination, a flat, black-colored lesion, 0.4 cm in diameter, with well-defined borders was observed on the buccal mucosa. Teeth 25, 26, and 27 were previously extracted five to seven years ago Figure .As a routine procedure, an orthopantomography was made. It did not show the presence of X-ray contrast areas that could explain the symptoms of the patient Figure .A consultation with a maxillofacial surgeon was conducted. The symptomatic nature of the lesion as well as the negative radiological findings for contrast areas prompted a surgical treatment and excisional biopsy with subsequent histological evaluation to rule out oral malignancy.The surgical treatment was undertaken after a thorough antiseptic of the operative field using a Braunol solution. Local infiltrating anesthesia was applied with 0.5 ml Ubistesin forte. Using a leaf incision around the lesion of the mucosa in the left buccal area, the latter was excised within clear gross surgical margins. It was fixed in a 10% solution of formalin and sent for histological examination. After a thorough hemostasis, the wound was sutured with 4/0 non-resorbable monofilament.Postoperatively, at home, the wound was treated by the patient with Listerine locally, three to four times a day. The postoperative period was smooth, without swelling and complaints Figure . During The histological examination revealed the presence of single, scattered perivascular lymphocytes and scarce black extracellular pigment in the lamina propria. The pigment had no association with cellular elements like nevus cells and was absent in the overlying squamous epithelium. The conclusion of the pathology report was "histological findings and clinical data consistent with amalgam tattoo" Figure .During the follow-up period of six months, which the patient describes as uneventful, none of the symptoms occurred again.Pigment lesions in the oral cavity can be divided into physiological and pathological. Physiological ones include only ethnic pigmentation. All other pigment colors are pathological and are divided into exogenous and endogenous. Exogenous pigments are drug-induced lesions, tobacco-chewed/smoking pigmentations, heavy metals induced, and amalgam tattoos. Endogenous are lesions caused by endocrine disorders , the syndrome associated (like neurofibromatosis and hemochromatosis), infectious agents , posttraumatic and postinflammatory chronic irritation, reactive lesions , and neoplastic lesions  .According to another classification, there are two groups of pigmented lesions of the oral cavity depending on the type of the pigment that causes them - melanin-associated lesions, which refer to the melanin pigment  and lesions caused by other pigments  .Physiological (ethnic) pigmentation is related to greater melanocyte activity. Development is usually in the first two decades of life and is common for the African, Asian, and Mediterranean populations. Intraorally, the clinician can notice pigmentations that vary from light to dark brown and are located on the attached gingiva, buccal mucosa, hard palate, lips, and tongue. These lesions are asymptomatic and appear as a well-demarcated, ribbon-like band that can spread to the marginal gingiva. No treatment is required ,4.Melanocytic macules are benign lesions, most commonly located on the lower lip. They are caused by increased melanin production without an increase in the number of melanocytes. Melanotic macules are present with smooth, well-demarcated borders and are usually small in diameter, below 1 cm. The color varies from light to dark brown and is homogeneous within each lesion. As they are of benign nature, the treatment of these lesions includes excisional biopsy and histological examination. Once the diagnosis is confirmed, no further treatment is required. These lesions are not known to transform into melanoma .Melanocytic nevi are lesions most commonly present on the buccal mucosa. Their color is brown or blue. They can be classified histologically as junctional, intramucosal, or compound nevi. The intramucosal is the most common lesion and is typically light brown in color and dome-shaped. The clinical differentiation between a nevus and an early form of mucosal melanoma may be difficult if the location is the palate. Transformation of oral pigmented nevi to melanoma has not been well-documented. It is believed that melanocytic naevus may be a precursor