Epiploic appendagitis is a torsion of fatty appendages of ligamentum trees (1), it’s a rare cause of abdominal pain that usually manifests by right or left iliac fossa pain, reminding of appendicitis, diverticulitis or ischemia of the omentum.We report the case of a 56 years old male patient admitted for an epigastric pain and a right-upper quadrant abdominal pain, for whom he underwent an abdominal ultrasound and a CT-scan who shown an abscessed mass under colic transverse to the unusual seat.CT scan is still the key modality for diagnosis, avoiding unnecessary surgery. Complications of primary epiploic appendagitis have rarely been described in the literature . Another more rare complication is appendagitis with associated abscess, in this condition, we must also think about complicated diverticulitis.The treatment of uncomplicated forms is generally conservative, however, some authors have suggested a surgical method .For therapeutic management of its complication, there has been much interest in the use of minimally invasive techniques such as percutaneous drainage to minimize the morbidity and mortality that is associated with surgery , 2019).The diagnosis of epiploic appendagitis is still uncommon, CT scan can eliminate other diagnosis of acute abdominal pain such as diverticulitis and appendicitis. It also allows the diagnosis of the rare complicated forms such as abscesses associated with epiploic appendagitis.The treatment of typical forms is usually conservative, while the complicated form requires surgery because of the potential associated pathology. There aPrimary epiploic appendagitis is frequent  and corrThe clinical and biological aspects are non-specific . They ofOur work is focused on an uncommon complication of epiploic appendagitis which is abscess and it follows perfectly the SCARE criteria .256 years old male, obese, smoker since 20 years, without occupation, admitted in our structure for epigastric and right hypochondrium pain progressing since one week with a 5 days of sub occlusive syndrome. The initial clinical examination showed epigastric and right hypochondrium sensibility associated with a fever reaching 38.5°.Biology revealed hyperleukocytosis at 13,000 elements/mm3 associated with a raised C reactive protein at 57 mg/l.An emergency abdominal ultrasound examination was performed and revealed a left supra-umbilical pseudo-mass, containing multiple partitions with significant fat and infiltration all around .Fig. 1UlThe patient had an abdominal CT scan with contrast injection, which showed a rounded formation at the expense of the large supra-umbilical omentum slightly lateralized on the left, under the transverse colon, which had a low-density, with thin septas inside, a regular wall and peripheral contrast enhancement. It is associated with a significant local infiltration. The appendix had a normal morphology: there was no intestinal occlusion .Fig. 2CTThe surgeons indicated an exploration by midline laparotomy, and not radiological drainage, considering the clinical peritonitis and also the suspicion of ulcer perforation due to the patient's smoking history, even without pneumoperitoneum, its revealed an inflammatory epiploic mass, associated with a single microbial abscess, without any abnormalities of the gastrointestinal wall, so surgical excision of the mass was performed, and then the surgical piece was sent for anatomo-pathological study. The post-operative status was normal without immediate or late complications; the patient received antibiotic therapy with good clinical evolution.One week after his hospitalization, the biological results improved with a hemoglobin level from 10.3 to 12 g/dl, leukocytes from 13,000 elements/mm3 to 11,000 elements/mm3 without significant variation in other parameters.The microbiological results of the collection revealed that it was a sterile abscess, with no isolated germ.The anatomopathological study of the pseudo-mass showed a macroscopic appearance of a fibrinoleukocyte layer . The mic3Epiploic appendagitis also known as “appendicitis epiploica” or “appendagitis,” results from an inflammation of the epiploïc appendix and is usually characterized by acute abdominal pain with localized defense. This symptomatology is due to the torsion-necrosis of an epiploïc fringe , which iThe vascularization of an epiploic fringe is provided by 1 or 2 small arteries. The pedicular and mobile nature of these epiploic fringes leads to torsion on their axis, resulting to vessel thrombosis, ischemia and necrosis. Thrombosis of the own vessels can also occur and induce the same ischemic and necrotic effects ,6,8.In pathophysiology, a distinction is made between primary appendagitis when torsion or thrombosis occurs spontaneously and secondary appendagitis when it results from the spread of inflammation from nearby organs, especially in cases of diverticulitis, appendicitis or pancreatitis .It is a rare pathology frequently diagnosed by laparotomy or laparoscopy . The meaAtypical signs such as respiratory symptoms can be found in cases of appendagitis on the transverse colon as observed in our study or at the angles of the colon, and exceptionally may simulate clinical forms of cholecystitis ,5.Biologically, appendagitis is not associated with biological changes such as hyperleukocytosis or inflammatory syndrome, however changes in these parameters may not necessarily mean that the diagnosis is excluded, but they may suggest complications such as an epiploic abscess, as in the current case ,8,9.Our patient was obese with a body mass index (BMI) of 30 kg/m2, so the ultrasound examination was difficult, however, we visualized a pseudo-mass, ovoid, non-compressible in the painful area, surrounded by a hyperechoic peripheral halo, and these aspects were compatible with those described in the literature .CT scan is still the key modality for diagnosis, avoiding unnecessary surgery, by showing on unenhanced CT images a solitary mass adjacent to the colon, ovoid in a “shuttle” shape, with a higher density than normal peritoneal fat, surrounded by a high-density border [1 mm thickness] that shows inflammation of the visceral peritoneum covering the epiploic appendage, a peripheral fat infiltration is usually associated with the mass.A central high density focus can be seen as a “dot sign” appearance, which is highly suggestive of venous thrombus within an inflamed epiploic appendage ,8. Post-Generally, the treatment of uncomplicated forms is conservative, and requires an observation for 24 h, analgesic and hypocaloric diet. However, some authors have suggested that the surgical method of ligation and excision of inflamed epiploid appendages is the only way to prevent recurrence .Complications of primary epiploic appendagitis have rarely been described in the literature ,15. In fAn anatomo-pathological study of the operating epiploic appendagitis with abscess usually reveals inflammatory changes, the presence of fibrin and neutrophil polynuclear cells, with associated peritoneal reaction including congestion, oedema, and bleeding in the peripheral fat area; also some fibrinoleukocyte exudates on the surface of abcess .4The diagnosis of epiploic appendagitis is still uncommon, however, it is important that a clinician can consider it based on the different imaging modalities available especially abdominal CT scan, which allows to eliminate other conditions presenting as acute abdominal pain such as diverticulitis and appendicitis. It also allows the diagnosis of the rare complicated forms such as abscesses associated with epiploic appendagitis.The treatment of typical forms is usually conservative, while the complicated form requires surgery because of the potential associated pathology.The authors report no declarations of interest.No source of funding was received.Our study is exempt from ethical approval.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.CY, and HH performed and interpreted the patients CT scan and ultrasound. OA’s service did surgical procedure on the patient and the data are led to the pathology performed by CL, and the professor AB was a major contributor in writing the manuscript. All authors read and approved the final manuscript.NA.Dr Charifi Yahya.Pr Alami Badreddine.Not commissioned, externally peer-reviewed.


A pigmented carcinoid is an extremely rare variant of carcinoid characterized by melanin pigmentation of the tumor, with only five cases described in the literature. In addition, thymic carcinoids are rare in elderly patients and their prognosis after resection of the carcinoid tumor is unclear.An anterior mediastinal tumor was incidentally found in an 82-year-old man who had been diagnosed with acute thoracic empyema. The tumor was considered most likely to be a noninvasive thymoma or thymic carcinoma for which surgery was indicated after the resolution of the empyema. The tumor was completely resected 4 months after the empyema surgery, and the patient had an uneventful postoperative course. A cut surface of the resected specimen was extensively pigmented and appeared dark-brownish, with abundant melanin pigmentation later confirmed in the spindle-shaped tumor cells. Based on the histologic examination and immunohistochemical study, melanoma was eliminated as a differential diagnosis and the tumor was diagnosed as a pigmented atypical carcinoid of the thymus.This report provides additional knowledge on thymic pigmented carcinoids and thymic atypical carcinoids in elderly patients. A pigmented carcinoid (PC) is an extremely rare carcinoid variant. The unique histologic feature of PCs is that the tumor cells contain melanin pigment and show melanocytic differentiation. Herein, we report a case in which a thymic atypical carcinoid with melanin pigmentation was incidentally found as a solitary tumor of the anterior mediastinum in an octogenarian patient.An 82-year-old man with no relevant medical history was admitted to our hospital with a diagnosis of acute left thoracic empyema. Computed tomography revealed a solitary mass measuring 7 × 5 × 3 cm in the anterior mediastinum Fig. a. The coCarcinoids are distinctive neuroendocrine tumors that occur most frequently in the gastrointestinal tract, followed by the respiratory tract . Thymic A PC is an extremely rare variant of carcinoid that has often been reported to originate in the lung, although fewer than ten cases of bronchopulmonary origin have been described in the literature . We founThe prognosis of our patient depends primarily on the aggressiveness of AC, given that melanin pigmentation has no definite prognostic implications . ApproxiWe treated an octogenarian patient with PC of thymic origin. PC is an extremely rare variant of carcinoids and this report provides additional knowledge on mediastinal PCs and thymic atypical carcinoids in elderly patients.


