Purpose: The glandular odontogenic cyst (GOC) is considered a rare developmental cyst, with an odontogenic origin and both epithelial and glandular characteristics, with less than 200 reported cases in the literature. Methods: In the present case, a 29-year-old man was referred for evaluation of an asymptomatic slow-growing swelling in the anterior region of the mandible, with one-year history. The patient’s medical history did not reveal any systemic alteration. The extraoral examination did not show enlargement of the facial contour and the intraoral examination showed vestibular and lingual swelling. Panoramic radiography and CT scan revealed a well-defined unilocular radiolucent lesion involving the inferior incisors and canines bilaterally. Results: Histopathological analysis revealed multiple cysts lined by stratified epithelium with varying thickness and characteristics, in addition to duct-like structures filled with PAS-positive amorphous material, suggestive of GOC. Conservative treatment was performed through surgical curettage, peripheral ostectomy of the surgical site and apicectomy of the teeth involved in the lesion. There was one recurrence, which was detected in postoperative follow-up, leading to a new surgical approach. Conclusions: Fifteen months after the second procedure, no signs of recurrence were identified, and bone neoformation within the surgical site occurred, supporting that a conservative approach for the treatment of GOC is viable.  The glandular odontogenic cyst (GOC) is a rare odontogenic cystic lesion of the jaws, defined as “a cyst arising in the tooth-bearing areas of the jaws and characterized by an epithelial lining, with cuboidal or columnar cells, both at the surface and lining crypts or cyst-like spaces within the thickness of the epithelium” . It is a relatively new entity as it was first described in 1987 by Padayachee and Van Wyk . It was Chrcanovic and Gomez  conducteAlthough GOC is a recently described lesion, its recognition and definitive diagnosis are essential due to its potential for locally aggressive behavior and a tendency to recur . TreatmeManagement guidelines in the literature have been based on case reports, not scientific evidence. This absence of a technical basis is expected (it is highly complex to carry out a study with a robust methodology) since GOC is a very rare lesion .Herein, a case of recurrent GOC is presented along with its differential diagnosis, histopathological features and treatment—all of which are emphasized and discussed.A 29-year-old male patient was referred to the Stomatology Clinic, School of Dentistry of the University of São Paulo, with an asymptomatic slow-growing swelling in the anterior region of the mandible, for approximately one year. The patient’s medical history did not reveal any systemic alteration.The extraoral examination did not show enlargement of the facial contour, and the intraoral examination showed vestibular swelling between the mandibular canines, in addition to a slight bulge in the lingual region, with healthy mucosa and no signs of inflammation. Panoramic radiography revealed a well-defined unilocular radiolucent lesion involving the mandibular incisors and canines bilaterally, reaching the mandibular base . In addiThe histopathological examination showed multiple cysts lined by stratified epithelium with varying thicknesses and characteristics. The cystic lining was characterized partially by a flat squamous stratified epithelium with areas of thickening and partially by a cuboidal epithelium, evidencing foci of hobnail cells. Clear cells and mucous cells were present, in addition to duct-like structures, which were filled with eosinophilic amorphous material that was positive for periodic acid–Schiff (PAS) staining after diastase digestion. The cyst wall was composed of dense connective tissue and a mild diffuse chronic inflammatory infiltrate . Based oA conservative surgical approach was planned, which consisted of curettage and peripheral ostectomy of the surgical site and apicectomy of the teeth involved in the lesion. Preoperatively, the patient was referred to an endodontist for root canal treatment of the involved teeth—the mandibular central and lateral incisors and canines, bilaterally.The removal of the lesion was performed under local anesthesia, upon the administration of three anesthetic cartridges of 2% mepivacaine with epinephrine 1:100,000 . An osteotomy was performed in the vestibular cortex to access the lesion A. FollowConsidering the high recurrence rates of GOC, adequate follow-up appointments were set. Eight months after the first procedure, a recurrence was detected by CT scan in the lingual portion of the cortical bone A,B. The Fifteen months after the second procedure, the panoramic radiograph showed a nearly complete bone neoformation within the surgical site. Clinically, the mucous membranes were found to be intact, with no signs of recurrence. Furthermore, all teeth were in function, without clinical or aesthetic repercussions .The GOC is a rare lesion of the jaws that affects mainly men between the 5th and 6th decades of life, with reported frequency rates ranging from 0.012% to 1.3% ,15,16,17Regarding dental changes, GOC seems to be related to an unerupted tooth or tooth displacement in 30.9% of cases, root resorption in 13.8%, cortical bone perforation in 26% and clinical symptomatology in 24.3% . In our GOC does not have a pathognomonic radiological appearance. Several lesions of the jaws, such as low-grade mucoepidermoid carcinoma, central giant cell lesion, odontogenic keratocyst, ameloblastoma, and botryoid odontogenic cyst, have similar radiological characteristics, being common diagnostic hypotheses . MoreoveIn a systematic review that analyzed radiological features of GOC, lesions were unilocular in 29 patients and multilocular in 27 (48%). In addition, these lesions had a width ranging from 0.5 to 12 cm (mean 4.9 cm), most of them had cortical expansion, comprising 87% (33/38), cortical perforation in 50% (12/24) and presented tooth root resorption in 22% (9/41) and tooth displacement in 24.4% (10/41) .Perhaps the most controversial topic about the GOC is the histological criteria to confirm the diagnosis, without an established consensus in the literature. GOC histological features may be similar to many oral lesions, such as radicular, dentigerous, botryoid cysts or mucoepidermoid carcinoma . MoreoveConcerning the GOC treatment, it may be performed through conservative approaches, such as curettage/excision and enucleation, or radical approaches, such as partial resection or resection with continuity. In the study of Chrcanovic and Gomez , from thIn the present case, after an initial conservative approach, one recurrence occurred, which was promptly treated. After 15 months, no recurrences were detected. Bone neoformation was verified within the entire surgical site and the maintenance of all teeth involved in the lesion was achieved, with no visible scars.If the treatment had been radical, all teeth involved in the lesion would have been lost, further compromising speech, mastication, and facial aesthetics. In addition, the patient would have experienced significant morbidity since resection of such extension would have required bone reconstruction with a free graft or microsurgical flap. In a recent study , the heaGOC is a rare, locally aggressive odontogenic cyst that, besides with regards to high recurrence rates, may be treated with a conservative approach, thus preserving involving teeth and anatomical structures, and diminishing the morbidity associated with radical surgical treatment. In the present report, one recurrence was detected 8 months after the removal of the lesion, reinforcing the importance of follow-up, especially when a conservative approach is chosen, as in this reported case. Nevertheless, extended monitoring periods are required, regardless of the modality of treatment.


MRE has become a standard imaging test for evaluating patients with small bowel pathology, but a rigorous methodology for describing and interpreting the pathological findings is mandatory. Strictures, abscess, inflammatory activity, sinus tract, wall edema, fistula, mucosal lesions, strictures, and mesentery fat hypertrophy are all indicators of small bowel damage in inflammatory and non-inflammatory small bowel disease, and they are all commonly and accurately explained by MRE. MRE is a non-invasive modality that accurately assesses the intra-luminal, parietal, and extra-luminal small bowel. Differential MRE appearance allows us to distinguish between Crohn’s disease and non-inflammatory small bowel disorder. The purpose of this paper is to present the MRE pathological findings of small bowel disorder. Crohn’s disease (CD) is a chronic granulomatous inflammatory disorder of unknown etiology, characterized by transmural intestinal inflammation. The terminal ileum and the caecum are the most affected areas of the digestive tract, even though it can occur in any region of the digestive system. Typically, in CD the inflammatory areas are multiple, and they are clearly separated from healthy tissue at both macroscopic and microscopic level, giving rise to the so-called skip lesions.Imaging has an undisputed role in the diagnosis of CD and in the evaluation of the disease after treatment. Furthermore, MRE has a great impact considering that it is possible to comprehensively assess the small bowel for pathology and classify it according to extent, severity, and complications, as well as to assess their response to therapy. According to ESGE  and ECCOIn order to accurately estimate the precise disease burden through the imaging manifestations, radiologists have to provide a rigorous methodology for describing and interpreting the pathological findings.Our review aims to provide an overview of the current status of small bowel imaging, with an emphasis on MR enterography. The historical, technical, and clinical underpinnings of these small bowel imaging methods were discussed in part 1 of this review . Here in part 2, we focus on current and emerging clinical applications of MR enterography in Crohn’s disease and other small bowel disorders. The several opportunities and challenges in the clinical translation and deployment of small bowel imaging in routine clinical practice are presented. With continued progress in this active field, MR enterography in Crohn’s disease is expected to have an increasing role in our understanding of small bowel diseases.The MRE signs of CD have been extensively investigated and meticulously described over the years ,5,6,7,8.Bruining et al.  well desThe three great fields in the CD are (a) bowel wall manifestations, (b) penetrating disease, and (c) mesenteric findings. They represent the macroscopic manifestation of the chronic transmural inflammatory condition that potentially leads to structural damage (bowel damage or organ damage). In CD, segmental bowel wall mural hyperenhancement represents the pathological tissue that at contrast-enhanced MRE is revealed as increased mural signal intensity in a small bowel’s segment compared with the normal adjacent intestinal tract . Mural hTo assess the wall thickness, a good bowel distention is required A. DependCrohn’s disease progressively involves the entire thickness of the bowel wall by an uncontrolled inflammation process. Approximately 20–30% of patients develop complications such as fistulas or abscesses at diagnosis.Transmural involvement can develop a sinus tract that reaches the serosa resulting in a fistula’s channel that connects different structures . In fact, sinus passages are closed off from perforations that result in phlegmons or, if infected, abscesses, but do not affect the nearby organs or the skin .Unlike the sinus tracts, a fistula is defined as a pathologic channel connecting two or more epithelialized surfaces . FistulaAn abdominal phlegmon is an obsolete term that refers to an inflammatory mass that can develop in the setting of penetrating Crohn’s disease. The