lesion to oral melanoma. The recommended treatment plan is again an excisional biopsy and histological examination ,3,6.Malignant melanoma is a rare lesion on the oral mucosa and constitutes less than 1% of all oral malignancies. Usually, malignant melanoma lesions are found on the palate but can be present on other oral mucosal sites. Clinically, these lesions are most commonly asymptomatic and slow-growing, their color is brown or black, and their borders are asymmetric and irregular. Oral melanomas tend to grow rapidly, and ulceration, bleeding, pain, and bone destruction may be present. Some of these lesions may be amelanotic. The guideline for treatment is radical surgical excision with histologically verified clear margins. Chemotherapy and radiation therapy are ineffective, which means that the early detection of oral melanoma is key for a better prognosis ,5.Blood pigmentations in the oral mucosa can be induced by the accumulation and degradation of hemoglobin to biliverdin and bilirubin. Extravasation of blood is the cause and is commonly associated with trauma. Clinically, the lesions are red to black in color and not painful. Treatment is not required if the lesions are not infected ,8.The increased levels of heavy metals  in the blood are known as causes for changes in the color of the oral mucosa. In adult patients, the most frequent cause for such increased levels is exposure to heavy metal vapors. The pigmentations are clinically observed as a black and blue line around the border of the gingiva. Depending on the type of heavy metal, many systematic symptoms and conditions can be related to chronic exposure. The most important aspect in order to prevent systematic toxic complications in the case of oral mucosal pigmentation is the identification and treatment of the main cause ,7.Dental amalgams are the oldest obturation material, with over 150 years of history. Depending on the sputtering technology that determines the form of the particles in the powder, there are two types of amalgam alloys - lathe-cut and spherical. Depending on the components, they are classic and have high copper content (without ℽ 2-phase). Due to their good biological tolerance and mechanical qualities, the amalgam obturations of age over 25-30 years are frequently found during intraoral examination and registration of the tooth status for patients in Bulgaria. The increased esthetic requirements of the patients in the last years led to their replacement with composite obturation materials in some cases. In other cases, the occurrence of secondary carious foci as a result of the volume increase and deformation of the amalgam during chewing leads to complications such as fracturing of the enamel edges or whole walls of the clinical tooth crown, deformation of the amalgam at approximal contacts of the obturation with the filling of the interdental spaces, and other complications, which may show indications for tooth extraction. All described conditions are potential etiological factors for the occurrence of a pigmented lesion. With the establishment of the diagnosis amalgam tattoo, additional treatment is not required in general cases . Follow-In their research, Batra et al. present a clinical case of pigmentation of the gingiva in the area of the lower front teeth of a 45-year-old patient. The pigmented lesion is a result of retrograde filling with amalgam during apical osteotomy in the same area, performed four years earlier. The lesion localization in the aesthetical area requires excising and subsequent histological verification .This case described by us is unusual because the leading factor for directing the operative treatment was the subjective complaint of pain, the progressive increase of the lesion size, as well as the negative radiological findings for contrast areas in orthopantomography. Pain as a clinical symptom is not typical for pigmented intraoral lesions ,10,12. IMost frequently, the amalgam tattoos in the mucosa of the oral cavity are not a pathological finding. However, there are very rare symptomatic cases, like the one we are presenting in this case report, and their prognosis after surgical treatment is good. Each case of a pigmented lesion should be approached individually with great care due to the difficulties in the differential diagnosis of malignant lesions, even when the assessment is performed by an experienced clinician.