To present a case of central serous chorioretinopathy (CSC) in association with regressed familial retinoblastoma. A 23-year-old man with regressed unilateral familial retinoblastoma in his left eye presented with decreased vision of the left eye since two months ago. The patient had undergone chemotherapy and cryotherapy for the treatment of retinoblastoma 20 years ago. In the left eye, funduscopy disclosed regressed mass of retinoblastoma, inferonasal to the optic disc, and focal subfoveal neurosensory detachment. Optical coherence tomography (OCT) and fluorescein angiography revealed CSC. As there was no sign of recurrence of retinoblastoma and retinal findings did not show late-onset chemotherapy-related retinopathy, the patient was diagnosed with CSC and followed up. After two months, visual acuity of the left eye improved, and repeated macular OCT revealed absorption of the subretinal fluid.Subretinal fluid accumulation in a patient with regressed retinoblastoma is not always a sign of tumor recurrence or a treatment-related retinopathy. The pathogenesis is poorly known, and retrospective studies have recognized a number of risk factors. These include male sex, psychological tension, personality type A, corticosteroid use,,6 gestation, and, infrequently, endocrine disorders (such as Cushing's syndrome) or tumors with steroid products.Central serous chorioretinopathy (CSC) is a retinal disease in which there is serous detachment of the neurosensory retina, typically restricted to the macular area. The disease is believed to be a disorder with multiple etiologies that lead to a common pathway of choroidal vascular abnormality. Concerns about patients with a history of retinoblastoma, especially those treated with external beam radiotherapy, are related to the risk of recurrence, secondary malignancies, and development of radiation retinopathy or retinal damage secondary to chemotherapy. All these conditions can develop even after a long period from the initial treatment.,12,13Retinoblastoma is an inherited pediatric malignant neoplasia, assumed to be the most frequent intraocular malignancy in children.Here, we report a case of regressed retinoblastoma and coincidental CSC in the same eye. The association between regressed retinoblastoma and CSC has not been reported in the literature.A 23-year-old man presented to the ophthalmology clinic with a two-month history of blurred vision in the left eye. The patient had a history of unilateral familial retinoblastoma in the left eye, which had been treated with cryotherapy and systemic chemotherapy 20 years before. Medical and drug histories were otherwise unremarkable. The patient had a positive family history of retinoblastoma, as his father and two siblings were diagnosed with bilateral familial retinoblastoma.Ophthalmic examination showed a corrected distance visual acuity of 10/10 in the right eye and 5/10 in the left eye. Intraocular pressure was normal, and relative afferent pupillary defect was negative. Anterior segment examination showed normal findings. Fundus examination of the left eye revealed a white elevated regressed retinoblastoma mass with intralesional cavitation and focal subfoveal neurosensory detachment . The right eye was completely normal. Spectral-domain optical coherence tomography (OCT) revealed echo-free subfoveal fluid accumulation and a small pigment epithelial detachment. Additionally, enhanced depth imaging OCT of both eyes showed thick choroid and dilated choroidal vessels . Fluorescein angiography (FAG) of the left eye revealed an expansile leaking dot near the fovea in the mid-to-late phase. Indocyanine green angiography showed hyperpermeability of dilated choroidal vasculature . Based on clinical examination and paraclinical findings, a diagnosis of CSC coincidental with regressed unilateral familial retinoblastoma was made. As there was no sign of retinoblastoma recurrence or secondary malignancy and the clinical findings did not reflect late-onset retinopathy related to prior treatment, a close follow-up was planned. During the follow-up period, oral propranolol was prescribed. At the two-month re-examination, the best corrected visual acuity of the affected eye improved to 7/10, the retinoblastoma mass was unchanged, and the new macular OCT revealed absorption of the subretinal fluid .Blurring of vision and new accumulation of subretinal fluid in a patient with history of retinoblastoma is usually suggestive of recurrent retinoblastoma, adverse effect of chemotherapy on the chorioretinal tissue, or late-onset radiation retinopathy. As there was no history of radiotherapy and intra-arterial chemotherapy in this case, ocular complications of these therapeutic interventions were not considered for the patient. however, retinal findings of cisplatin-induced retinopathy are different from those seen in our case. Moreover, retinal ischemia and subsequent neovascularization have been reported in a patient receiving chemotherapy with bleomycin, etoposide, and cisplatin. However, FAG of this patient revealed no sign of retinal ischemia or neovascularization. Subretinal fluid and choroidal changes have not been reported in ocular conditions associated with common agents used for systemic chemotherapy. The impact of intravenous chemotherapy on choroidal microvasculature was analyzed in a previous study, where the authors concluded that systemic chemotherapy cannot cause a significant change in choroidal thickness. These findings support the impression of increased choroidal thickness in the current case as a primary event.Posterior segment side effects of systemic chemotherapy have been studied for some drugs. Secondary retinopathy with visual loss develops with cisplatin use; Following systemic chemoreduction, the recurrence rate of retinal tumors ranges from 24 to 44%. The majority of new tumors will be detected within three years of initial retinoblastoma diagnosis. In a previous study, most retinal tumors recurred within five months of initiating chemoreduction, when the therapeutic period of chemotherapy had not ended. Although recurrence of retinoblastoma after 20 years is rare, complete retinal examination for any active retinal tumor was performed in our patient, and no sign of retinal recurrence was detected.Recurrence of retinoblastoma may be manifested by a new retinal tumor, vitreous seeding, subretinal seeding, or extraocular findings. Shields et al suggested an average interval of two months for the recurrence of subretinal seeding after completion of chemotherapy. However, calculated recurrence rates of 53 to 62% at one and three years, respectively, suggested that subretinal recurrence may happen after several years. The subretinal seeds may be free running or fixed to the external retinal surface. Retinal detachment, in addition to position-dependent ophthalmoscopic contours, is a characteristic finding in subretinal seeding of retinoblastoma. Features of subretinal fluid and its absorption on follow-up examinations ruled out the probability of recurrent subretinal seeding as the cause in our patient.In eyes presenting with exophytic tumors with subretinal seeding at presentation, recurrence of subretinal seeding is a particular concern.,21Helicobacter pylori infection, obstructive sleep apnea, and corticosteroid-releasing tumors have been reported to be related to the pathophysiology of CSC. Among these, no ocular malignancy has been shown to be associated with CSC. Although some conditions with choroidal origin such as radiation choroidopathy and choroidal neovascularization have been reported after treatment of retinoblastoma, in case of subretinal exudation in an eye with regressed retinoblastoma, retinoblastoma recurrence or secondary malignant tumors are considered prior to choroidal conditions.CSC is an ocular condition characterized by neurosensory detachment associated with pathological dilation of choroidal vessels. A number of systemic disorders, including autoimmune diseases, hypertension, allergic respiratory diseases,This is the first report on the coincidence of CSC and retinoblastoma in the same eye. Although blurring of vision and accumulation of subretinal fluid in a case of retinoblastoma should be considered as indicators of recurrent retinoblastoma or treatment adverse effects, coincidence of CSC and retinoblastoma could be detected in our patient.


Congenital hepatoblastoma (CHB) is the most common hepatic malignant tumor of fetus or neonates, but few studies focusing on the radiological characteristics of CHB have been reported to date.To investigate the characteristic clinical and computed tomography (CT) findings of CHB to facilitate recognition and noninvasive diagnosis.Medical records of 7 patients with CHB were retrospectively reviewed. The demographic, clinical, and laboratory data were extracted from the electronic medical records. Two pediatric radiologists evaluated the abdominal CT examinations for the hepatic tumor location, size, enhancement characteristics, vascular invasion, and intra-/extra-hepatic metastasis.Among the included 7 patients , only 1 had an elevated serum alpha-fetoprotein level. All patients had solitary intrahepatic mass with a mean size of 4.7 cm (range: 2.9–10.2 cm), of which liver SV-VII were most involved. 4/7 tumors were round while 3/7 irregular or lobulated. 6/7 tumors were well-defined. Microhemorrhage, cystic necrosis, and coarse calcification were present in 5/7, 4/7, and 1/7 tumors, respectively. All lesions showed inhomogeneously significant enhancement, with multiple nodular or striped appearance in the center and periphery of the tumors on the arterial phase, and then the enhancement area showed progressive expansion and fusion filling over time but the attenuation gradually declined on the portal and delayed phases, and finally the majority (6/7) of tumors presented multiple band- or island-like characteristics with prominently peripheral enhancement on the delayed phase while the remaining 1 relatively small tumor showed nearly complete but inhomogenous enhancement. In addition, only 1/7 tumor had hilar hepatic bile duct and portal vein invasion and secondary intra-hepatic bile duct dilation. No metastatic lesions were identified in all patients at diagnosis. The abdominal aorta distal to the coeliac trunk was significantly narrowed in 3/7 patients. Pathological examinations suggested that 6/7 tumors showed fetal histology with only 1 containing mesenchymal elements.The relationship between serum alpha-fetoprotein and CHB could be more complicated and yet to be determined. Dynamic contrast-enhanced CT can facilitate recognition and noninvasive diagnosis of CHB, presenting a pattern of progressive expansion and fusion filling but inhomogeneously significant enhancement. Up to now, however, few studies focusing on the radiological characteristics of CHB has been reported. It has not been studied as thoroughly as HB diagnosed at an older age.Hepatoblastoma (HB) is the most common hepatic malignant tumor of childhood, mostly occurred before 5 years of age. Congenital HB (CHB), those detected in utero or diagnosed within the first 28 days after birth, accounts for less than 10% of all pediatric HB.Therefore, the purpose of our study was to review the characteristic clinical and radiologic findings of 7 patients with CHB to facilitate noninvasively preoperative diagnosis and avoid misdiagnosis or unnecessary surgical exploration.2This retrospective study was approved by our institutional review board and patient consent was waived. We identified 7 HB patients diagnosed in the neonatal period based on pathological findings from 2012 to 2019 at our hospital through queries of the radiology and pathology search engines. Patient demographic information, clinical signs and symptoms, laboratory tests, and treatment were obtained from the electronic medical records. All patients underwent abdominal contrast-enhanced computed tomography (CT) examinations before surgical resection. Two pediatric radiologists  reviewed CT scans of the eligible patients by consensus, and evaluated the main imaging features regarding hepatic tumor location, size, morphology, margin, enhancement pattern, presence or absence of cystic necrosis, hemorrhage or calcifications, adjacent anatomical structure involvement, and intra-/extra-hepatic metastasis. The tumor size was indicated by the maximum dimension. The radiologists were blinded to the clinical information and pathological diagnosis.35ng/mL6). Other blood tests including hemoglobin, white blood cells count, and platelet level were relatively nonspecific. Focal abnormality in the liver was detected by ultrasound in 4 patients antenatally, while the liver tumors were found accidentally in the other 3 patients due to respiratory diseases. No patients had a family history of Beckwith–Wiedemann syndrome, hemihypertrophy, or familial polyposis coli.The demographic and clinical characteristics of included patients in this study are shown in Table At the abdominal CT examinations, all the 7 cases of CHB were single solid and the mean tumor size was 4.7 cm (range: 2.9–10.2 cm). Liver S (V∼VII) were most involved, with 2 cases in S VI, 2 in S VII, 1 in S (V + VI), 1in S (II + III), and 1 in S (IVa + V + VIII). The majority (6/7) of tumors were well-circumscribed. 