term phlegmon is ambiguous and relates to an ill-defined inflammatory dense mesenteric mass. It typically spreads without a well-defined wall and involves the mesentery and adjacent bowel with fistula or abscess as possible complication . InflammAnother possible imaging findings of mesenteric inflammation is an abscess that appears as the usual appearance of an encapsulated collection with a rim enhancement and/or a central zone containing air or necrotic material. Moreover, MRE may show perienteric edema/inflammation as a high T2-W signal or a restricted diffusion in the mesenteric fat adjacent to abnormal bowel loops and the engorged vasa recta that supply an inflamed bowel loop (“comb sign”)  Figure .In the last decade, several MRE indices have been proposed to quantify the active disease to grade CD to ensure in any stage the best therapeutic option. They are the Magnetic Resonance Index of Activity (MaRIA), the Clermont score, the Crohn’s Disease Magnetic Resonance Imaging Index (CDMI), the Magnetic Resonance Enterography Global Score (MEGS), and the Lemann index . The mosThe formula of the segmental MARIA is MARIA = A global MaRIA score is the sum of the values calculated in each of the six bowel tracts  . Simplified MARIA scores greater than 1 identifies segments with active CD with 90% sensitivity and 81% specificity; by contrast, scores of 2 or more detect severe lesions (ulcers) with 85% sensitivity and 92% specificity.MARIA is a valid and reliable index assessing response to therapy with evidence of correlation with endoscopic mucosal healing (MH), a remarkable endpoint to reach related with the decrease in the number of hospitalizations and surgeries and corticosteroid prescriptions. There is evidence that after treatment, a reduction of 50% or more in the global MARIA score provides good specificity (80%) and sensitivity (73%) for the diagnosis of endoscopic response (reduction in Crohn’s Disease Endoscopic Index of Severity). Similarly, a global MARIA score below 5 shows good specificity (80%) and sensitivity for the diagnosis of endoscopic MH (88%) .Therefore, findings like bowel wall thickening (>3 mm), submucosal edema, fat stranding, superficial or transmural ulcerations are signs of an active disease stage, all present in the MaRIA score. Nevertheless, active inflammation is shown on MRE imaging as a layered pattern of enhancement and restricted diffusion . EngorgeIn the setting of bowel wall evaluation, a stratified/layered pattern of enhancement is a specific radiological sign of active inflammation in CD ; on the In chronic disease, there is a fat deposition in the submucosal layer that appears as hypo-intensity in the thickness of the intestinal wall on T2-weighted images with fat saturation B. During subacute transmural inflammation, the thickened and fibrotic bowel wall exhibits diffuse and homogeneous contrast enhancement, and the mild mucosal enhancement with hypo-intensity of the deep layers suggests fibrotic condition .In spite of this, stratified or layered enhancement in the intestinal wall, which typically indicates active inflammatory CD, can also exist when fibrostenotic disease coexists with active inflammation. In fact, in patients with small bowel CD, fibrosis and active inflammation sometimes coexist at regions of luminal constriction ,20,21,22In this scenario, MRE cine images are helpful to determine the burden of the fibrous component . Cine imFinally, an ileocolonic Crohn’s disease (MRI) Segmental Magnetic Resonance Activity Index (MaRIA) score calculator is available online and can be very useful particularly for those starting out in the field of MRE ,25.A large spectrum of non-inflammatory disorders can potentially lead to small bowel mural alterations, including infectious, vascular, or neoplastic conditions. Diagnostic imaging is critical in the assessment and differential diagnosis of small bowel disorders. MRI, especially MRE, allows the evaluation of both small bowel wall and extra visceral structures. The correct assessment of the small bowel in MRE necessitates appropriate bowel distension, which can be obtained by administration of the correct amount of a water solution. This solution can be administered orally or through a nasogastric tube ,27,28.Most common errors are related to the poor bowel distension, which can be responsible for a false positive, when a small bowel segment is identified as pathological just because it is not very distended, or for a false negative, when the presence of pathology is not recognized in a collapsed segment. Therefore, the knowledge of how to perform an MRE is crucial .Following the MR examination, images are examined to identify pathological small bowel loops. Pathology of the small bowel can occur as thickening of the bowel wall and/or as intraluminal alteration. In the presence of small bowel thickening, degree, type, and extension of wall thickening must be indicated in the report. Depending on the wall thickness, thickening can be mild (<1 cm), moderate (>1 cm and <2 cm), or marked (>2 cm)  Figure A.Thickening throughout the intestinal loop circumference might be eccentric (asymmetric) or circumferential (symmetric) depending on the type of involvement B,C 29,3,329,30. The white pattern is caused by intestinal wall enhancement that is more than or equal to vein enhancement of the same degree. The gray pattern  occurs when the enhancement of the bowel wall is similar to muscle attenuation on a contrast-enhanced exam .MRI is also very significant in identifying intraluminal alterations thanks to the possibility of matching imaging morphological information with functional data, the high contrast resolution, and a relatively safe intravenous injection of gadolinium. The elevated signal intensity of the intraluminal content on balanced steady-state GRE and echo-planar fast spin echo sequences allows the identification of the intraluminal alterations showing intermediate signal intensity .Once bowel pathology has been identified, the radiologist’s first step is trying to define the benign or malignant nature of the alteration. When intestinal pathology is found, the radiologist’s initial step is to determine if the alteration is benign or malignant, starting from patient’s history and clinical information. In the presence of small bowel thickening, a benign condition is probable when thickening is mild or moderate in degree, focal or segmental and symmetrical A,B, withDiffuse thickening, especially when almost all small bowel loops are affected C, is alwIn case of intraluminal alteration, filling defect with low signal intensity on FIESTA sequences and high enhancement similar to the bowel mucosa after intravenous gadolinium injection can be detected . HoweverAfter determining whether the results are benign or malignant, the radiologist must attempt to make a conclusive diagnosis by correlating MRI with clinical and laboratory data.Despite accounting for over 75% of the length and 90% of the mucosal surface area of the gastrointestinal tract, small bowel neoplasms are uncommon, accounting for 3% to 6% of all gastrointestinal tumors. They can be divided into benign and malignant. Benign cancers include inflammatory polyps, adenomas, leiomyomas, and lipomas. Neuroendocrine tumors, gastrointestinal stromal tumors, lymphomas, adenocarcinomas, and metastases are examples of malignant malignancies. Tumors appears as nodules, annular lesions, excavating masses, or stricturing lesions. Patients with small bowel tumors may complain of various symptoms such as anemia, weight loss, gastrointestinal bleeding, generalized or localized abdominal pain, bowel obstruction or perforation ,34.The main MR features of small bowel tumors are summarized in Among benign tumors of the small bowel, leiomyomas are the most common symptomatic forms. They are preferentially located in the stomach, developing in the circular or longitudinal muscle layer of the bowel wall ,35. LeioHistological diagnosis is made when positivity for smooth muscle myosin heavy chain and negativity for CD117 (c-kit) and S-100 with proliferation index (Ki-67) < 10% are observed in the specimen. Based on the type of growth, four types of leiomyoma can be identified: submucosal or intraluminal (the most frequent), intramural, subserosal or extraluminal, and bidirectional (dumbbell-shaped) .On MRI, leiomyomas appear as a spherical or ovoid nodule, ranging from 1 to 10 cm in diameter, with soft tissue intensity and uniform enhancement after gadolinium injection. Differential diagnosis with leiomyosarcoma can be possible when there are signs of benignity, such as homogeneous enhancement after contrast-medium injection and absence of mesenteric alterations or metastases ,34,35.Adenomas are the most prevalent asymptomatic benign small bowel tumors, accounting for 14–20% of all benign small bowel neoplasms. They are composed of glandular epithelium with a specific malignant predisposition, are identical to their large bowel counterparts , and can be premalignant. The duodenum is the most prevalent location for adenomas . AdenomaAdenomas have an epithelial origin, with a dysplastic or irregular columnar surface epithelium and lamina propria, forming more elongated, straight frondlike or villous projections that originate from the mucosal base. On MRI, they appear as sessile or pedunculate well-defined, soft tissue mass surrounded by a thin rim of oral contrast that shows moderate enhancement after intravenous contrast administration. They may exhibit bleeding, obstruction, and intussusception. MR images can help to differentiate adenomas from adenocarcinomas by identifying smooth margins, lack of mesenteric invasion, and clear fat planes around the tumor .Among malignant cancers of the small intestine, neuroendocrine tumors are the most common, arising from enterochromaffin cells, and there is an equal distribution between men and women, with an average age of onset of 65 years ,37,38,39Even if abdominal pain, weight loss, melena, intestinal obstruction, or ischemia are present, NETs can be asymptomatic. An accurate diagnosis is also based on the overproduction of circulating biologically active hormones, peptides and amines, such as gastrin, glucagon, insulin, serotonin, somatostatin, vasoactive intestinal polypeptide, CgA, and 5-HIAA. NET may present on MRI as a tiny submucosal nodule or as focal asymmetric wall thickening, with marked enhancement in the arterial phase, sometimes with hyper-vascular mesenteric enlarged lymph nodes . SometimOther malignant disorders of the small bowel should be considered in the differential diagnosis. NET diagnosis is made when avid enhancement after gadolinium injection, desmoplastic reaction, and hyper-vascular enlarged lymph nodes are observed. NETs can become complicated with obstruction due to the desmoplastic reaction or involvement of serosa .They include benign and malignant forms, representing the most common mesenchymal cancer of the gastrointestinal system. People over 40 years are more frequently involved ,34,41.GISTs arise from interstitial cells of Cajal. It is distinguished from leiomyomas by the frequent expression of a particular tyrosine kinase growth factor receptor (c-KIT) ,34,41. CIf there are some diagnostic doubts , immuno-hystological diagnosis requires CD117 immunopositivity or molecular analysis for activating mutations in KIT or PDGFRA.On MRI, GISTs usually look like asymmetrical mass-like thickenings of the bowel wall; the malignant form often shows inhomogeneous enhancement after gadolinium injection due to necrotic or bleeding or cystic findings  33,34,4,434,41.Unlike adenocarcinoma, exophytic growth with infiltration of the muscular layer and asymmetrical thickening of the bowel wall characterize this type of cancer; therefore, bowel occlusion rarely occurs even when it reaches large dimensions . Like lyLymphomas are the third most common cancer of the small bowel. Ileum is involved in more than 60% of all cases because of the lymphoid tissue more contained in the terminal ileum than in the duodenum