The patient had a slow, but uneventful postoperative course. Given the rarity of cases, the high variability of clinical presentation and the potential seriousness of mesh migration complications, the authors review the topic of mesh migration.Case of a 79-year-old male previously submitted to Rutkow-Robbins inguinal hernia repair. He presented himself at the Emergency Room with an inguinal inflammatory mass and bowel obstruction for 5 days. A strangulated recurrent inguinal hernia was assumed and emergency surgery was performed. Since an inguinal abscess was present, a midline laparotomy was performed. The previous polypropylene plug was found in an intraperitoneal position, fistulizing to the cecum and creating a 2 cm wide perforation, without intraperitoneal collections or bowel compromise. An  One of the landmarks in Abdominal Wall Surgery was the development of meshes in treatment. However, their use is not free of risks and can lead to serious complications , 2. One With a range of clinical presentations as wide as the anatomic locations that the mesh can acquire, 91% of the patients who present with this condition need a surgical intervention .Considering the rarity and the potential seriousness of this complication, a larger database of reported clinical cases seems necessary to develop a more detailed study and guidelines regarding the approach to these patients.Inspired by a particular clinical case of cecum perforation by plug displacement, the authors review migration of abdominal wall meshes.We present the case of a 79-year-old male, with a known history of atrial fibrillation, chronic obstructive pulmonary disease due to smoking (46 pack-years), submitted to a bilateral hernia mesh repair in 2015: Lichtenstein technique on the left side and Rutkow-Robbins technique on the right side, the latter due to an European Hernia Society PL3 inguinal hernia.The patient presented himself at the Emergency Department in 2018 with a 1-week painful right inguinal mass with inflammatory signs, located 3 cm above the inguinotomy scar and associated with bowel obstruction for the past 5 days. He was previously medicated with flucloxacillin without improvement.There being no other symptoms or signs, an abdominal wall abscess secondary to a strangulated recurrent inguinal hernia was assumed.6/L), neutrophilia (80%) and an elevated C-reactive protein value (20.6 mg/dL).Blood tests showed leukocytosis (13 100 x 10Computerized tomography (CT-scan) revealed an apparent right recurrent inguinal hernia with satellite regional lymph nodes of 15 mm and an 8-cm fluid collection and air in the subcutaneous tissue  and b.An exploratory midline laparotomy was performed. It revealed a 2 cm cecum perforation caused by direct contact with the polypropylene plug , which hen bloc with the plug. The abdominal wall abscess was drained through a right inguinotomy. It was not possible to remove the flat portion of the mesh due to its strong incorporation in the abdominal wall.We performed an atypical resection of the cecum The pathological analysis of the cecum atypical resection specimen documented ischemic focal alterations with erosions, congestion, inflammatory infiltrate and granulation tissue.The microbiological exam of the purulent exudate identified intestinal flora microorganisms.Enterococcus faecium, Enterococcus avium, Escherichia coli, Bacteroides fragilis and Candida albicans) and a negative pressure therapy device, enabling the wound to be completely closed afterwards.The postoperative period was noteworthy for a surgical site infection, treated with ampicillin, metronidazole and fluconazole directed against the isolated agents , on average 59.8 years old, and having been submitted to inguinal hernia surgery (62.9%)  Table 1Table 1. There is a wide range of clinical presentations since the movement of the mesh allows direct contact with different organs , which mIt is estimated that 91% of mesh migration cases need new surgical intervention to treat the related symptoms [in extremis may require organ resection [These postoperative complications can be resolved with a simple mesh removal or esection .Some authors classify mesh migration as primary or secondary , 3.Primary migration occurs due to essentially mechanical causes, and is the movement of the mesh through the weak points of the surrounding tissues, generally due to inappropriate fixation or to external forces that cause the movement of the mesh , 3.Secondary migration occurs due to foreign body reaction and subsequent erosion of the nearby structures, allowing slow and gradual mesh displacement through the different anatomic planes , 3. ThisA mixed mechanism is also found in which, after a primary migration, the erosion of tissues was not initially in contact with the mesh .Prolene) fixation points of the mesh, the origin of the mesh migration was interpreted as a foreign body reaction. This reaction induced erosion of the posterior wall of the inguinal canal, enabling plug migration to the peritoneal cavity and subsequent cecum adhesion and perforation.In the case described, considering the intra-operatory visualization of two non-absorbable (None declared.None.All the data are presented in the main manuscript or additional supporting files.