4/7 tumors presented round while 3/7 tumors with extrahepatic extension irregular or lobulated. Microhemorrhage, cystic necrosis, and nodular calcification was seen in 5/7, 4/7, and 1/7 tumors, respectively. All tumors showed inhomogeneously significant enhancement. All tumors presented marked enhancement with multiple nodular or striped appearance in the center and periphery of the tumors on the arterial phase. The enhancement area showed progressive expansion and fusion filling over time but the attenuation gradually declined on the portal and delayed phases, and finally the majority (6/7) of tumors presented multiple band- or island-like characteristics with prominently peripheral enhancement on the delayed phase epithelial;(2)mixed epithelial and mesenchymal. Patients with pure well-differentiated fetal HB usually have a good outcome with complete excision and no chemotherapy.–16 6/7 tumors in our study showed fetal subtype with only 1 containing mesenchymal elements and all patients had a favorable outcome after excision without additional chemotherapy. The histological immunomarkers that were detected in our series included Ki-67, glypican, alpha-fetoprotein (AFP), cytokeratin, vimentin and B-lymphocyte marker CD34. In recent years, more and more attention has been paid to the significance of glypican-3 in the diagnosis, occurrence and development of HB. Glypican-3 is highly expressed in fetal epithelium, weakly expressed or absent in embryonic epithelial cells, but not expressed in small cell tumor cells. In routine immunohistochemical detection of HB, the intensity and sensitivity of glypican-3 is higher than that of AFP and it has been reported to be an excellent marker for the diagnosis of infantile HB.The former is further divided into multiple subtypes, including fetal, embryonal, small cell undifferentiated, mixed epithelial, and cholangioblastic, according to the degree of cellular differentiation. CHB mainly consists of fetal and embryonal components compared with infants beyond the neonatal period.,19,20 Consistent with the observations seen in previous literature, we also found the occurrence of hemorrhage and cystic necrosis in CHB, and higher incidences in larger tumors. On dynamic contrast-enhanced CT, all the 7 tumors showed early peripheral and intratumoral nodular or striped significant enhancement on the arterial phase, and then the enhancement area showed progressive expansion and fusion filling over time but the attenuation gradually declined, presenting multiple band-like or island-like characteristics with prominently peripheral enhancement on the portal and delayed phases. Our imaging finds validated other 3 previous studys which also discribed hypervascular HB.,22,23 This imaging appearrence differs from that of HB in older children generally showing enhance less than surrounding normal liver.,24 We infered these imaging features of CHB might be associated with tumor microanatomy that was highly vascularized reflected in abundant tumor vessels and large blood sinuses in the stroma,25 and intratumorally multifocal extramedullary hematopoiesis. Decreased aortic caliber below the celiac axis may be present when there is enlargement of the celiac axis or hepatic artery due to vascular shunting into the hepatic mass.,23Imaging can play a crucial role in diagnosis of hepatic neoplasms in neonates. Most CHB developed in the right lobe of the liver probably resulting from the difference of the circulation to the right and left lobes in fetus. 1/7 tumor among our cases appeared calcification. Calcification is relatively rare and presents usually small and fine in epithelial tumors. while CHB dose not. In our study, several patients were misdiagnosed as congenital hemangioma at admission, which might result from our lacking recognition of CT characteristics of CHB and neglecting the importance of serial measurements of AFP in the neonatal period.The most challenging differential diagnosis of CHB is congenital hemangioma. A single AFP measurement is often unhelpful because the normal range at birth is high. Although congenital hemangioma has some distinctive imaging manifestations—a heterogeneous mass with no pseudocapsule, more common calcification, rarely extrahepatic extension, and gradual centripetal fill-in enhanced pattern till delayed phase, the best strategy to distinguish these 2 hepatic neoplasms is a short period of observation. The congenital hemangioma size may decrease and serum AFP level often falls rapidly after birth,The main limitations of our study were the retrospective nature and a small sample size, though to our knowledge this is the largest case series reported regarding the CT characteristics of CHB. In addition, it didn’t allow us to adequately understand the imaging difference between different histologic types given that our study subjects were mainly fetal type.Our study suggested that the clinical and CT characteristics of CHB could differ from those occurred beyond the neonatal age. AFP level should be interpreted with more caution in neonates, and most CHB had fetal components in histopathology. Dynamic contrast-enhanced CT can facilitate recognition and noninvasive diagnosis of CHB, presenting a pattern of progressive expansion and fusion filling but inhomogeneously significant enhancement. However, the estimates of our study are based on too few patients to reach a firmer conclusion. Larger multi-center studies confirming these radiological findings are needed.Conceptualization: Li Li, Wen Liu, Ke Jin.Data creation: Li Li, Wen Liu, Rong Wen, Ke Jin.Formal analysis: Li Li, Wen Liu.Methodology: Li Li.Supervision: Li Li, Ke Jin, Wen Liu, Rong Wen.Validation: Li Li, Ke Jin.Writing – original draft: Li Li.Writing – review & editing: Li Li, Wen Liu, Rong Wen, Ke Jin.


Congenital unilateral hypertrophy of the plantar musculature is a rare condition, and to our knowledge, reports of only 14 cases have been previously published. As only one describes a concomitant orthopedic toe deformity, we report our case of abductor hallucis, flexor digitorum brevis, and abductor digiti minimi muscle hypertrophy in combination with hallux valgus and claw toe deformity as well as a laterally abducted fifth toe. Thus, this report presents the rare case of congenital hypertrophy of the plantar musculature associated with complex toe deformities. Moreover, the present article contains a detailed description of our surgical technique as well as a review of the current literature. Congenital unilateral hypertrophy of the plantar musculature is a rare condition of unknown incidence. In 1974, Jahss was the first to publish a description of a congenital hypertrophy of the quadratus plantae muscle, which he assessed as “pseudotumor of the foot” in a 4-year-old female –9. MoreoThis article reports the unusual case of a 17-year-old man with this rare condition in combination with multiple toe deformities: hallux valgus, claw toe (second toe), and laterally abducted digitus quintus. To our knowledge, this atypical presentation of complex osseous and soft tissue deformities has not been previously published in the medical literature. Therefore, this case study is aimed at reporting a detailed description of the present patient and explains the rationale behind our chosen surgical procedure. Moreover, a review of the current literature related to congenital hypertrophy of the plantar musculature is presented to discuss its possible etiology as well as diagnostic and therapeutic regimen.A 17-year-old man presented with painless hemihypertrophy of the right foot and calf and was treated at our institution between 10.2017 and 12.2019. The asymmetry of his feet, which has never been progressive, was first noticed at the time of his birth . Since tDuring maturity, his only physical complaints had been muscle cramps on the lateral aspect of his foot, which occasionally occurred after extensive activities. Apart from that, he experienced no difficulty in walking, running, or even playing football. However, since the age of 15, the patient suffered from typical hallux valgus deformity symptoms: pain over the medial eminence and local skin irritation.Physical examination revealed a painless, soft mass on the medioplantar, plantar, and lateroplantar surface of the right foot. This soft tissue mass completely obliterated the plantar arch of the foot. Range of motion in the right upper limb's joints did not differ from the left side. Motor function, vascularization, and sensibility were normal. The patient exhibited clinical presentation of a pes transversoplanus in combination with a hallux valgus deformity, which showed a slight hallux valgus interphalangeus component. We also observed a claw deformity of the second toe and a digitus quintus with laterally abducted phalanges; however, neither were causing any clinical symptoms.Radiographs in two planes  confirmed the clinical presentation . An inteRoutine laboratory testing revealed elevated blood creatine kinase levels: 306 units/liter (reference range: <190 units/liter).The procedure was performed with the patient supine and under general anesthesia using an Esmarch's bandage for surgical hemostasis. First, a crescentic skin incision, approximately 10-centimeter-long, was made on the medial side of the right foot. After dissecting the abductor hallucis brevis muscle, the plantar hypertrophic portion of this muscle was resected with a cautery knife. The plantar portion of this muscle was insufficient, partly due to strong connective tissue fibers toward the subcutaneous fat tissue. Below this muscle, the neurovascular bundle appeared flattened in a delta-shaped manner in the intermuscular fascia . Next, tHistological analysis of the resected tissue revealed skeletal muscle fiber hypertrophy as well as focal skeletal muscle atrophy, microfocal skeletal muscle necrosis, and local, chronic inflammation with interstitial fibrosis. Postoperatively, the foot was immobilized with a below-knee cast for six weeks, after which the K-wire was removed . FollowiCongenital isolated hypertrophy of the plantar musculature is a rare condition with only 14 cases previously described in the literature. As with other accessory tissue of the foot, e.g., polydactyly with additional digits consisting of soft tissue, no information on incidence or etiology is available . AlthougThese characteristics have been reported among patients between four months and 33 years. Left and right feet are approximately equally affected. In reviewing the literature, we identified 14 cases of this condition, all of which occurred without any correlation to a congenital syndrome or disorder. We have decided to present cases affecting an isolated muscle  separateWith respect to treatment options for this condition, we emphasize that surgical intervention should only be indicated if clinical symptoms cannot be handled with more conservative options. Particularly, resection of functional plantar musculature has several potential complications, such as motor imbalances causing secondary joint deformities, local paralysis due to nerve injury, necrosis due to compromised blood supply, and general wound healing and scar problems. In this context, In summary, our procedure is aimed at relieving the hallux valgus symptoms, correcting its triggering factor, and preventing the patient from further symptomatic foot deformities, while restoring—and not destroying—the physiological muscular function by partial resection. For this reason, we did not surgically address the asymptomatic claw deformity on the second toe or the laterally abducted fifth toe, assuming that these deformities will stop proceeding or even regress after removal of the presumed triggering factor.