and the jejunum ,42,43,44Lymphomas can involve the bowel primarily or consequently to systemic disease.Epigastric discomfort, weight loss, and anorexia are common symptoms. Nausea and vomiting are more common in the later stages of the disease. The small bowel is primarily affected by bleeding, the presence of an abdominal tumor, and bowel perforation.Endoscopic biopsies are required because laboratory tests may reveal low hemoglobin levels, pancytopenia, and elevated tumor markers such as LDH or CRP lactate dehydrogenase. Primary lymphomas may appear in the polypoid, mass, infiltrative, or aneurysmal form.The polypoid pattern is so called for the evidence of polypoid nodules, without thickening of the bowel wall; in this form, intestinal intussusception could be a frequent complication. The mass pattern refers to the evidence of a mushroom-shaped mass with exophytic extension, responsible for complications such as ulceration and fistulas.The infiltrative pattern is characterized by circumferential involvement of the wall, and it is responsible for different degrees of wall thickening and disappearing of the normal wall layers. Bowel wall infiltration looks like segmental and circumferential thickening, with homogeneous enhancement after gadolinium injection ,34 Figu.The aneurysmal pattern often coexists with the infiltrative one and it can be its evolution. In this pattern, lymphomatous infiltration and disruption of the muscle layer and neural plexuses may be appreciated, resulting in loss of muscle tone and consequent bowel dilatation. Regarding the differential diagnosis, an aggressive adenocarcinoma with ulcerations should be considered.MRI is suggestive for lymphoma when a bowel wall aneurysmal mass without proximal bowel occlusion is seen. The diagnosis can be supported by splenomegaly and retroperitoneal and mesenteric enlarged lymph nodes. Adenocarcinoma is characterized by the invasion of the surrounding mesenteric folds (less for lymphoma), while mesenteric ill-defined confluent masses enveloping the bowel are more frequent in lymphomas .Adenocarcinomas account for around 2% of all gastrointestinal tumors and are the most prevalent type of small bowel primary malignancy.Adenocarcinomas typically develop from the glandular epithelium, consisting of villous or tubular structures. Depending on gland formation and mucin production, they can be classified into mucinous, signet-ring cell, and undifferentiated forms, even if moderately to well-differentiated forms are more frequent.The site most frequently involved is the duodenum (50% of cases), followed by the jejunum and ileum. Patients with adenocarcinomas frequently have altered bowel habits (constipation and/or diarrhea) and iron deficiency anemia. Among laboratory tests, a high level of CEA is most probably associated with adenocarcinomas. Adenocarcinoma may have different patterns such as infiltrating, stenosing, or polypoid . The polypoid pattern is more frequently observed in the duodenum, while stenosing and infiltrating patterns are generally located in the jejunum or ileum due to circumferential infiltration of the wall . Full waMRI typically displays inhomogeneous signal intensity and moderate enhancement. Lymph nodal involvement is not of the same entity as lymphomas. MRI may be required to identify and stage this condition by detecting hepatic, lymph nodal, and peritoneal involvement. Sometimes, adenocarcinoma of the ileum can simulate Crohn’s disease. However, the suspicion of malignancy arises from the absence of local hypervascularization and the evidence of a single finding without skip lesions .This cancer arises from the smooth muscle of the bowel wall, and it is usually slow growing with prevalent extraluminal and eccentric pattern.In the early stages, leiomyosarcomas are often asymptomatic. Fatigue, fever, weight loss, a general sensation of ill health , and nausea and vomiting may occur in the later stages. Another frequent symptom is bleeding in the gastrointestinal system, causing black, tarry, foul-smelling stools (melena), or blood vomiting (hematemesis). Laboratory tests may reveal low hemoglobin levels and neutropenia. On MRI, it looks like a large inhomogeneous mass with a necrotic and/or hemorrhagic core. The signs of malignity, such as large dimensions (>5 cm), inhomogeneous enhancement after gadolinium injection, and evidence of mesenteric or metastatic disease, help in the differential diagnosis with leiomyoma ,34.Metastases account for about 50% of all small bowel tumors and they should be considered as the most probable diagnosis in an oncological patient. There are four ways of metastasizing a primary cancer into the small bowel: direct invasion, intraperitoneal, lymphatic, and hematogenous spread. The tumors originating from the gastrointestinal system metastasize more frequently to the small bowel; moreover, melanomas, lung cancers, breast cancers, and thyroid tumors should be considered .Small bowel metastases are relatively rare. In general, non-specific clinical manifestations such as intermittent stomach pain, nausea, vomiting, and weight loss are prevalent.Laboratory tests may reveal iron deficiency anemia and thrombocytopenia.The MR aspect of metastases may be variable, appearing as smooth or rounded polypoid nodules that can cause ulceration and invagination, or as wall thickening with invasion of adjacent mesenteric tissue, particularly in cases of mucinous origin. They are often focused on the anti-mesenteric side of the bowel ,47,48. Different non-inflammatory conditions are associated with small bowel wall thickening, such as tuberculosis, ischemia, vasculitis, radiation enteritis, hemorrhage, and amyloidosis.In rare cases, tuberculosis can affect small bowel, especially ileo-cecal segment. Fever, anorexia, weight loss, stomach pain, abnormal bowel habits, recurrent partial bowel obstruction, or the existence of an abdominal tumor could be clinical symptoms. Extra-intestinal symptoms such as polyarthritis, uveitis, and (less commonly) erythema nodosum may be associated.The tuberculin skin test (Mantoux test) with an induration of 20 or greater is the primary laboratory test for tuberculosis diagnosis. In the first phase of the disease, MRI shows a circumferential and symmetrical wall thickening involving the terminal ileum and the cecum , while tDiagnosis of bowel tuberculosis can be suggested when thoracic findings and/or other abdominal signs of tuberculosis, such as hepato-splenic involvement and peritoneal dissemination, are observed.Nowadays, computed tomography (CT) is used as a first line imaging modality for differentiating small bowel tuberculosis from Crohn’s disease. MRI is preferred in pediatric patients and for follow-up studies .Small bowel ischemia is caused by different pathological entities. Acute ischemia can be induced by the occlusion of the superior mesenteric artery (about 50% of the time), caused by an embolus usually starting from the heart or thrombosis of the mesenteric artery (about 25% of the time), and caused by atherosclerotic stenosis. Other causes are non-occlusive mesenteric ischemia (about 20% of the time), due to a reduction in the bowel blood supply with secondary mesenteric vasoconstriction or thrombosis of mesenteric vein (about 5% of the time).Severe stomach pain , nausea, vomiting, diarrhea, and blood per rectum are possible clinical symptoms.Leukocytosis, neutrophilia, a shift to immature leukocytes in the differential, and metabolic acidosis could all be detected by laboratory tests.Extension, degree of wall thickening, and type of wall enhancement depend on the cause of ischemia , the degree of ischemia (transient or durable), and the coexistence of infection or hemorrhage. On MRI, bowel wall thickening is usually present, even if this sign is not observed in arterial acute occlusion. Acute ischemia can simulate different bowel conditions, and the pattern of wall thickening could be localized or diffuse, focal, or segmental, superficial or transmural. In the early stages of bowel ischemia, a stratified contrast enhancement can be observed, showing mucosal hyperemia or hypoperfusion and submucosal edema . Other fSevere ischemia is characterized by the bowel pneumatosis with the coexistence of gas in the portal vein. Pneumatosis is the presence of air bubbles in the bowel wall, located in submucosal or subserosal layers. These bubbles are more apparent on gradient-echo images due to “blooming” associated with magnetic field inhomogeneities at air-tissue interfaces . NecrosiChronic mesenteric ischemia is caused by insufficient blood flow in the postprandial period. It is usually caused by an atherosclerotic occlusive condition that affects the origin of the mesenteric arteries .Clinical symptoms may include stomach postprandial pain, food avoidance in later stages, weight loss, diarrhea, nausea, and fever. Laboratory tests do not help with reaching a diagnosis.Diagnostic imaging can identify mesenteric arterial stenosis; recently, some authors demonstrated the value of mesenteric blood flow measurement with contrast-enhanced MRI, resulting in a significant lower increase in the postprandial period in patients with chronic mesenteric ischemia . Other aVasculitis represents a rare cause of bowel ischemia that occurs predominantly in the polyarteritis nodosa, typical of young patients. MRI usually shows bowel wall thickening with stratified enhancement, involving unusual tracts  and without confinement in a vascular territory. The distinction between vasculitis-related ischemia and other causes of mesenteric ischemia can be difficult to discern based on the imaging findings alone, so association with clinical factors  is mandatory to make a correct diagnosis ,30. Due to its disposition in the abdomen, the small bowel is particularly sensitive to abdominal or pelvic radiation therapy, especially when it is preceded by pelvic surgery  .In the early stages, the mucosal damage leads to cellular change from normal villous epithelium to non-functioning cells, losing the barrier effect. In a later phase, the damage is due to the association of submucosal fibrosis and vascular degeneration .Anorexia, nausea, vomiting, stomach cramping, and diarrhea are common early symptoms. A partial obstruction of the small bowel could be a late sign.Laboratory testing can reveal low hemoglobin levels, high white blood cell counts due to intestinal perforation or necrosis, and blood in stool investigations.If radiation enteritis is suspected, the diagnosis must be confirmed by imaging, for its ability to identify the loops involved, to classify the pattern , and to search for complications, especially if clinicians consider the possibility of a surgical treatment . In caseThis type of disorder is characterized by the pathological accumulation of eosinophils in the bowel wall, without evidence of other conditions of eosinophilia  .Eosinophils may infiltrate the mucosal layer, the muscular layer, or the serosal layer of the bowel wall, with a predilection for the distal antrum and jejunal loops, so symptoms depend on which layer is involved.Clinical manifestations consist in nonspecific symptoms, so diagnosis requires pathological evidence of eosinophilic infiltration of at least one intestinal tract and exclusion of other causes of enteric eosinophilia.MRI demonstrates bowel wall thickening with abnormal enhancement. In the mucosal form, imaging shows ulcers and polyps, while when the muscle layer is involved, imaging may show intestinal strictures and reduced luminal caliper . When thSmall bowel disorders present a significant challenge for the radiologist. When performed correctly, MRI is a useful tool for diagnosing small bowel disorders that manifest as mural thickening or intraluminal alteration. An attempt to formulate a reliable diagnosis should be made once the benign or malignant nature has been determined. Furthermore, it is critical to link imaging findings with clinical and laboratory data in order to develop the fewest and most accurate diagnostic hypothesis.