To summarize the clinical and dermatoscopic features of temporal triangular alopecia in infants and explore the clinical significance of dermatoscopy in the diagnosis of triangular alopecia temporalis in infants.A retrospective analysis was performed on 20 children with temporal triangular alopecia diagnosed in the dermatology clinic of Tianjin Children's Hospital from January 2015 to December 2021. Dermatoscopy was performed on all children, and images were collected.The clinical features of 20 children were 15 males and five females, all of which were born immediately after birth; There were eight cases (40%) in the left temporal region, 10 cases (50%) in the right temporal region, one case (5%) in the head region, and one case (5%) in the occipital region; 19 cases were single (95%), one case was multiple (5%); There were 21 skin lesions, 15 triangular lesions (71.4%), four quasi‐circular lesions (19%), and two lance‐shaped lesions (9.5%). Trichoscopic features: The hair follicle opening in all skin lesions is normal, and the hair follicle opening can be seen with fluffy hair (vellus hair). The vellus hair is evenly distributed, and the length is diverse (both short and long vellus hair exist in the same hair loss area). There are 14 cases of white vellus hair (70%), five cases of white spots (25%), one case of honeycomb pigment pattern (5%), and one case of vascular dilation pattern (5%).Temporal triangular alopecia in infants has typical clinical and dermatoscopic characteristics, and the dermatoscopy can provide clinical basis for its diagnosis and differential diagnosis. It is characterized by alopecia plaques without any potential skin changes, which are usually limited to the frontotemporal region of the scalp.22.1Twenty children with TTA, aged from 10 months to 4 years old, with an average age of 1.98 years, were collected from the outpatient department of dermatology of Tianjin Children's Hospital from January 2015 to December 2021.2.2(1) Triangular or lance‐shaped alopecia in the frontotemporal region of the scalp. (2) Dermatoscopic examination showed that normal hair follicle opening, with vellus hair, was surrounded by normal terminal hair. (3) Dermatoscopy showed no black spot sign, yellow spot sign, hair dystrophy, and reduction of hair follicle opening. (4) There was no obvious hair growth after the vellus hair was confirmed by dermatoscopy and clinical examination.2.3The Dermoscopy—II desktop dermatoscope of Beijing Demetricom was used to observe 21 skin lesions in 20 children with 20 times magnification. The lens is in parallel contact with the skin lesion, and 75% ethanol is used as the infiltrating liquid. Adjust the best angle and image definition, and collect the dermoscopic image of the skin lesion. Dermatoscopic images were collected by the same staff.33.1Fifteen males and five females, all of which were born after birth; There were eight cases (40%) in the left temporal region, 10 cases (50%) in the right temporal region, one case (5%) in the head region, and one case (5%) in the occipital region; 19 cases were single (95%), one case was multiple (5%). There were 21 skin lesions, 15 triangular lesions (71.4%), four quasi‐circular lesions (19%), and two lance‐shaped lesions (9.5%). The long axis is about 2–8 cm, and the average long axis is about 3.8 cm. A large amount of fine and soft vellus hair can be seen in the lesion area, which is difficult to remove. The boundary of the hair loss area is clear, and the scalp surface is normal, without erythema, scale and atrophy.No other systemic diseases occurred in all cases. See Figure FIGURE 1(A–H) Left temporal part, (I‐Q) Right temporal part, (R) head restraint, (S) head top, (T) right temporal, two places,  round; (T) triangle and lance‐shaped.3.2All skin lesions have normal hair follicle openings, and there are plush hair (vellus hair) at the hair follicle opening. The vellus hair is surrounded by the terminal hair, and the vellus hair is evenly distributed, and the length is diverse (both short and long vellus hair exist in the same hair loss area). There were 14 cases of white vellus hair (70%), five cases of white spots 25%), one case of honeycomb pigment pattern (5%), and 1 case of vascular dilation pattern (5%). The skin color of all skin lesions is normal, without atrophy, nodule and ulceration. All skin lesions had no black spot sign, yellow spot sign, broken hair or exclamation mark hair, and the hair stretch test was negative (See Table 5%, one c4TTA was first described by Sabouraud in 1905, and fewer than 200 cases have been reported so far.Under the TTA skin microscope, all hair follicle openings have vellus hair, which is evenly distributed and of different length, reflecting the diversity of vellus hair length and surrounded by normal terminal hair. This pattern represents the typical characteristics of TTA.The differential diagnosis related to TTA mainly includes congenital skin hypoplasia, sebaceous nevus, alopecia areata, trichotillomania, telogen alopecia, and tinea capitis. See Table TTA generally does not require treatment intervention. Hair transplantation and surgical resection are the main treatment options at present. Both topical and systemic steroid therapy are ineffective.The authors have no conflict of interest to declare.