Mixed squamous cell and glandular papilloma (MSGP) of the lung is rare neoplasm, only 19 cases previously reported in Japan. MSGP is one of three separate categories of solitary endobronchial papillomas, which account for less than 0.5 % of all lung tumors. MSGP is rarest of the three. We present a rare case of MSGP and review the literature in Japan.A 49-year-old man presented with a nodulous shadow in the right lower lung field identified on a chest X-ray performed for back pain. Computed tomography demonstrated a well-circumscribed, 9-mm mass in the S8 segment of the right lower lung lobe. Positron emission tomography showed accumulation of 18F-fluorodeoxyglucose in the tumor with a standardized uptake value of 2.29. Following thoracoscopic partial resection, adenocarcinoma was diagnosed by frozen section, and radical segmentectomy of S8 was performed. The final diagnosis was mixed squamous cell and glandular papilloma. The patient had an uncomplicated postoperative course and remains asymptomatic 3 years after the procedure.The etiology and pathological characteristics of MSGP remain unclear. There has been no report of recurrence in MSGP cases treated with complete resection; thus, limited resection that preserves pulmonary function is desirable. Further data including new cases are required.We present a rare case of mixed squamous cell and glandular papilloma (MSGP) of the lung and review the literature in Japan. Limited resection that preserves pulmonary function, while ensuring complete resection, is desirable. Further investigations with new cases are required. MSGP isThe work has been reported in line with the SCARE criteria .2A 49-year-old man presented to our division for evaluation of a nodulous shadow in the right lower lung field on chest X-ray performed for back pain. He had a smoking history of 45 pack-years. Chest computed tomography (CT) showed a well-circumscribed, 9 mm mass in the S8 segment of the right lower lung lobe . Positro3MSGP of the lung is extremely rare; thus, its etiology and clinicopathological characteristics remain unclear. Only 20 cases have been reported in Japan, including the present case  , Inamura et al. reported that MSGP is seen predominantly in males, and that a history of smoking and human papilloma virus (HPV)-negative status may indicate an etiological association between MSGP and tobacco smoke . FurtherIt is difficult to diagnose MSGP and exclude malignancy preoperatively. Only three patients, all of whom had central tumors, reported receiving a definite diagnosis of papilloma before surgery. Four cases were diagnosed as lung cancer before surgery  . PeripheConcerning treatment, lung resection was performed in 19 cases; in the remaining case, bronchoscopic resection was performed. Lobectomy was performed in 12 cases. Since MSGP is classified as a benign tumor and there is no report of recurrence in the case of complete resection. If a definitive diagnosis is reached before surgery, limited resection that preserves pulmonary function is desirable. However, as described earlier, it is difficult to achieve preoperative diagnosis and there is also a risk of preoperatively misdiagnosed malignancy ,19. Thus4We report an extremely rare case of MSGP in the lung. The etiology and pathological characteristics of MSGP remain unclear. There has been no report of recurrence in cases treated with complete resection, thus limited resection that preserves pulmonary function is desirable. Further investigations with additional new cases are required.All authors have no funding of research.This study was approved by the institutional review board in June 2019 , and the need to obtain informed consent was waived.Written informed consent was obtained from the patients for publication of this case report and accompanying images.Yoshihito Iijimaa carried out the operation, wrote this manuscript and carried out data collection. Yuki nakajima, Hiroyasu Kinoshita, Hirohiko Akiyama, Yu Nishimura and Tomomi Hirata carried out the revision of the manuscript.N/A.Yoshihito Iijima.Not commissioned, externally peer-reviewed.All authors report no conflict of interest.


Helicobacter pylori gastric mucosal-associated lymphoid tissue (MALT) lymphoma in a sleeve gastrectomy specimen with no gross examination findings.Mucosal-associated lymphoid tissue (MALT) lymphoma can typically be identified as a mass lesion or nodularity endoscopically and macroscopically. We report an incidental finding of a  The macroscopic examination of specimens and the selection of representative sections for subsequent microscopic examination are crucial and fundamental to the accurate diagnoses in pathology. William Grossman claims that in over 90% of specimens, an accurate diagnosis can be made with just the gross examination only . The decHelicobacter (H.) pylori stain on three of the blocks was negative. With these histological findings, the patient was diagnosed with a MALToma. Positron emission tomography (PET) scan was performed which revealed a lesion in the sigmoid colon. Subsequently, the patient underwent another round of biopsies which showed mild chronic inactive gastritis within the stomach and benign lymphoid aggregates in the colon. The patient was placed on omeprazole, clairthromycin, and amoxicillin. And, six-month follow-up established endoscopic and histologic remission.This case report describes a 54-year-old male who underwent a laparoscopic sleeve resection procedure for morbid obesity. Prior to the procedure, the patient had a weight of 115.9 kilograms and a body mass index (BMI) of 49.77 and had failed both diet and medical weight management. His other medical history included hypertension, dyslipidemia, and sigmoid diverticulosis. His surgical history comprised of a laparoscopic cholecystectomy and an open reduction internal fixation of fracture on his ankle. He has a family history of diabetes mellitus type 2 in both parents. The patient admitted to drinking alcohol weekly but denied tobacco and recreational drug use. Physical examination did not reveal lymphadenopathy or hepatosplenomegaly. Preoperative evaluation of the peripheral blood was within normal limits with no evidence of a hematological malignancy or lymphoproliferative process. In addition, the patient did not have any positive findings on review of systems or any symptoms. Preoperative gastroduodenoscopy did not reveal any lesions; however, two antral biopsies were taken which revealed mild chronic inactive gastritis. A “sleeve gastrectomy specimen” was received in the pathology department. On gross examination, the gastric mucosa was described as tan-pink, smooth, and glistening with a focal area of hemorrhage . There wH. pylori status was available for all but 1 of the cases and they were negative.This is not the first case report of an incidental MALT lymphoma in a sleeve gastrectomy, as several other investigators have identified a MALT lymphoma in other bariatric specimens –6. A litInterestingly, this case report was the only case report that had no significant gross findings, whereas all the other cases reported identified a mass lesion in the specimen. A recent article by AbdullGaffar et al. challenges the need for routine microscopic evaluation of bariatric sleeve gastrectomy specimens . Their pIn conclusion, our case emphasizes the importance of examining surgical specimens both macroscopically and microscopically for the identification of incidental malignant findings in asymptomatic patients. Although a large majority of MALTomas can be identified with gross lesions endoscopically and macroscopically on the specimen, a small percent of MALTomas have no gross findings. It is imperative to perform representative sampling on these specimens.


We report the case of a woman with primary hyperparathyroidism suspected of mediastinal ectopic parathyroid adenoma revealed to be a thymoma. Our aim was to focus on some possible criticisms in distinguishing between ectopic parathyroid and thymus. We report the case of a woman with primary hyperparathyroidism suspected of mediastinal ectopic parathyroid adenoma revealed to be a thymoma. Our aim was to focus on some possible criticisms in distinguishing between ectopic parathyroid and thymus. We report a case of primary hyperparathyroidism in a woman with mediastinal tumor. False‐positive imaging, intraoperative findings, and changing surgical strategy make the case very educational.2A 68‐year‐old woman under medical supervision from 2013 for osteoporosis presented a clinical history characterized by symptomatic kidney stones, bone fractures, diarrhea, abdominal pain, dysphagia, and dyspnea. In 2019, she performed the first check at Endocrine Surgery Division because of gradual osteoporosis worsening and recurrent urologic symptoms. Laboratory results  confirmed diagnosis of primary hyperparathyroidism with normal calcium serum level. Tc 99 m sestamibi showed a main pathologic increased uptake on immediate imaging and a decreased signal on delayed imaging in the anterior mediastinum and a slight uptake at the lower third of left thyroid lobe . It was repeated at 30 minutes, but value increased (259.5 pg/mL).Therefore, endocrine surgeons performed neck exploration through a transverse cervical incision. Left upper parathyroid gland appeared enlarged and was removed. Frozen section was suggestive of hypercellular parathyroid. Also, the left lower gland appeared enlarged and was removed; pathology was suggestive of hypercellular parathyroid and residual thyme tissue. Since parathyroid hyperplasia typically involves all four glands and the right lower gland was increased in size, it was removed as well. Frozen section was suggestive of hypercellular parathyroid. Final PTH was 35 pg/mL. Postoperative was uneventful. Oral calcium was administered, and she was discharged in the 4th postoperative day.Contradicting intraoperative findings, at definitive examination the mass revealed no immunostaining for PTH but immunoreactivity was coherent with type AB thymoma (sec WHO). Definitive diagnosis was primary hyperparathyroidism in parathyroid hyperplasia and concurrent thymoma. Masaoka stage I did not necessitate further intervention.3Parathyroid adenoma and thymoma are uncommon diseases. However, the simultaneous presentation of both tumors has been described, sometimes with ectopic cervical thymus or mediastinal parathyroidAmong concurrent cases reported in literature, the most of patients presented hyperparathyroidism and coexisting or subsequent myasthenia gravis, suggesting for a mediastinal disease. By contrast, in few cases, thymoma was accidentally found during cervicotomy, thanks to its ectopic position. Therefore, Verroiotou et al,However, the diagnosis can be even more challenging. In 2014, Cunningham et alAs in their clinical case, we had to deal with a false‐positive for original mediastinal parathyroid adenoma Tc 99 m sestamibi scan and false‐negative for cervical adenoma/hyperplasia. In both cases, a mediastinal mass suspected of ectopic parathyroid was found to be a thymoma. Scintigraphy sensitivity and positive predictive values are 82.1% and 93%, respectively. Usually, false uptake has been documented in both benign and malignant disease with elevated mitochondria such as in thyroid tissue but also in other tissues, such as lung, brain, bone, thymus, or lymphatic. Thymomas and other mediastinal tumors with pathological technetium Tc 99m sestamibi uptake have been already described and investigated, so much so that Fiorella et alOur case requires the utmost care in reading the scintigraphy in those clinical contexts in which patients present hyperparathyroidism and mediastinal tumor. Indeed, an unexpected thymoma or a silent cervical parathyroid adenoma could not be excluded in advance. Therefore, in these rare cases, the preoperative assessment should always be completed with the chest CT scan and the ultrasound of the neck.Moreover, we underline the role of intraoperative PTH levels measurement and frozen section in influencing surgical strategy. The pathologist should always be accurately informed in advance about patients’ clinical history and about specific need of a differential diagnosis between thymus or parathyroid tissue. Indeed, surgical strategy could be modified in midcourse, based on mediastinal sample examination findings and PTH levels. In the case of thymoma, complete removal of mediastinal adipose tissue should be considered, whereas in the case of persistent PTH high levels, involvement of endocrine surgeons and neck exploration are mandatory.None declared.All authors: were involved in substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafted the article or revised it critically for important intellectual content; and involved in final approval of the version to be published.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available on request.