Mycobacterium tuberculosis is the most frequent agent. The authors describe a rare case of primary abscess of the thoracic wall. The patient presented with a painful, growing mass in the chest wall that later fistulized to the skin, draining a purulent exudate. Extensive analytical and imagiological workup was performed, showing no changes other than an expansive soft tissue formation extending from the skin surface and destructing the cartilage of the 7th right costal arch. Culture of the purulent exdudate identified Pseudomonas aeruginosa and Staphylococcus epidermidis. The patient improved under directed antibiotic treatment. The diagnosis of a primary abscess of the thoracic wall and the causative agents contribute to the rarity of this case.Primary abscess of the thoracic wall is a very rare condition that occurs spontaneously due to hematogenous dissemination of bacterial, fungal, or mycobacterial pathogens, of which  Pseudomonas aeruginosa and Staphylococcus epidermidis, contribute to the rarity of this case as no other cases of a primary abscess of the thoracic wall due to these agents were found in the literature. This article was previously presented as a poster at the 27th National Congress of Internal Medicine in October 2021.An abscess of the thoracic wall can arise because of hematogenous dissemination of pathogenic microorganisms (primary infection), or it can occur either as a complication of thoracic open trauma or surgery or as a result of contiguous pulmonary or pleural infection (secondary infection). In contrast to secondary infection, primary abscess of the thoracic wall is very rare, and hematogenous dissemination of mycobacteria is its most prevalent cause . PrimaryA 73-year-old man with a history of type 2 diabetes mellitus (hemoglobin (Hb)A1C of 7.6%) and hypertension, treated with vildagliptin/metformin and olmesartan/amlodipine was referred to the medical consultation with a history of a growing mass in the anteroinferior portion of the chest wall during the last two months that later fistulized to the skin, draining a purulent exudate. The mass was painful, with a stable size after taking amoxicillin/clavulanic acid for seven days. The patient denied fever, chills, chest trauma, surgical or dental procedures, implantation of medical devices, or recent infections or hospitalizations. However, he had undergone a polypectomy three weeks before the onset of symptoms, and the histology of the excised colon polyps revealed adenomas with low- and high-grade dysplasia. On physical examination, the patient was afebrile, and a firm mass in the anteroinferior portion of the right chest wall with mild signs of inflammation and drainage of purulent exudate was noted. Further evaluation included blood tests, with negative inflammation biomarkers and serologies  Figure  showed aPseudomonas aeruginosa and Staphylococcus epidermidis, with a negative culture for mycobacteria. Antibiotic therapy was initiated according to the antibiogram with amoxicillin + clavulanic acid and levofloxacin for 21 days, resulting in progressive regression of the mass and suppuration. Two months after completing therapy, the patient remained asymptomatic, and a chest CT scan showed only slight soft tissue densification at the level of the anterior 7th costal arch, while the bone scan showed no abnormalities.Histological examination of the mass biopsy revealed fibrous connective tissue with a polymorphous inflammatory infiltrate, compatible with a fistulous tract, and no neoplastic structures were identified. Culture of the lesion exudate identified the growth of Primary abscess of the chest wall is a rare condition that requires the exclusion of secondary causes. Early diagnosis is essential, as it can progress to serious infections, especially in older or immunocompromised patients. Adequate antibiotic therapy and surgical treatment affect the prognosis ; howeverMycobacterium tuberculosis, while cases of abscesses caused by other bacterial agents have been reported very sporadically in the literature. The agents identified in these cases include Staphylococcus aureus, Streptococcus, Escherichia coli, Salmonella sp., Bartonella henselae, Actinomyces, and Bacteroides. No described cases of abscesses caused by Pseudomonas aeruginosa or Staphylococcus epidermidis were found.Primary abscesses of the chest wall are generally caused by Pseudomonas aeruginosa is an opportunistic pathogen infecting immunocompromised individuals, such as patients with cystic fibrosis, bronchiectasis, neutropenia, burns, neoplasms, acquired immunodeficiency syndrome, organ transplantation, and uncontrolled diabetes mellitus and those admitted to intensive care units [re units . In addire units .Staphylococcus epidermidis is typically present as normal skin flora. However, its pathogenicity has been demonstrated, and it is often implicated in surgical implant infections, endocarditis, and skin and soft tissue infections. It is currently recognized as the most frequent cause of nosocomial sepsis. Increasing evidence suggests that it should not always be considered a contaminant in cases of skin and soft tissue infections. Therefore, if a coagulase-negative Staphylococcus is isolated in a bacterial culture from a suspected infectious skin or soft tissue lesion, the organism should be considered a pathogenic agent for the infection, and targeted antibiotic therapy should be instituted. Predisposing factors for skin and soft tissue infections by coagulase-negative Staphylococcus include advanced age, immunocompromised status, particularly in patients with diabetes mellitus [mellitus , and surmellitus .Pseudomonas aeruginosa being uncommon, they have been described as post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis, enteritis, and enterocolitis. Except for diabetes mellitus, which increased this patient’s susceptibility to infections [In this presented clinical case, it was not possible to identify the primary source of infection. However, given the temporal correlation between the polypectomy and the onset of the chest abscess, it is possible that this procedure may have been responsible for transient bacteremia with subsequent focalization in the chest wall. Despite gastrointestinal infections by fections , there wPseudomonas aeruginosa, it is not possible to conclude that Staphylococcus epidermidis was only a contaminant, so it was considered a pathogen and treated as such.Considering the isolation of This case report describes a rare case of primary chest wall abscess of bacterial origin with the aim of reminding the medical community to consider this pathological entity in the differential diagnosis of chest wall masses. Although this is a rare clinical condition, early diagnosis, identification of causative agents, and adequate treatment are crucial, as progression to severe infections can occur, especially in older and immunocompromised patients. Unusual pathogens should always be considered, as adequate and timely antibiotic therapy, and eventually, surgical approaches affect the prognosis.


Surgical ciliated cysts occur primarily in the maxilla after radical maxillary sinus surgery. We report the first case of a surgical ciliated cyst that developed in the infratemporal fossa 25 years after the patient sustained severe facial trauma. The patient complained of mandibular pain and limited mouth opening. The patient’s condition was completely resolved 5 months after marsupialization via Le Fort I osteotomy. Surgical morbidities can be minimized by proper diagnosis and less invasive surgery. Surgical ciliated cysts, also known as postoperative maxillary cysts, respiratory implantation cysts, or paranasal cysts, are the collective term for non-odontogenic cysts lined by the respiratory epithelium because of traumatic implantation to the sinus or nasal mucosa . It occuHere, we present a case of a surgical ciliated cyst in the infratemporal fossa that was completely resolved using marsupialization via Le Fort I osteotomy.A 40-year-old man was referred to the Department of Oral and Maxillofacial Surgery with mandibular pain and limited mouth opening. Symptoms had started a year previously and gradually deteriorated. He was otherwise healthy but had experienced a facial bone fracture 25 years ago. On initial clinical examination, the maximum mouth opening was 26 mm because of pain. Radiographic investigations included Panorex imaging a, a tranUnder general anesthesia, old plates and screws on the anterior maxilla were removed, and a standard Le Fort I osteotomy was performed. After the downfracture, the lesion was carefully dissected and visualized. Aspiration was performed to confirm the lesion was a cyst, and slightly yellow, serous fluid was withdrawn. A partial excision of an ovoid shape was made in the cystic wall (0.8 × 2.4 × 0.3 cm) for a histopathologic exam. After repositioning the maxilla, a 1 × 1 cm sized bony window was made in the canine fossa area. The 10 cm Penrose drain tube was inserted at the end of the cyst through the anterior bony window. The drain was secured in place with a 3-0 non-absorbable suture to the anterior vestibular mucosa. The operative course was uneventful, and the patient was discharged on the third postoperative day. Before discharge, the patient was instructed to independently irrigate the wound with saline using a syringe after each meal. Histopathologic evaluation showed a pseudostratified ciliated columnar epithelium and focally squamous epithelium compatible with the diagnosis of a surgical ciliated cyst .Regular follow-up visits were scheduled every other month for Penrose drain adjustments. The drain was shortened by 1 cm monthly. A follow-up CT scan performed 2 months after surgery showed a decreasing bony defect and regenerating bone around the drain. The drain was fully removed 5 months after surgery. A CT scan taken 3 years postoperatively showed evidence of complete bony regeneration without recurrence a,b.The infratemporal fossa is a rectangular posterior maxillary space located deep in the skull base that contains important neurovascular structures such as the pterygoid muscle, mandibular nerve, tympanic cord, middle meningeal artery, internal maxillary artery and vein, and pterygoid venous plexus . The forLe Fort I osteotomy was neglected as a surgical approach for decades before regaining popularity, especially for the removal of tumors at the base of the skull and midface, in the late 1980s .For the treatment of surgical ciliated cysts, most previous studies have recommended a Caldwell–Luc operation consisting of the complete removal of the cyst lining, together with nasal antrostomy ,12,13. PIn our patient, based on the high T1/T2 signal detected via MRI, the lesion was suspected to be cystic. Some benign tumors, such as epidermal inclusion cysts, fibromas, and schwannomas may present with similar features in the infratemporal fossa. Differential diagnosis includes neurogenic tumors, lymphangioma dermoid/epidermoid cysts, and surgical ciliated cysts. Because the lesion was regarded as non-malignant, we considered surgical excision immediately without performing an incisional biopsy before surgery. During surgery, complete enucleation of the lesion without injury to the adjacent structures was considered impossible because of the thin cystic wall and extensive bone loss, and the lesion was marsupialized.Surgical ciliated cysts occur as a delayed complication after radical surgical intervention and trauma in the maxillary sinus and rarely recur after appropriate surgical treatment. Surgical procedures are determined according to the location or aggressiveness of the lesion. This is the first report of the marsupialization via Le Fort I osteotomy of a surgical ciliated cyst in the deep infratemporal fossa. The risk of significant morbidity associated with an isolated surgical ciliated cyst of the infratemporal fossa can be minimized by proper diagnosis and less invasive surgery, including the most appropriate surgical approach.


Paragangliomas are catecholamine-secreting neuroendocrine tumors that originate from the chromaffin cells of the sympathetic ganglia. Roughly 10% of paragangliomas are malignant, resulting in a rare occurrence of 90-95 cases per 400 million people. Herein, we report a case of a 29-year-old female patient who presented with nausea, vomiting, and bloating and was found to have a large left retroperitoneal tumor upon imaging. The tumor was successfully removed, and subsequent histological analysis was compatible with the presence of a paraganglioma. This case serves as a reminder that despite its rarity, paragangliomas should never be dismissed as a differential diagnosis if correlating symptoms and diagnostic findings are consistent with that of paraganglioma etiology. Paragangliomas (PGs) and pheochromocytomas (PCs) are catecholamine-secreting neuroendocrine tumors that originate from the chromaffin cells of the sympathetic ganglia . PGs shaPGs and PCs are mostly benign, with only 10% being malignant [A 29-year-old, African American female, with no significant past medical history or current medication use, presented to the emergency room with complaints of nausea, vomiting, and bloating. A computed tomography (CT) of the abdomen with contrast was ordered, which showed the presence of a left retroperitoneal mass approximately 6.8 x 9.5 x 1.4 cm in size with necrotic components  . ApproxiPGs have a strong genetic susceptibility and approximately 35% are hereditary . FamiliaPGs can be difficult to diagnose due to the diverse presentation they can exhibit . PathogeAlong with symptomology, biochemical testing and histological analysis help in diagnosing PGs. Biochemical diagnosis involves the measurement of urinary and plasma catecholamines, urinary fractionated metanephrines, plasma-free metanephrines, and urinary vanillylmandelic acid . EvaluatThe use of imaging is also important in helping locate and characterize PGs as benign or metastatic and is usually performed after biochemical tests have confirmed the presence of excess catecholamines ,18. The For lesions that are highly suspicious of PGs or PCs but express inconclusive biochemical testing results, functional imaging is recommended. Different nuclear medicine modalities can be used for functional imaging, including metaiodobenzylguanidine (MIBG) scan/scintigraphy, positron emission tomography (PET) with 18F) fluorodihydroxyphenylalanine (FDOPA), (18F) fluorodopamine (FDA), (18F) fluorodeoxyglucose (FDG), and PET with radiolabeled dodecane tetraacetic acid (DOTA) peptides F fluorod. As a thAs stated previously, surgical resection of the tumor is the primary treatment method for PGs . Due to In this manuscript, we presented a case of a malignant paraganglioma in a young adult female patient. The patient presented with nausea, vomiting, and bloating and subsequent imaging showed the presence of a left retroperitoneal mass. The tumor was surgically removed, and histological analysis of the excised specimen was consistent with a paraganglioma. Due to the chance of tumor reoccurrence, the patient was started on a long-term follow-up protocol with plans to re-image in six months. Given the rarity of malignant paragangliomas, 90-95 occurrences per 400 million people, this case serves as a good reminder for physicians to always keep uncommon conditions on the differential if case findings are compatible with their etiology.


Intraductal papillomas are tumors that arise in the epithelial cells of the mammary duct. Common presenting symptoms for intraductal papilloma include serous or serosanguinous nipple discharge or a palpable mass. We present a case of a 48-year-old woman who presented with spontaneous right breast nipple discharge and a palpable mass. Diagnostic imaging for the patient included mammography and ultrasound with color doppler imaging that revealed a mass at eight o’clock in the right breast at a distance of 2 cm from the nipple and that corresponded to the area of palpable concern. Percutaneous ultrasound-guided biopsy of the mass confirmed a diagnosis of intraductal papilloma. Surgical excision may be required in many cases of an intraductal papilloma due to the variety of diagnoses that can be included on the differential, the increased risk for cellular atypia, and the treatment for spontaneous nipple discharge. Intraductal papillomas (IDP) are benign, proliferative lesions of the mammary duct ,2. AlthoIDP can be present in women of all ages, but most commonly occurs in women 30-50 years of age ,7. The mA 48-year-old female presented with a palpable mass in the right breast and spontaneous clear right nipple discharge for years. The patient reported a prior history of hypertension, hyperlipidemia, and deep venous thrombosis. Pertinent family history included breast cancer in the patient’s maternal aunt. Based on the patient’s clinical presentation and exam, she was recommended for further diagnostic imaging. A bilateral diagnostic mammogram was performed and showed a high-density oval, circumscribed mass at approximately eight to nine o’clock at anterior depth Figure . The lefAdditional spot compression nonmagnification views were obtained during the diagnostic exam. These included craniocaudal spot compression, right mediolateral oblique spot compression, and a true lateromedial view of the right breast, as seen in Figure Based on the mass seen mammographically, a targeted diagnostic right breast ultrasound was performed. Ultrasound images showed a complex solid and cystic mass at eight o’clock and 2 cm from the nipple, corresponding to the mammographic mass and area of palpable concern. Color Doppler imaging shows vascularity in the solid component of the complex solid and cystic mass, as seen in Figure Based on the results of the diagnostic mammogram and targeted diagnostic right breast ultrasound, a Breast Imaging-Reporting and Data System (BI-RADS)® four category assessment was assigned. The patient subsequently underwent a percutaneous ultrasound-guided core needle biopsy of the solid component of the complex solid and cystic mass with multiple core biopsy specimens obtained. Pathology results revealed an intraductal papilloma with sclerosing adenosis and apocrine metaplasia. The pathology results were concordant with imaging findings.An IDP can be seen in mammography, ultrasound, galactography/ductography, and magnetic resonance imaging (MRI), but not all imaging modalities are necessary (Appendix 2). However, a definitive diagnosis of an IDP can only be made via pathology. Mammography is typically the first imaging modality for symptomatic spontaneous single duct nipple discharge, which has many differential diagnoses including intraductal papilloma, fibrocystic changes, Paget’s disease of the breast, and intraductal carcinoma . On mammUltrasound is performed as part of the diagnostic imaging workup following a diagnostic mammogram. The usual ultrasound findings of an IDP are a solid hypoechoic mass within the duct or as part of a cyst (complex solid and cystic mass)  and whenBreast MRI can also be used if there is a clinical concern of an intraductal papilloma or breast carcinoma in the setting of spontaneous nipple discharge after a negative initial workup using mammography and ultrasound. There are many imaging features of an IDP that can resemble invasive ductal carcinoma (IDC). One study by Zhu et al. determined MRI findings to assist in differentiating benign IDP from malignant IDC. Findings that support a diagnosis of IDP include a round or oval shape, and circumscribed or irregular margins, with irregular margins showing no spiculation. Conversely, IDC will show an irregular shape with spiculated or irregular margins. The study also concluded that both intraductal papilloma and invasive ductal carcinoma showed rapid initial enhancement on dynamic contrast enhancement-MRI (DCE-MRI). However, IDP showed an evolution from homogenous or heterogenous enhancement in the early phase to an increased signal intensity in the periphery during the late phase. This evolution of enhancement pattern was less likely found in IDC .Finally, galactography/ductography can be done to detect an intraductal papilloma. On galactography/ductography a mural-based filling defect with smooth or lobulated contours or an abrupt filling defect, as seen in Figure This case demonstrated a classic presentation of intraductal papilloma with corresponding mammographic and sonographic findings representative of this diagnosis. Despite the range of imaging modalities that can be used to help further substantiate this diagnosis, a definitive diagnosis is not possible on imaging alone. Diagnosis of IDP requires either percutaneous image guided biopsy or surgical excision to direct further management and treatment.