Retroperitoneal fibrosis (RPF) is a rare systemic disease. Two-third of the cases are idiopathic but assumed to have autoimmune process related to IgG-4. It is often a diagnosis of exclusion due to its non-specific clinical presentation. Early manifestation commonly causes back pain, raised erythrocyte sedimentation rate level and renal impairment. Investigations of choice are MRI and contrast-enhanced CT but biopsy should be performed for diagnostic confirmation. This case report describes a delay in diagnosing RPF in a 57-year-old female who initially presented to primary care with back pain, mild anaemia, raised erythrocyte sedimentation rate and progressive renal function decline. She was seen urgently in haematology clinic who arranged bone scan to rule out osteoblastic metastases, finding demonstrated possible pelviureteric junction dysfunction. The investigation was followed by a MAG3 renogram 4 weeks later instead of an abdominal CT leading to diagnostic delay. She then presented acutely 1 day after renogram with life-threatening hyperkalaemia and AKI 3. RPF was then suspected. Renal ultrasound scan and CT scan consecutively showed bilateral gross hydronephrosis and retroperitoneal mass around the aorta. The pelviureteric junction dysfunction was due to ureters getting embedded into the dense retroperitoneal fibrous tissue. She subsequently underwent bilateral ureteric stent placement and was commenced on steroid therapy, with satisfactory outcome on follow-up. Laparoscopic retroperitoneal biopsy later confirmed the diagnosis. This case not only highlighted important learning points on the presenting features and radiographic findings of RPF, but also the clinician’s cognitive biases leading to diagnostic delay of a rare but life-threatening disease. This prompted her GP to refer her urgently to a Haematology team. Additionally, her renal function deteriorated from 6 months ago. Her creatinine increased from 52 to 88 mmol l−1 and estimated glomerular filtration rate (eGFR) decreased from 90 to 57 ml/min/1.73 m2. This was, however, not mentioned in the GP referral at the time.A 57-year-old Caucasian female patient presented to her General Practitioner (GP) with worsening lower back pain in the past 3 months. She was known to suffer from chronic mechanical back pain related to her job as a driver and also from a minor lumbar spine injury 15 years ago due to car accident. Initial blood investigations showed mild normocytic anaemia, with Haemoglobin (Hb) of 114 g l−1 and eFGR was 53 ml/min/1.73 m2. Again, this was not commented upon during the clinic.She was seen at the haematology clinic within 2 weeks. With the history of acute on chronic back pain and mild anaemia, the differential diagnosis included underlying osteoporotic wedge fracture, possible inflammatory rheumatological condition and haematological malignancy such as multiple myeloma. Examination showed no lymphadenopathy or hepatosplenomegaly. Her anaemia was thought to be reactive caused by inflammatory response. Bone scan was then arranged to investigate possible myeloma bone disease. At this point, she was deemed suitable to be discharged from clinic pending additional investigations looking for haematological malignancy such as serum light chains and beta-2 microglobulins, which were later found negative. She also had repeated blood test at the clinic that showed further renal function decline. Her creatinine was now 95 mmol lThe bone scan happened 3 days post-haematology clinic which did not show evidence of osteoblastic metastases. Interestingly, retention of tracer in the right pelvicalyceal system was noted . The repThe MAG3 renogram was performed 4 weeks after the bone scan and the right kidney showed poor tracer uptake (which was less than 5%), with significant pooling of tracer in the collecting systems at 30 min and minimal excretion towards the end of the examination. There was a significant reduction of tracer uptake in the left kidney with corresponding low tracer excretion. The relative renal function for both kidneys were 81% on the right and 19% on the left . These f1The differential diagnosis associated with PUJ dysfunction were secondary to pelvic mass or retroperitoneal mass effect, for instance from a lymphoma or metastatic disease. Infective cause such as local spread of tuberculosis from paraspinal abscess was considered. However, this was thought to be unlikely given the absence of infection signs and the demographics of this patient. Other less common differential diagnoses included multiple myeloma, sarcoma, carcinoid and histiocytosis.−1 and creatinine 686 mmol l−1. The hyperkalaemia required urgent interhospital transfer to her local renal centre to facilitate emergency haemodialysis. The possibility of suspected retroperitoneal fibrosis (RPF) was now raised . She had renal ultrasound scan (USS) which demonstrated grossly hydronephrotic kidneys bilaterally  and severe hyperkalaemia; with potassium level of 7.9 mmol laterally .2,3 There was no significant para-aortic lymphadenopathy, hence unlikely to represent lymphoma.4Dialysis was provided via temporary right internal jugular catheter after several unsuccessful right femoral cannulation attempts. Right groin USS performed to assess damage showed 27 × 17 × 29 mm pseudoaneurysm. Subsequent CT scan to assess hydronephrosis was modified to include CT angiogram to assess right femoral artery damage. Findings were reported as bilateral severe hydronephrosis with poor enhancement of the left kidney. A rind of soft tissue around the aorta, inferior vena cava and iliac vessels was noted without evidence of vascular invasion . The CT The CT angiogram also demonstrated a lobulated pseudoaneurysm measuring a maximum of 4 cm craniocaudally in the right groin. This was arising from the anterior wall of the superficial femoral artery where the line insertion attempt had been made . Additio−1).Bilateral ureteric stents were inserted 1 day post dialysis via a retrograde ureteropyelogram in order to relieve the PUJ obstruction caused by the soft tissue mass effect. Additionally, the right femoral artery open repair was also performed at the same time. Retroperitoneal fibrosis was treated with immunosuppression using oral prednisolone 40 mg once daily. The patient was discharged on Day 7 and her renal function significantly improved  1 year after treatment showing significant reduction of RPF and resolution of hydronephrosis  is a disease of unknown aetiology but assumed to be an autoimmune process related to IgG-4 with periaortitis as the initial pathophysiological mechanism.3,5 Such is its rarity that, naturally, more common causes must be excluded before making the diagnosis. The presenting symptoms of this patient were also compatible with her pre-existing co-morbidity of chronic back pain and post-menopausal bleeding (which may cause anaemia), contributing to further diagnostic challenge.The literature describes patients often presenting with non-specific symptoms such as back or abdominal pain, and then renal failure at a later stage. ESR levels tend to be elevated. The non-specific clinical manifestations pose difficulties in early diagnosis.6 As haematology is a super-specialised field, the patient was initially investigated by bone scan primarily from haematological perspective (such as myeloma), which is an example of "availability bias". This is a common occurrence when clinician favours a course of action based on readily available knowledge and familiarity.7,8 Moreover, the reporting radiologist recommended MAG3 renogram to further assess the suspected PUJ dysfunction which was not the most appropriate diagnostic scan in context of suspecting malignancy and progressive renal function decline. This was likely due to "anchoring bias" when clinicians focused exclusively on a single finding.8 This is when "diagnostic momentum" occured  leading to diagnostic delay.6 As a result, other differential diagnosis causing renal function decline were not fully assessed. These cognitive effects are an important learning point particularly in the world of increasing super-specialisation. Each step was valid in isolation, but like a swiss cheese model in this case aligned towards a life-threatening presentation.9Upon analysing the clinical courses, this patient would have clearly benefited from early abdominal evaluation such as CT abdomen or abdominal ultrasound after the initial bone scan result. Particularly, in the context of suspected haematological malignancy and abnormal renal function. This case report reflects upon the several cognitive biases leading to diagnostic delay. In this instance, the GP referred her to haematologist for back pain, high ESR and anaemia without mentioning the renal function, resulting in "Framing bias". This is a cognitive effect when clinicians come to decision based on how the information is initially presented and may account for why the renal function decline were not addressed at the time.2,10 Previously, fluoroscopy was used to perform intravenous urogram. Findings of hydronephrosis or even delayed contrast excretion into the collecting system and medial deviation of the middle ureters can be appreciated along with tapering of ureteric lumen around L4-S1.6 Now CT imaging is the main modality for investigating RPF. On portal-venous phase imaging a retroperitoneal soft tissue density homogeneous mass is noted, typically encasing the infra renal abdominal aorta and iliac vessels moving cranially towards the renal hila. This soft tissue changes do not invade these vascular structures or the ureters.2,10 Other diseases which can present with similar radiological findings include retroperitoneal lymphoma, which is typically centred more cranially to L4-5, and rarely retroperitoneal extramedullary haematopoiesis, seen as a retroperitoneal mass but displaces the ureters laterally and the aorta anteriorly from the vertebrae spine.10There are currently no set guidelines on how to approach the diagnosis of RPF. Most of the current literature identifies CT and MRI as the most useful tools in confirming RPF.10 RFP appears dark, low intensity on T1 and 2T weighted images, and in the presence of active inflammatory process the 2T weighted signal can be variable or hyperintense.2,11MRI is also useful though not as easily accessible, has the added advantage of better contrast resolution. The sensitivity is equal to that of CT imaging.10In active inflammatory phase, where metabolic activity is high, RPF can show avid radiotracer fludeoxyglucose uptake in positron emission tomography (PET)-CT imaging. Though not a specific nor sensitive test for RPF, it has the advantage of demonstrating active disease and follow up assessment.12 Displacement of the proximal and mid-ureter to the mid-line on imaging is typical of RPF and should trigger a differential of this disease.As the disease progresses, the fibroinflammatory mass extends into the retroperitoneum, enveloping the adjacent structures, with the ureters being the most affected, causing associated proximal hydroureter and hydronephrosis.2 However, patients with RPF often presents with poor renal function due to obstructive uropathy, which causes the debate whether i.v. contrast agents should be administered.5 In case of non-specific imaging features, a biopsy is