We present a rare case of myoepithelioma in the subcutaneous layer of the shoulder with ultrasonography (US) and magnetic resonance imaging (MRI). US showed a lobulated hyperechoic mass, leading to an impression of lipoma. MRI showed the mass with low signal intensity on T1-weighted images (T1WI), high signal intensity on fat-suppressed T2-weighted images (T2WI), intermediate signal intensity on T2WI, and intense enhancement with adjacent fascial thickening. Imaging findings of soft tissue myoepithelioma have not been established. We report its US and MRI features mimicking features from a lipomatous tumor to infiltrative malignancy. Although soft tissue myoepithelioma has nonspecific image findings to confirm its diagnosis, some findings may help to make the differential diagnosis. Preoperative pathologic confirmation is recommended in a soft tissue neoplasm. Myoepithelial cell tumors are unusual neoplasms composed of myoepithelial cells. They most commonly occur in salivary glands and are thought to be due to the proliferation of myoepithelial cells between the epithelium and basement membrane. Soft tissue myoepithelioma is a rare entity that primarily presents in the upper and lower limbs ,2. To thA 69-year-old male patient presented with a slowly growing, painless mass on his right posterior shoulder noted four months ago. He had a history of total thyroidectomy with central lymph node dissection for papillary thyroid cancer, four years ago. Initial physical examination revealed an about 3 cm sized hard movable mass in the superficial layer of his right posterior shoulder. US presented a multi-lobular hyperechoic mass measuring about 2.8 cm, with internal echogenic striations in the subcutaneous layer of the right posterior shoulder. However, vascularity was not increased . The iniThis is the first matched US and MRI report of myoepithelioma in the upper extremity. Myoepithelioma of soft tissue was first reported in 1997 . Since tMyoepithelioma is a tumor presenting a wide spectrum of epithelioid, spindled, histiocytoid, or plasmacytoid cells with myxoid or hyalinized stroma. Most reports show positivity for cytokeratin and variable positivity for epithelial membrane antigen (EMA). It is also positive for the S-100 protein in most cases. Myogenic marker expression, such as calponin, is positive in most cases, while smooth muscle actin (SMA) is positive in roughly half of cases . PositivSoft tissue masses in the extremities, including myoepithelioma, are composed of a broad spectrum of benign and malignant lesions and they may mimic each other. Soft tissue masses can be distinguished according to their location in skin layers, including epidermis, dermis, subcutaneous and deeper layers, histological composition, and related abnormalities . When weMRI is widely regarded as the best imaging method for evaluating soft tissue masses due to its high tissue contrast, ability to demonstrate relationships between the mass and adjacent structures, and to indicate specific components using multiple sequences . If MRI 18F-fluorodeoxyglucose [Although several cases have been reported so far , the radyglucose . In anotyglucose . Howeveryglucose . It showyglucose , the tumMyoepithelioma is difficult to diagnose with a single imaging modality due to nonspecific radiological findings and overlapping features from benign to malignant tumors. Thus, when we encounter a lobulated hyperechoic mass on US which shows T1 low and T2 intermediate to high signal intensity on MRI with diffuse enhancement and infiltrative features, we should consider including myoepithelioma as well as its malignant counterpart in the differential diagnosis. Therefore, acquiring a pathologic specimen is strongly recommended .This case report presents a subcutaneously located soft tissue myoepithelioma of the shoulder with US, MRI, and histopathological findings. When approaching an echogenic lobulated soft tissue mass, we should be familiar with its differential diagnosis including myoepithelioma.


Thoracic duct cysts are extremely rare mediastinal tumors. We report a case of a thoracic duct cyst extending from the caudal aspect of the left main bronchus to the left renal artery that was safely and completely resected via bilateral thoracoscopic surgery in the prone position.A 77-year-old male was referred to our hospital for follow-up computed tomography (CT) of prostate cancer, which revealed a mediastinal tumor and fatty low-density along the posterior mediastinum of the para-aortic artery with a slightly high-density component. Magnetic resonance imaging revealed a T2-weighted image with high intensity. The preoperative radiological diagnosis was lipoma or well-differentiated liposarcoma. CT in the prone position suggested that the tumor could be resected from the thoracic cavity to the caudal side, and bilateral thoracoscopic surgery was performed in the prone position. Based on the surgical findings, the tumor was diagnosed as a thoracic duct cyst rather than a lipoma. Dissection around the thoracic duct cyst was performed using a vessel-sealing system to prevent leakage of the chyle, and reliable clipping was performed to resect the cisterna chyli. Histopathological examination revealed smooth muscle structures around the cyst, suggestive of a thoracic duct cyst. The diagnosis of a thoracic duct cyst was made based on a high triglyceride level of 1310 mg/dL on examination of the milky-white cyst fluid. The patient's postoperative course was uneventful, and he was discharged 4 days postoperatively. A CT scan performed 13 months after surgery showed no recurrence.A rare thoracic duct cyst extending from the mediastinum to the cisterna chyli was safely and completely resected using bilateral thoracoscopic surgery, with the patient in the prone position. Thoracic duct cysts can occur anywhere along the pathway from the abdominal cisterna chyli to the subclavian and internal jugular veins of the neck . MediastA 77-year-old male patient was referred to our hospital after a computed tomography (CT) scan performed during a follow-up after prostate cancer surgery at another hospital revealed a gradually enlarging mediastinal tumor. He had a history of hypertension, no recurrence after prostate cancer surgery, right inguinal hernia surgery, no medications, occasional drinking, and smoking 20 cigarettes per day. Blood test results revealed the following: total cholesterol, 283 mg/dL; low-density lipoprotein cholesterol, 191 mg/dL; triglyceride (TG), 44 mg/dL, tumor-related marker carcinoembryonic antigen, 6.2 ng/mL; alpha-fetoprotein, 3.9 ng/mL; squamous cell carcinoma antigen, 1.9 ng/mL; cytokeratin 19 fragment, 4.5 ng/mL; soluble interleukin-2 receptor, 429 U/mL; pro-gastrin releasing peptide, 63.9 pg/mL; thyroid stimulating hormone, 1.770 μIU/mL; and human chorionic gonadotropin beta subunit, ≤ 0.1 ng/mL. Contrast-enhanced CT revealed a cephalocaudally continuous multifocal cystic lesion from the posterior mediastinum to the retroperitoneum at the level of the 8th thoracic vertebra to the 2nd lumbar vertebra. The tumor was approximately 20 mm in maximum size, tortuous throughout, but about 180 mm in linear distance, with a predominantly fatty component inside, septal and partly contrast-enhanced components (Fig. Thoracic duct cysts are thought to be caused by congenital fragility of the thoracic duct wall as well as degeneration and lymphangiomatous changes secondary to infection and inflammation . ThoraciWe report a rare case of a thoracic duct cyst extending from the mediastinum to the cisterna chyli. Complete resection was safely achieved using bilateral thoracoscopic surgery, with the patient in the prone position.


Colonoscopic diagnosis of acute appendicitis is extremely rare. Although a few appendicitis cases were reported in literature following colonoscopy, we present a case today of a patient who underwent elective colonoscopy for colorectal cancer screening. The presence of an inflamed appendiceal orifice with projecting pus was documented, and the patient was referred to the surgical team for intervention. Endoscopic and intra-operative results are also illustrated. Acute appendicitis is one of the most common causes of acute abdomen. It occurs in 100 cases per 100,000 patients per year . ColonosA 56-year-old woman with a history of dyslipidemia, prediabetes, subclinical hypothyroidism, and multilevel disc herniation was booked for an elective diagnostic colonoscopy after a positive fecal occult blood screening. She presented to the endoscopy department with a history of mild chronic abdominal pain mainly in the epigastric area for one year. Colonoscopy revealed a protruding caecal opening that resulted in pus discharge when an attempt was made to biopsy the region Figure . DrainagAcute appendicitis is mainly caused by luminal obstruction, especially in elderly patients. In young people, the main cause is suspected to be lymphoid follicular hyperplasia, which can be triggered by a local infection -6. The aAlthough cases of appendicitis after colonoscopy have been reported, to our knowledge, we have documented purulent acute appendicitis endoscopically for the first time. Therefore, endoscopists must be aware of the potential for appendicitis during colonoscopy and its occurrence so that appropriate treatment can be promptly instituted to avoid serious complications.


Pancoast tumors, also defined as superior sulcus tumors, still represent a complex clinical condition requiring high technical surgical skills within more articulated multimodality treatment. The morbidity and mortality rates after Pancoast tumor treatments range from 10 to 55% and 0 to 7%, respectively, and the 5-year survival rate has significantly improved in recent years thanks to the advancement of treatments. Although a multimodality approach combining chemotherapy, radiotherapy, and surgery allows for radical resection and effective local control in the vast majority of patients, many patients cannot receive surgical resection or complete the whole programmed therapeutic regimen. Systemic relapse, particularly cerebral recurrence, still poses a significant issue in this cohort of patients. Surgical resection still plays a pivotal role within the multimodality approach. Here, we focus on surgical approaches to both anterior and posterior Pancoast tumors: the anterior transclavicular approach (Dartevelle); the anterior transmanubrial approach ; the anterior trap-door approach ; the posterior approach (Shaw–Paulson); the hemiclamshell approach; and hybrid approaches. Global clinical condition, tumor histology, and long-term perspectives should always be taken into consideration when embarking on such a demanding oncologic scenario. In 1932, Henry K. Pancoast—a radiologist at the Hospital of the University of Pennsylvania (USA)—first reported the radiological and clinical characteristics of pulmonary tumors arising in the apex of the lung and infiltrating closer structures of the thoracic outlet [In 1979, Masaoka et al. described an anterior approach consisting of a proximal median sternotomy extending anteriorly into the fourth intercostal space and the lower part of the neck, thus providing a wide surgical view anteriorly, but with limited control of posterior structures like the transverse process of the vertebrae, the brachial plexus, and the posterior aspect of the ribs . To overIn 1993, after a previous experience in 1981 on the basis of the pioneering experience of Cormier regarding the surgical approach to the subclavian artery, Dartevelle et al. described the transclavicular approach, subsequently defined as the “Dartevelle” approach; this technique consisted of an L-shaped anterior cervical incision, followed by the resection of the internal half of the clavicle, providing excellent subclavian vessel exposure, conditioned by not-negligible cosmetic and functional side effects on shoulder mobility ,6,7.In 1997, Grunenwald and Spaggiari described the transmanubrial approach, consisting of an L-shaped transection of the manubrium of the sternum with first cartilage resection, allowing for the safe retraction of an osteo-muscular flap, including but preserving the clavicle together with its muscular insertion. As a result, this technique not only provides excellent exposure of the subclavian vessels, but also avoids both cosmetic and functional damage related to clavicle resection .With the advent of minimally invasive techniques, hybrid procedures combining robotic- and video-assisted approaches with chest wall resection have recently been reported ,11,12,13The thoracic inlet represents the apical aperture of the chest and the boundary between the neck