indicated, which remains the mainstay for diagnostic confirmation, allowing a confident differentiation of benign or malignant RPF.1,2The soft tissue mass may demonstrate varying degree of enhancement in CT depending on the stage of the disease. During the acute stage, there is avid enhancement of the soft tissue mass with little or no enhancement seen in the later or chronic stage.1 Corticosteroids are commonly used and has been shown to improve the obstructive symptoms and reduce the size of retroperitoneal mass.1,12 Other immunosuppressants such as azathioprine and cyclophosphamide can be used in recurrent disease or when corticosteroids are contraindicated. Surgical management to relieve ureteral obstruction is indicated in a patient who failed to improve with medical treatment. This is usually done by open ureterolysis with intraperitoneal transposition and follow by omental wrapping of the ureters.1 Surgical approach also allows multiple retroperitoneal biopsies to be carried out if diagnosis remains unclear.The initial acute management of RPF is decompression of hydronephrosis with insertion of “double J” ureteric stents. The mainstay of medical treatment is by using immunosuppressants to inhibit progression of the fibroinflammatory reaction caused by RPF.Overall, retroperitoneal fibrosis is uncommon and carries good prognosis following appropriate treatment when there is no underlying malignant cause. It should be included in a broad differential diagnosis for a patient with unexplained impaired renal function and ureteric deviation or PUJ dysfunction. Currently, there are no set pathways or guidelines available to aid clinicians in the diagnosis of RPF. Further study is needed for a better understanding of this disease. Cognitive biases can occur in multispecialty settings leading to diagnostic delay. The current practice of increasing subspecialisation and specialty referrals may once more lead to a long and winding path to diagnosis without vigilance and taking an overview.Retroperitoneal fibrosis is a rare disease often presents with non-specific symptoms causing diagnostic difficulty. It should be considered in a patient presenting with back pain, raised ESR and renal impairment. Progressive deterioration in creatinine and eGFR without a clear cause may reflect its early sign that should prompt urgent nephrology and urology referral.CT imaging is the main modality for investigating retroperitoneal fibrosis. Findings often consist of a retroperitoneal soft tissue density mass encasing the infrarenal abdominal aorta moving cranially towards the renal hila.Retroperitoneal fibrosis typically causes PUJ dysfunction and medial deviation of the ureter without aortic displacement and usually centred around L4-5 region.Cognitive biases such as framing, availability, anchoring and diagnostic momentum could explain clinicians’ behaviour leading to diagnostic delay. This is particularly common in current practice where multiple specialty referrals are involved.


Pancreatic schwannomas are very rare neoplasm arising from Schwann cells that present in the nerve sheath. Schwannoma usually occur in the extremities but can also be found in the trunk, head and neck, retroperitoneum, mediastinum, pelvis and rectum.We briefly describe a 30-year-old female patient with upper abdominal pain and on examination by ultrasound and Computed tomography of abdomen revealed a solid tumor arising from body of the pancreas. A laparoscopic splenic vessel preserving distal pancreatectomy (kimura) was performed.Approximately only 50 cases reported in the literature and none of these cases were diagnosed as schwannoma preoperatively. CT scan is often useful to establish pancreatic lesion which usually demonstrate hypodense lesion with encapsulationAlthough the incidence of pancreatic schwannoma is low, it must be considered as one possibility in the differential diagnosis of mass lesions in the pancreas and whenever possible especially in large tumors surgical resections should be considered due to increased chance of transformation to malignancy. Work has been reported in line with the SCARE criteria .2A 30 year old female came with epigastric pain radiating to upper back Laboratory values including amylase and tumour markers were in normal range. On investigating her a 6*3.5 cm solid well defined oval shaped mass with central specks of calcification arising from the body of the pancreas is identified , Fig. 2.Intra-operatively a well defined solid mass arising from the anterior surface and inferior border of body portion of pancreas was noted . Examina3Pancreatic schwannoma arise from either autonomic sympathetic or para sympathetic fibres, both of which course through pancreas via vagus .In 1910, Verocay reported a schwannoma as a true neoplasm which originated from Schwann cells, and which did not contain neuroganglion cells .Commonly seen in adults with almost equal male to female ratio. Non-specific abdominal pain is the most commonly reported symptom , Fig. 6.Majority of these tumors located in the head (38 %) and body (25 %) of the pancreas .Reported cases of intrapancreatic schwannoma have recently increased in the literature. However, none of these cases were diagnosed as schwannoma preoperatively .CT scan is often useful to establish pancreatic lesion which usually demonstrate hypodense lesion with encapsulation ,6.Microscopically, a typical schwannoma is composed of 2 areas, namely Antoni A and Antoni B areas.In most of the cases, the histological sections of the tumors show the lesion well encapsulated and associated with Antoni A or B patterns, present in a variable proportion .The Antony A pattern has a spindle-long cell which shows a tight fence and higher cells with nuclear double-sequence field . The Antony B pattern has a loose distribution of the cells with varying degrees of lipoidization .Tumors with a preponderance of Antoni A cells may not appear to be homogeneous due to their high lipid content. Their vascular component gives rise to contrast enhancement.In tumors with a high level of Antoni B components, poor cellularity and loose stroma may cause a cystic or multiseptated appearance on CT scans . DegenerThese changes result from vascular thrombosis and subsequent necrosis.The MRI findings usually showed hypointensity on T1-weighted images and hyperintensity on T2-weighted images .Immunohistochemically, pancreatic schwannomas are positive for S 100, Vimentin and CD 56. Conversely, spindle cells in pancreatic schwannomas stain negative for cytokeratin, CD117, desmin, CD34, AE1/AE3, alpha smooth muscle actin, and smooth muscle myosin [A review of the treatment in 37 cases revealed that the most commonly performed operation was distal pancreatectomy (10/37) and Whipple procedure (9/37) .Moriya et al., pointed out that malignant formation and cystic formation is strongly associated with increase in tumor diameter . In viewAuthors have no conflict of interest.Nothing to declare.Ethical committee approval given - reference number awaited.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Study concept and design - DR. P sai krisshna.Data collection - DR. P. sai Krishna.Editing - DR. A. Sivasankar.Name of the registry:Unique identifying number or registration ID:Hyperlink to your specific registration (must be publicly accessible and will be checked):Not applicable.


Angiosarcoma of the colon is rare, as is colonic amyloidosis. To our knowledge, there have been no reported cases of angiosarcoma arising in association with amyloid deposition. Herein, we described a case of 77-year-old man who presented with hematochezia, and a sigmoid mass was found on colonoscopy. Histologic examination of the resected specimen showed extensive nodular deposition of AL-lambda amyloid material in the colonic wall, as well as high-grade angiosarcoma which was closely intermingled with the amyloid deposits. While the occurrence of both colonic amyloidosis and angiosarcoma in this patient may represent pure coincidence, given the intimate association of the angiosarcoma and the amyloid deposition and the rarity of both of these lesions, we hypothesize that angiosarcoma could be secondary to amyloid deposition. Angiosarcoma is a rare malignant vascular neoplasm that involves mainly skin and superficial soft tissue and is extremely rare in the gastrointestinal tract. Most sporadic cutaneous angiosarcomas arise in the setting of significant sun damage and are thought to be related to long-term UV radiation damage . AnotherA 77-year-old man with history of dementia, chronic kidney disease, gout, malignant melanoma of the skin, osteoarthritis, and gastroesophageal reflux disease presented with hematochezia. A nearly completely obstructing mass lesion in the sigmoid colon was found on colonoscopy. Follow-up staging CT scan of chest, abdomen, and pelvis showed a discrete mass in the distal sigmoid colon measuring approximately 10 cm in length, severe colonic wall thickening involving the distal colon and extending through the rectum, and a 2.5 cm right upper pole renal mass with heterogeneous enhancement worrisome for renal cell carcinoma. The patient underwent open sigmoidectomy. Grossly, there was a 3.4 × 2.0 × 0.5 cm ulcerated mass with raised borders. Sections submitted from the mass demonstrated extensive deposition of amorphous, pale eosinophilic material involving the lamina propria, muscularis mucosa, submucosa, muscularis propria, and subserosa with prominent involvement of vessels . The matAmyloid typing by laser microdissection (LMD) followed by high-performance liquid chromatography and tandem mass spectrometry (LC-MS/MS) confirmed the presence of amyloid and was consistent with AL (lambda)-type. No infiltration of plasma cells in the vicinity of amyloid deposits was seen. Due to the patient's advanced dementia, the family decided not to pursue aggressive therapy and opted for palliative care.Angiosarcoma is a rare malignant vascular neoplasm that involves mainly skin and superficial soft tissue but may occur in large vessels, deep soft tissue, and parenchymal organs such as the liver, spleen, bone, breast, and heart. It can be primary or secondary. Long-term sun exposure, radiation, chronic lymphedema, and exposure to Thorotrast, polyvinylchloride, and arsenic are known risk factors –5. AngioColonic angiosarcoma is extremely rare. Wang et al. reported a case of colonic angiosarcoma and summarized the results of 33 previously reported cases . The meaAmyloid has multiple precursor proteins and can occur in different settings including chronic inflammatory conditions, certain neoplasms, genetic/inherited, and age-related. Hematologic malignancies and medullary thyroid carcinoma are two neoplasms that are known to cause amyloid deposition where medullary thyroid carcinoma causes calcitonin type amyloid and plasma cell dyscrasia and some types of lymphoma can cause immunoglobulin related amyloidosis . AmyloidIn summary, we report an extremely rare occurrence of a high-grade colonic angiosarcoma arising in close association with colonic amyloidosis. Although the exact relationship between the tumor and amyloid is obscure, it is tempting to speculate that the amyloid deposits may have served as the inciting tumorigenic event, although pure coincident cannot be completely excluded.