and the mediastinum. The manubrium of the sternum and the first rib cartilage anteriorly, the first thoracic vertebra posteriorly, and the first rib laterally represent the margins of the thoracic inlet. The esophagus, the trachea, and the great vessels providing blood supply to the head and the upper extremities exit the chest through the thoracic inlet. This anatomical district can be partitioned into three regions by considering the posterior, middle and anterior insertions of the scalene muscles on the ribs (first and second ribs) as section planes. The anterior region is defined as “prescalene” and is located anteriorly to the insertion of the anterior scalene muscle onto the first rib; the subclavian vein is located in this space, lying closely behind the clavicle. Moreover, the thoracic duct flows into the jugulo-subclavian confluence, and notably, the phrenic nerve lies on the anterior aspect of the anterior scalene muscle. The middle region is defined as “interscalene”, extending from the posterior border of the anterior to the posterior margin of the middle scalene muscles. This compartment is crossed on the right side by the innominate artery, which provides the right subclavian artery and the right carotid artery; on the left side are the left carotid artery and the left subclavian artery. In addition, in the interscalene space, we find two neurological structures: the trunks of the brachial plexus and the vagus nerve. The posterior region is defined as “extrascalene”, extending posteriorly to the middle scalene muscle: here, we find the posterior scapular arteries and many neurological structures, which are the neural foramina, the stellate ganglion, the accessory spinal nerve, the sympathetic chain, and finally, the vertebral bodies.As superior sulcus tumors compress or infiltrate the surrounding anatomical structures (which occurs more often), they generate several signs and symptoms, which are cumulatively defined as Pancoast syndrome. Very frequently the brachial plexus infiltration causes arm and shoulder pain; in fact, this symptom is observed in almost all affected patients.Thoracic pain can also be due to parietal pleura, vertebral bodies, or rib infiltration. Usually, respiratory symptoms are observed at a later stage and, for this reason, the first reported symptoms are often misdiagnosed as orthopedic diseases, thus often leading to a delayed oncologic diagnosis. When C8 T1 roots are widely infiltrated, paresthesia and pain in the fourth and fifth finger is reported, as well as pain in the arm, forearm, and hand. In more advanced cases, the involvement of intrinsic hand muscles might result in fine motor skill impairment and reduced handgrip. In the case of cervical ganglion and sympathetic trunk involvement, hyperidrosis and facial flushing—only of the same side—can be observed because of neurogenic irritation. In more advanced cases, Claude Bernard Horner syndrome  is reported, sometimes associated with contralateral hyperidrosis and facial flushing due to hyperactive sympathetic response of the other side (Harlequin syndrome).Preoperative assessment of patients suffering from a superior sulcus tumor consists of medical history, physical evaluation, standard blood tests, cardiological evaluation, spirometry, and—in case of planned pneumonectomy—perfusion lung scanning and cardiopulmonary exercise testing. Proper staging protocols require whole-body computed tomography and positron emission tomography; flexible bronchoscopy is required to obtain histologic diagnosis and to explore the anatomy of the airways. Magnetic resonance imaging and angiographic studies are not routinely required and can be considered in some cases. M1 status, as well as pN3 disease, are oncologic absolute contraindications to lung resection. Clinical N2 disease should be always confirmed by endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA), or mediastinoscopy if EBUS TBNA is not available. Patients presenting ipsilateral supraclavicular lymph node metastasis—without proven N2 disease—can be still considered for surgical resection. In fact, it has been shown that patients affected by superior sulcus tumor—with single ipsilateral supraclavicular disease—present a long-term prognosis similar to pN1 patients and much better than pN2 patients. Cardiopulmonary preoperative assessment plays a pivotal role in the whole preoperative program in order to properly stratify surgical risk and estimate expected quality of life after surgical excision. It requires a careful medical history, physical evaluation, standard blood tests, cardiological evaluation, spirometry, and in case of planned pneumonectomy, perfusion lung scanning and cardiopulmonary exercise testing. Predicted preoperative FEV 1 greater than 40% allows for low-risk resection; predicted preoperative FEV 1 ranging from 30% to 40% requires further tests , and functional operability should be determined on a case-by-case basis. Before embarking on such a demanding therapeutic protocol, smoking cessation is considered mandatory, and preoperative respiratory exercises are suggested to reduce the risk of postoperative complications.This approach was first described by Dartevelle et al. in 1993, reporting 29 patients undergoing complete, en bloc resection of the tumor invading the thoracic inlet, chest wall (first and second ribs), and lung, either through the anterior transcervical approach alone in 9 cases or by adding a posterior thoracotomy in 20 cases. The authors performed 14 wedge resections, 14 lobectomies, and 1 pneumonectomy without any perioperative deaths. They observed encouraging overall 2- and 5-year survival rates of 50% and 31%, respectively, with a median follow-up time of 2.5 years.In this approach, the patient lies in the supine position; the neck is hyperextended, and the head is turned to the opposite uninvolved side. The skin incision consists of an L-shaped cervicotomy, whose branches follow the anterior border of the sternocleidomastoid muscle  and the inferior border of the internal half of the clavicle .The attachment of the sternocleidomastoid muscle on the sternum is divided, thus yielding an excellent view of the superior aspect of the subclavian vein and artery; after a careful inspection, showing that the tumor is deemed resectable, the medial half of the clavicle is resected. The dissection starts with the jugular and subclavian veins and—when operating on the left side—thoracic duct ligation could be required. In the case of innominate vein infiltration for the tumor, the vessel can be resected without the need for vascular reconstruction. The dissection continues with the subclavian artery, often requiring dissection and isolation of the internal mammary artery, the ascending cervical artery, and more rarely, the vertebral artery. If the tumor clearly infiltrates the subclavian artery and subadventitial dissection does not allow radical resection, the vessel should be resected and then reconstructed with a vascular prosthesis connected by an end-to-end anastomosis. In the case of brachial plexus infiltration, which is usually present in true Pancoast tumors, the lower trunk and C8 and T1 nerve roots can be dissected up to the spinal foramen. Subsequently, vertebral bodies, sympathetic chain, and the stellate ganglion are easily exposed and freed from the tumor. Finally, resection of the first two ribs is performed, thus allowing en bloc resection of the neoplasm within the lung parenchyma. In the case of larger tumors widely extending to the posterior aspect of the thoracic inlet, an additional posterior thoracotomy may be required to better resect the chest wall and control the pulmonary vessels ,6.In 1997, Grunenwald and Spaggiari significantly overcame the limits of the transclavicular approach due to the removal of the internal half of the clavicle and section of its muscular insertions, leading to shoulder instability with functional and cosmetic consequences. They described a transmanubrial approach through an L-shaped incision of the manubrium and first costal cartilage resection, allowing wide mobilization of an osteo-muscular flap, including but preserving the entire clavicle and all its muscular insertions. The retraction of the osteo-muscular flap allows for great exposure of the whole subclavicular district, with safe control and resection of vascular and neurological structures involved in anterior apical chest tumors. They reported an initial series of six patients operated on using the transmanubrial approach, in which no wound or bony alterations were reported; all patients received early postoperative shoulder mobilization and did not present any functional problems. On the contrary, in the authors’ previous experience on 20 consecutive patients operated on using the transclavicular approach, 14 patients suffered from postural and esthetic defects, which were severe in 8 patients. The transmanubrial approach consists of an L-shaped cervico-manubriotomy with the section of the first rib cartilage. The sternocleidomastoid muscle is then dissected, and the internal jugular vein is easily exposed. The fibers of the pectoralis major muscle are spared, thus allowing for the isolation of the first costal cartilage and the mammary vessels, which are subsequently ligated and transected. The resulting sternoclavicular flap is then progressively mobilized, allowing for the safe dissection of the posterior half of the clavicle, leaving part of the subclavian muscle on the subclavian vessels, representing an ideal plane of dissection. A lace around the manubrial edge can be used to further elevate the flap. The subclavian vein is widely dissected and mobilized, starting from the jugulo-subclavian confluent (Pirogov); the anterior scalene muscle is transected, thus exposing the underlying subclavian artery with its branches. After these steps, all thoracic apical structures can be controlled and resected as required.In conclusion, this approach provides wide exposure of apical chest structures, allowing a safer resection of elements involved in apical cancers when needed; the whole clavicle is left in site and no major muscular resection is needed, thus preserving full shoulder girdle function, preventing shoulder instability with related esthetic and functional side effects  Figure .In 1979, Masaoka et al. described a new approach for the resection of apical tumors of the chest. It consists of a proximal median sternotomy continuing anteriorly into the fourth intercostal space and extending to the base of the neck on the same side . This inIn their first report, Masaoka et al. reported their experience only in two cases; in 2014, Nomori et al. reported their 25 years’ experience in 33 patients treated using modified trap-door thoracotomy. The modification from the original Masaoka approach involves the transection of the first rib. After sectioning the apical site of the mammary artery, the first rib is isolated and transected from the chest. This procedure, according to the authors’ point of view, can more easily prevent iatrogenic injury to the subclavian vein. The authors reported only one case of postoperative chylothorax without any residual deformity of the chest wall or clavicle [This approach requires posterolateral decubitus to expose the scapular region and the posterior aspect of the neck. The first step is a standard thoracotomy to explore the pleural cavity and to confirm resectability by assessing the involvement of the chest wall, lung parenchyma, thoracic inlet, and mediastinal structures. Once the procedure is considered feasible, the incision is continued, running posteriorly under the tip of the scapula, and then vertically between the medial border of the scapula and the vertebral bodies up to the seventh cervical vertebra. The latissimus dorsi and the trapezius muscles are divided first, and the dissection then proceeds by dividing the serratus anterior, rhomboids, and elevator of the scapula muscles. In this phase, both the dorsal scapular nerve and the scapular artery—close to the medial margin of the scapula—should be carefully preserved. When the chest wall is widely exposed, chest wall resection is accomplished first to allow easier subsequent lung resection; en bloc resection of bony structures together with the lung is the best option to avoid incomplete resection, which could result from extrapleural dissection without rib resection. In the vast majority of Pancoast tumors, the first two or three ribs are involved and need to be resected, although a wider resection could be necessary to achieve radicality.The first rib resection is technically challenging: the middle and anterior