Gardner syndrome is a subtype of familial adenomatous polyposis (FAP), characterized by a combination of adenomatous intestinal polyps and extracolonic lesions such as multiple osteomas, dental abnormalities, and soft tissue tumors. Although 12% of patients with intestinal polyposis of FAP may occur intra-abdominal desmoid tumors, pregnancy complicating with giant abdominal desmoid tumors is a relatively rare case.2 in size. After multidisciplinary consultation and discussion, the decision of fetal preservation treatment was made. After the delivery of a baby girl, abdominal mass resection was performed, and pathological examination revealed a fibrous adenoma. The patient was discharged after a week and was uneventful in the follow-up for half a year.A 28-year-old pregnant woman was diagnosed with Gardner syndrome in whom an intra-abdominal tumor was found a year after undergoing a laparoscopic total colectomy due to family adenomatous polyposis. At 32 weeks’ gestation, she presented to our department for the third time complaining upper abdominal pain caused by the giant abdominal mass about 21 × 12 cmGardner syndrome is characterized by typical syndrome including family adenomatous polyposis and extra-intestinal tissue tumor. Were desmoid tumors rarely as large as fetus and local aggressively. In our case, we selected surgery to remove the intra-abdominal desmoid tumor after the natural delivery of the fetus and no abnormalities were observed during the 6 months follow-up. Women during pregnancy have an increased risk for the development of desmoid tumors, likely with the sex hormone to be one of the triggers. Therefore, we suggested that when a patient with Gardner syndrome desire to conceive again, they should go to the hospital for a regular review at least once every 3 months. Gardner syndrome, mainly manifested by multiple gastrointestinal polyps and universal lesions such as soft tissue tumor, ectopic teeth, osteoma, and retinal pigment epithelium, is a rare autosomal dominant genetic disorder caused by gene mutation in adenomatous polyposis coli (APC). Occasionally, Gardner syndromes also known as "deep" or "invasive" fibromatosis, characterized by fibroblastomas or desmoid tumors that originated from deep muscle or aponeurosis.The World Health Organization (WHO) classified desmoid tumors as one of the moderate fibroblastoma, which recurs locally and invasively rather than distant metastasis. The incidence of Gardner syndrome is 2–4 per million globally, more in females. Moreover, a few factors were identified to be responsible for desmoid tumor: surgery history, trauma, oral contraceptives, reproductive age and delivery history. To diagnose the desmoid tumor, spindle cells in the dense collagen stroma while rare mitosis and necrosis could be found under histopathological examination. In this paper, we report a case of Gardner syndrome in a female with a giant abdominal desmoid tumor during pregnancy.A 28-year-old female, gravida 2, para 1, discovered a massive mass in the abdominal cavity during the 8th month of pregnancy. Three years ago, this patient was admitted to our hospital in the Hematology and Oncology Department due to "repeated dizziness, fatigue and shortness of breath after activity". She was admitted at 60 g/L hemoglobin and was transfused with 3.0U of the same type of red blood cell suspension. The microscopic examination of colon revealed extensive polyp-like lesions in the entire colon. On-duty doctor in responsible for this case suspected "familial adenomatous polyposis (FAP)" and suggested transfer of this patient to our surgical department for further evaluation and treatment. After completing the preoperative examination and investigation, a laparoscopic total colectomy was performed. Postoperative pathological examination showed tubular adenomas (low-grade) and more than 1000 polyps, most of which were broad-based and fit the family adenomatous polyposis. One year later, fibroid adenoma was found in the upper right pubic symphysis. Taking the intestinal lesions into consideration, this case was diagnosed as "Gardner syndrome". In August 2019, the patient presented for the third time to our hospital due to upper abdominal pain at 32 weeks of pregnancy. A CT examination showed that the left side of the uterus in the abdominal cavity was occupied by a huge mass about 21 × 12 cm in size, with mild hydronephrosis in both kidneys Fig. . The posGardner syndrome is characterized not only by typical syndrome including family adenomatous polyposis and extra-intestinal tissue tumor but also by a rare presentation with giant abdominal desmoid tumors during pregnancy . The desGardner's syndrome is associated with familial adenomatous polyposis (FAP), involving a mutation in anaphase promoting complex gene and several extra-digestive manifestations: osteomas, epidermal cysts and desmoid tumors . ApproxiAlthough the mechanism of desmoid tumors remains largely unknown, desmoid tumors might be driven by alterations of the Wnt/APC/β-catenin pathway , e.g., sen bloc surgery is no longer regarded as a cornerstone treatment for desmoid tumors, given that the relapse rate after surgery exceeds 60% in larger series, and that spontaneous regression is documented to be approximately 25% of the cases [Regarding the treatment of desmoid tumors, new alternatives emerged especially in primary non-resectable locations in recent years. Initially, local surgery is the first chosen treatment for desmoid tumors. With advanced techniques, large he cases . Therefohe cases , which ihe cases . Howeverhe cases  showed the cases . In our


Hereditary multiple exostoses (HME) is a rare skeletal disorder characterised by a widespread.distribution of osteochondromas originating from the metaphyses of long bones.This case study examines a 55-year-old male cadaver bequeathed to the University of Liverpool who suffered from HME, thus providing an exceptionally rare opportunity to examine the anatomical changes associated with this condition.Findings from imaging and dissection indicated that this was a severe case of HME in terms of the quantity and distribution of the osteochondromas and the number of synostoses present. In addition, the existence of enchondromas and the appearance of gaps within the trabeculae of affected bones make this a remarkable case. This study provides a comprehensive overview of the morbidity of the disease as well as adding to the growing evidence that diseases concerning benign cartilaginous tumours may be part of a spectrum rather than distinct entities. Hereditary multiple exostoses (HME) is characterised by the presence of multiple osteochondromas situated throughout the skeleton in bones that form by endochondral ossification. Osteochondroma formation is caused by abnormal chondrocyte proliferation in the growth plate which subsequently herniate through the adjacent periosteum . These oOsteochondromas account for 20–50% of all benign bone tumours  equatingThe exostoses cause long bones to undergo bowing, undertubulation and synostoses if growths appear on adjacent bones. Overall, this can affect height with 40% of patients being of short stature . LocallyHME is an autosomal dominant disease caused by mutations and subsequent loss of function in exostosin (EXT) genes . PenetraThe reported rate of malignant change in sufferers of HME does vary, however most accounts have it between 0.5–5% , 12–15 wWith such a rare disease the majority of evidence has been inferred from imaging studies of living patients. This study is the first to correlate the radiological signs with a targeted and detailed anatomical investigation in adulthood, thus providing a more complete view of HME and informing future patient studies.A 55-year-old male cadaver who had suffered from HME was donated to the University of Liverpool for anatomical investigation. Consent was given by the donor ante-mortem and ethical approval for the study was obtained via the Health and Life Sciences Committee on Research Ethics. The cadaver was embalmed four days post-mortem with CT scans and radiographs obtained to establish a complete record of the cadaver. Following dissection bones were removed for MRI and microscopic investigation. The radius, ulna, femur, tibia and fibula were isolated and scanned in a 1.5 T Siemens Symphony MRI to document soft-tissue features. Multiple modalities were used with T2 turbo spin echo (TSE) and standard dual echo steady state (DESS) sequences  chosen fA combination of pre-dissection CT scans and radiographs showed that the cadaver had at least 73 separate external skeletal defects ranging in size and form and were apparent throughout the skeleton. The lower limb contained the most exostoses with 34 tumours, 5 of which were in the feet. The vertebrae displayed 22 growths with 12 located on the vertebral bodies and 10 on the spinous and transverse processes. Six growths were noted in the upper limb with 4 located on the scapula. Two exostoses were on the posterior iliac crests and 2 were located on the anterior of the sternum. The 7th left rib had a small growth on the sternal end, while the right 8th and 10th left rib had osteochondromas on the tubercles. No major dysplasia was evident in the bones of the skull, including the cranial base.On the basis of the features observed in the CT scans and radiographs the following dissection was targeted to the right elbow and right lower limb.Bowing of the radius caused by a shorter ulna had resulted in a radial head dislocation from the elbow joint. Dissection of this area revealed the extent of the soft tissue disfigurement with brachioradialis displaced laterally around the radial head while the radial nerve was stretched over its superior surface, quite possibly causing nerve entrapment Fig. a.Fig. 1The osteochondroma in the metaphysis of the radius had caused an unusual articulation at the elbow joint with the capitulum of the humerus now articulating with the deformed radial tuberosity Fig. b. IntereMRI scans of the proximal radius reveal the cartilage capped exostosis forming at the radial tuberosity Fig. c and theThe proximal femur had 3 exostoses on its surface, varying greatly in size and shape. The largest was formed around the medial and anterior aspects of the metaphysis; it was sessile, had a large amount of lobulation and was capped in cartilage. This large exostosis completely obliterated the neck of the femur causing difficulty in discerning the greater and lesser trochanters of the femur Fig. a and e. MRI scans showed osteochondromas surrounding and growing from the metaphysis Fig. d with caThe histological section through the pedunculated growth Fig. c showed To further discern the anatomy of the internal structures the proximal femur was bisected Fig. g. A softLike the radius, the exostosis in the head of the fibular was a large, lobulated mass with a cartilage cap and had caused considerable anatomical changes to the surrounding soft tissue. By extending into the muscle belly of soleus it had stretched and torn the muscle fibres Fig. a and b.CT scans of the growth revealed the full extent of the osteochondroma and showed that a synostosis had formed between the fibular and tibia heads Fig. c. Like tThe right hallux had a pedunculated growth on the medial aspect of the distal phalanx. There was also an exostosis present on the inferior surface of the head on the 1st metatarsal Fig. a.Fig. 4The anomaly that gave the external appearance that the second digit was shorter is in fact due to a growth of the 2nd metatarsal. The head of the metatarsal had become so overgrown that it had displaced the proximal phalanx of the 2nd digit laterally causing the articulation between the two to be in a sagittal plane as opposed to the normal coronal facing joint Fig. a and b. Findings reported here suggest that this is a severe case of HME with some interesting features. The severity of HME does vary between individuals and while no consensus has been reached regarding classification, Mordenti et al.  have devThe tumours were widespread; exostoses could be seen in the scapulae, ribs, humeri, radii, ulnas, pelvis, femurs, tibias, fibulas, feet and vertebrae. Whilst there are no signs of growths within the hands the medical notes state that tumours in the proximal phalanx of the right 2nd digit were surgically excised 25 years ante-mortem. The literature reports the most affected parts of the skeleton are, in order, the long bones, the scapulae, the ribs, the pelvis and the vertebrae .The most common site of osteochondromas in HME is the knee, with reports as high as 94% of sufferers having a knee exostosis . These cDeformities of the forearm are quite common in HME sufferers with 30–60% of patients suffering from them . They caIt is the exostosis at the distal growth plate of the ulna that ultimately leads to dislocation of the radial head. The distal growth plate of the ulna has a smaller cross section than the equivalent in the radius and therefore greater proportional contribution to growth of the forearm. An exostosis here disrupts ulna growth and subsequently forces the radius to undergo bowing to compensate. It is this bowing that leads to subluxation or full dislocation from the elbow joint , 24. DisFour exostoses where found in the scapulae of donor. 3–4.6% of all osteochondromas are found in this bone with the ventral surface more commonly affected than the dorsal surface . HoweverExostoses in ribs only make up 1% of all growths reported in HME, in this case, however, they make up 4% of all tumours. The 1% reported is likely a gross underestimation as only symptomatic tumours are reported. Indeed Mazza et al.  found asCases of HME with vertebral lesions have commonly been reported between 1 and 9% , 27, howLesions of the vertebral column are more common in the superior spine; 30–80% of the lesions have been reported in the cervical spine, 20–30% in the thoracic spine and only a few reports have cases in the lumbar region . SpecialSynostosis of neighbouring bones has previously been described in osteochondroma sufferers . This evOne of the most significant findings from this case study is the presence of cartilage masses within the metaphyses of the femoral heads which are likely to be either enchondromas or chondrosarcomas. Enchondromas are benign cartilaginous rests that continue to grow but have been displaced from the growth plate . Where tThe presence of enchondromas alongside osteochondromas raises the differential diagnosis of metachondromatosis. However, this is unlikely to be the case here as the location, anatomy, severity, deformities and disease progression of the osteochondromas are all classic signs of HME. The osteochondromas present in metachondromatosis are predominantly found in the hands and feet , 35, 36 MHE and metachondromatosis are both conditions of improper chondrocyte proliferation. Recent studies have suggested that despite having distinct genetic profiles there may be overlap between these conditions. Vining et al.  reportedA search of the literature reveals no information concerning the voids within the trabeculae that were seen in the femoral head, the tibia and the radius. Given the locations of these spaces it is possible that they are connected to the disease. There is evidence that shows the regression of enchondromas and transformation to bone marrow in adults . AlthougIn conclusion this case study represents the most detailed anatomical investigation into HME to date. By collecting both imaging and dissection data it has revealed a more complete picture of HME presentation, detailing a widespread distribution of osteochondromas, especially in the vertebrae, and a high volume of synostoses. This case study also documents trabecular voids and the presence of enchondromas in the femoral heads. These warrant closer scrutiny in future patient studies. As body donation increases, it is possible that more HME suffers will come forward for detailed anatomical investigation; this may reveal how common these findings are and may aid treatment of the condition in the future.


We herein report a rare case of an ectopic bronchogenic cyst of the gastric cardia. The initial diagnosis was a gastrointestinal stromal tumor (GIST); however, postoperative pathologic examination confirmed that it was a bronchogenic cyst.A 62-year-old woman visited our hospital for abdominal pain. The diagnosis prior to surgery was a GIST. Computed tomography imaging showed that the mass was located in the gastric cardia on the side of the lesser curvature. During the surgical exploration, it was noted that the tactility of the mass was not consistent with a GIST. Thus, we decided to perform local resection of the mass and part of the gastric wall without wedge resection. The pathological examination revealed a bronchogenic cyst.This case suggests that a bronchogenic cyst should be considered as a differential diagnosis of a GIST. It is also a unusual but necessary situation should be considered when explaining the etiology of a bronchogenic cyst. A bronchogenic cyst is a cystic mass caused by congenital dysplasia of the respiratory system. These cysts can be divided into three types according to the location of the disease: intrapulmonary, mediastinal, and ectopic . The ectA 62-year-old woman presented to our hospital with a 1-year history of persistent pain in the right lower abdomen. No abnormalities were observed during the physical examination, and no palpable abdominal mass was identified. Abdominal enhanced CT (Fig. The patient agreed to undergo laparoscopic surgery. After careful exploration, we found that the mass was located on the side of the lesser curvature, near the cardia. It was prominent on the stomach wall, and its diameter was approximately 6 cm. The mass was soft and mainly consisted of cystic components, which did not conform to the characteristics of a GIST. Therefore, we exposed the visual field of the cardia and endoscopically resected the muscular layer and mass. The mass was not significantly adhered to the surrounding tissues, and the separation was smooth; neither removal of the surrounding tissues nor lymph node dissection was needed. The specimen Figs.  and 4 waThe postoperative pathological examination findings Fig.  revealedGISTs are the most common type of mesenchymal tumor found in the gastrointestinal tract. They are usually found in the stomach and proximal small intestine but can occur in any part of the digestive tract  4]. Wed. Wed4]. In this case, we diagnosed the mass as a GIST before surgery, but intraoperative examination revealed that it did not have the typical characteristics of a GIST. Because of the risk of peritoneal dissemination by percutaneous biopsy , surgicaThe pathological examination of this specimen revealed that it was a bronchogenic cyst. CT and MRI can help us determine the nature of the mass, but in the end we need intraoperative exploration and pathological results to confirm the diagnosis. For suspected GISTs, MRI or endoscopic ultrasound-guided fine needle aspiration biopsy can help to further identify the origin of the tumor. The final diagnosis depends on the pathological examination , 8. AccoIn conclusion, we have herein described a rare case of an ectopic bronchogenic cyst of the gastric cardia. The initial diagnosis was a GIST, but postoperative pathological examination confirmed that it was a bronchogenic cyst. This case suggests that a bronchogenic cyst should be considered as a differential diagnosis of a GIST. It is also a unusual but necessary situation should be considered when explaining the etiology of a bronchogenic cyst.


Sarcomas are a heterogeneous group of malignant tumors that come from mesenchymal tissues. Undifferentiated sarcoma represents approximately 20% of soft tissue sarcomas. This entity represents approximately 20% of soft tissue sarcomas. These tumors are subdivided according to their appearance. Morphological in 4 subtypes: pleomorphic cells, fusiform cells, round cells, epithelioids. We report the case of a 72-year-old woman operated for a complicated adnexal tumor, but it turned out that it was sarcoma undifferentiated (unclassified) fusiform cell type of mesentery. It is a rare and a latent tumor. Its diagnosis is histological. Its treatment consists on surgical wide excision if possible. This type of sarcoma has a poor prognosis considering the limited benefits of radio-chemotherapy. Undifferentiated sarcoma type fusiform cells of the mesentery is an exceptional entity. Its diagnosis is difficult. Its treatment is to discuss case by case, surgery is the best option if it is possible. The prognosis is bad. This entity remains to be studied. Sarcomas are a heterogeneous group of malignant tumors that come from mesenchymal tissues . The terThis is a 72-year-old woman with a history of hypothyroidism, hypertension, atrial fibrillation (ACFA), ischemic stroke 3 years ago with left hemiparesis, cavum cancer 1 year ago treated with radiotherapy. She consulted the emergency room for pelvic pain that had been changing for 1 day. On examination we found an afebrile patient, with a PA at 16/08, a pulse at 100 bpm. On abdominal examination we found an abdominopelvic mass of 15*10 cm. A biology Hb = 7.1, GB = 9600, creatinine = 102, urea = 8. Abdominal computed tomography (CT) without contrast injection was reported for renal failure, which showed a pelvic mass of 15*10 cm probably necrotic . The diath edition of the classification of soft tissue and bone tumors of 2013, sarcomas are subdivided into several subtypes according to their differentiation  and sarcomas of uncertain differentiation. Recently a new chapter has emerged: that of undifferentiated or unclassified sarcomas [et al. [et al. magnetic resonance imaging (MRI) is the most performing in the diagnosis of mesenteric sarcomas with the possibility of predicting the benign or malignant nature of tumors and even the histological type and positron-emission tomography (PET) scan finds a place in the context of sarcomas with ganglionic extension on MRI [The mesentery is a frequent propagation pathway for malignant tumors through the peritoneal cavity, on the other hand, primary mesenteric tumors are rare and predominantly benign . The mossarcomas . This ensarcomas . In addisarcomas  such as sarcomas . Patientsarcomas , 11, 12. [et al. . Accordin on MRI . As any n on MRI , 15.Undifferentiated or unclassified sarcoma is a new entity that accounts for 20% of soft tissue sarcomas and 25% of irradiated tissue sarcomas. Its mesenteric localization is rare. In this context the undifferentiated sarcoma type fusiform cells of the mesentery is an exceptional entity. Its diagnosis is difficult. Its treatment is to discuss case by case, surgery is the best option if it is possible. The prognosis is bad. This entity remains to be studied.The authors declare no competing interests.