scalenus muscle insertions onto the first and second rib need to be divided to expose neurovascular structures—the subclavian vein and artery and the brachial plexus—crossing under the clavicle and above the first rib. To allow a radical and safe resection, the head of each involved rib has to be disarticulated from the transverse process of the corresponding vertebra by dividing the costotransverse ligament. Finally, the corresponding intercostal nerve, which originates from the relative intervertebral foramen, needs to be correctly identified and divided. Care should be taken while coagulating close to the spinal cord to prevent neurological injuries; moreover, hemostatic sponge migration into the spinal cord must be carefully prevented to avoid medullary compression with severe neurological sequelae. The lower trunk of the brachial plexus (C8 T1 nerve roots) is visualized and dissected; most commonly only T1 infiltration is observed, but when C8 is also involved, it is necessary to medially divide the lower trunk of the brachial plexus at its origin from the spine. Subsequently, the first rib is resected, thus making it possible to release the chest wall from the apex of the thorax: this allows for division of the lower part of the stellate ganglion, as well as the first intercostal artery. In the vast majority of cases, chest wall reconstruction is not required because of the protection of the scapula; when a more extended chest wall resection has been performed, i.e., removing more than the first three ribs, chest wall reconstruction via methylmethacrylate rigid prosthesis is recommended to prevent a trapped scapula ,17,18,19This is a combination of anterior thoracotomy in the fourth intercostal space (on the left or right side) with longitudinal median sternotomy extended from the manubrium to the fourth sternocostal joint. It requires mammary vessel ligation on the side of the anterior thoracotomy. The posture of the patient varies according to the planned resection: in the case of mediastinal involvement without any major airway infiltration, the supine position with 90° bilateral arms abduction is indicated. On the contrary, when major pulmonary resection is expected, the lateral or semilateral position should be preferred.Anterolateral thoracotomy is performed first in order to assess neoplasm extension, as well as structure infiltration, to confirm resectabilty; if the procedure is judged feasible, mammary vessel ligation is performed, and median sternotomy is then easily completed. This allows for the creation of a sternocostal flap, which is then gradually retracted to obtain excellent exposure both of the mediastinum and the involved pleural cavity. There is no need to approach the sternoclavicular joint, which is left untouched. This approach makes it possible to easily control the take-off from the aortic arch of the subclavian and carotid arteries, as well as the jugulo-subclavian vein confluence and the innominate vein, on the left side; on the right side, take-off from the jugulo-subclavian vein confluence and the superior vena cava can be controlled.On the contrary, this incision does not allow for ideal control of the distal part of the supra-aortic branches and venous vessels, as well as of the posterior aspect of the chest wall; the hemiclamshell approach should thus be reserved for apical lung or mediastinal tumors, which only proximally infiltrate the venous and arterial branches ,18,19,20With the advent of minimally invasive thoracic surgical approaches, hybrid techniques combining chest wall resection with video-assisted or robotic-assisted lung resection have been recently proposed ,21. UchiThe morbidity and mortality rates after Pancoast tumor treatments range from 10 to 55% and 0 to 7%, respectively . The 5-yIn this study, 46 patients with histologically proven Pancoast tumors were enrolled; they were staged as T3 or T4 non-small-cell lung cancers, N0 to N1 without any distant metastases (M0). They received induction treatment with cisplatin and etoposide, plus concurrent 45 Gy radiation therapy. Patients who did not show any progression received surgical treatment within seven weeks. Consolidation treatment was delivered with docetaxel every three weeks; the primary endpoint of the study was feasibility. Of the 46 registered patients, 44 were finally enrolled; 86% completed standard induction treatment; 66% received lung resection; and only 45% completed consolidation therapy with docetaxel. A total of 97% of operated patients (28 out of 29) received radical resection (R0), and among them, 2 patients (7%) died because of acute respiratory distress syndrome. The authors observed a complete or almost complete pathologic response in 21 of 29 operated patients (72%). Local recurrence was observed in two patients, systemic recurrence was reported in ten patients, and local and systemic recurrence was observed in one patient. Among the ten patients who presented systemic relapse, seven disclosed brain-only recurrence .Pancoast tumors still represent a complex clinical condition requiring considerable technical surgical skills within more articulated multimodality treatment.Although a multimodality approach combining chemotherapy, radiotherapy, and surgery allows for radical resection and an effective local control in the vast majority of patients, many patients cannot receive surgical resection or complete the whole programmed therapeutic regimen. Systemic relapse, particularly cerebral recurrence, still poses a significant issue in this cohort of patients. Global clinical condition, tumor histology, and long-term perspectives should always be taken into consideration when embarking on such a demanding oncologic scenario ,36,37,38


Liposarcoma is the most common retroperitoneal soft tissue tumor. Liposarcomas are often asymptomatic and are discovered after they become huge. Surgical resection is the first‐line treatment for retroperitoneal liposarcoma, but the surrounding organs are often resected with the liposarcoma.A man saw a hospital with a complaint of left lower abdominal distention, and a left retroperitoneal mass was noted on imaging examination. The patient was referred to our hospital. The mass extended from the retroperitoneum through the inguinal canal to the thigh and involved the femoral nerve and psoas major muscle. A well‐differentiated liposarcoma was suspected, and an open surgical resection was performed. Complete resection of a retroperitoneal liposarcoma extending to the thigh was achieved without postoperative complications.Treatment strategies for huge retroperitoneal liposarcomas are important to balance antitumor efficacy and postoperative quality of life. Retroperitoneal liposarcomas that extend through the inguinal canal to the thigh and lesser trochanter are rare. In many cases, concurrent resection of the surrounding organs is performed. In this case, we could completely remove the tumor maintaining postoperative quality of life through appropriate treatment strategies of surgical methods.Liposarcoma is a relatively frequent malignant soft tissue tumor with a predilection for the retroperitoneum and lower extremities.The patient was a 67‐year‐old man. He was referred to our department with a chief complaint of lower abdominal distention. On arrival at the hospital, Eastern Cooperative Oncology Group performance status was 0, and physical examination revealed only a palpable elastic hard mass in the left lower abdomen. Vital signs, neurological findings, and blood tests were normal. Contrast‐enhanced CT abdominal imaging showed a 16 × 11 × 28 cm long mass occupying the left retroperitoneal and pelvic cavities, extending through the left inguinal canal to the left thigh Fig. . CT imagThe operation was started through a midline abdominal incision Fig. , and adhLiposarcoma is a nonepithelial malignant tumor of soft tissue origin and is the most common (about 40%–50%) retroperitoneal soft tissue tumor.Liposarcomas grow slowly and painlessly and are usually distensible. Since there are no specific symptoms, it is difficult to diagnose the disease in its early stage; it is often detected after the tumor has grown to a large size.Giant retroperitoneal liposarcomas may be discovered in an inguinal hernia.The tumor had extended to the thigh and lesser trochanter, so an additional incision to the thigh allowed complete resection of the tumor with good visual field. There were no preoperative findings suspicious of a dedifferentiated component in this case, and the adhesions to the psoas major muscle, femoral nerve, external iliac artery, and spermatic cord were mild, so the surgery was completed with these organs preserved. Moreover, since no component of a dedifferentiated tumor was estimated preoperatively, the tumor was removed in 3 parts to preserve the psoas major muscle and femoral nerve. An orchiectomy was planned for adhesion between the tumor and the spermatic cord, but since there was no adhesion, the spermatic cord and testis were spared. Liposarcoma has a high recurrence rate and requires regular monitoring.In conclusion, we report a case of retroperitoneal liposarcoma extending through the inguinal canal to the thigh and lesser trochanter. The femoral nerve and psoas major muscle were spared, and the tumor was removed without compromising the postoperative quality of life. It is important to consider treatment strategies for huge liposarcomas, including preoperative preparation, to balance antitumor efficacy and postoperative quality of life.Takahiro Maekawa: Writing – original draft. Yoshiyuki Yamamoto: Writing – review and editing. Taigo Kato: Writing – review and editing. Koji Hatano: Writing – review and editing. Atsunari Kawashima: Writing – review and editing. Shinichiro Fukuhara: Writing – review and editing. Ryoichi Imamura: Writing – review and editing. Norio Nonomura: Writing – review and editing.The authors declare no conflict of interest.Not Applicable.Written informed consent was obtained from the patient for the publication of this case report and the accompanying images.Not Applicable.


Arteriovenous malformations from para-testicular structures are very rare, with only a limited number of cases reported in the literature. The present study reports a rare case of para-testicular arteriovenous malformation. A 6-year-old boy presented with painless swelling in the scrotum for 6 months. Upon examination, a non-tender and non-pulsatile cystic swelling was observed in the right hemi-scrotum below the testis. A scrotal ultrasound revealed a separate cystic lesion with a normal texture and the vascularity of both testes. Under general anesthesia, via a small scrotal incision, a cystic, blood-filled mass was excised. The results of a histopathological examination were suggestive of vascular malformation. The case described in the present study aims to shed light on vascular malformations. A number of vascular malformations are incorrectly referred to as hemangiomas, and numerous patients undergo inappropriate therapy due to this misclassification. Although para-testicular arteriovenous malformation is a very rare condition, it should be included in the differential diagnosis of para-testicular lesions. Arteriovenous malformations (AVMs) are vascular system anomalies considered to develop during embryogenesis, fetal development, or shortly after birth . AVMs arThe present study reports an extremely rare case of para-testicular AVM without the involvement of the epididymis or spermatic cord.A 6-year-old boy presented with a painless swelling on the right side of the scrotum that his parents had observed for 6 months. There was no history of surgery or trauma. Upon an examination, a blush-colored, non-tender, immobile, and non-pulsatile cystic swelling was observed in the right hemi-scrotum below the testis . A scrotScrotal swelling is a relatively frequent medical condition. Space-occupying lesions from these sites may be neoplastic or non-neoplastic . NeoplasAlthough vascular lesions, such as varicocele, hemangioma, lymphangioma, and AVMs are possible, they are uncommon and are rarely described in the medical literature . Adult met al  may be limited. If the results of the U/S are ambiguous or dubious, further radiography can be conducted using computed tomography or MRI, and tumor markers for testicular cancer can be sent for assessment . A U/S cThe preferred therapeutic options for AVMs are sclerotherapy, embolization, and surgical excision . SclerotIn conclusion, para-testicular AVMs are a very rare condition. Based on this case, the authors suggest that AVM should be included in the differential diagnosis of para-testicular lesions.