Skull base osteomyelitis is a rare but potentially fatal condition. It is often characterised by a series of non-specific clinical and radiological signs, making it difficult to distinguish from a malignant lesion. We present the case of an immunocompetent elderly gentleman with multiple cranial nerve palsies and an unremarkable initial ear examination, diagnosed and treated for skull base osteomyelitis, masquerading as malignancy. This initially regressed without antibiotic therapy. This case emphasises the importance of clinicians having a high degree of diagnostic suspicion in order to initiate prompt treatment, thereby improving patient prognosis. Skull base osteomyelitis (SBO) describes a rare and potentially fatal bone infection, with loss of cranial floor structural integrity ,2. It prWe describe an unusual presentation of SBO, masquerading as a neoplastic lesion, in an immunocompetent patient that partially regressed despite no medical intervention.A 78-year-old gentleman, with no previous otorhinolaryngological history, reported a four-week history of progressive dysphagia, dysphonia, and weight loss, following resolution of an ear infection treated with two courses of antibiotics. On examination, oral cavity, oropharynx, and external ears were unremarkable, with normal observations. He demonstrated weakness of right spinal accessory and winging of the scapula but no neck lumps. Flexible nasolaryngoscopy revealed nasal polyps and right vocal cord paralysis with dysphonia.Blood tests demonstrated a white cell count of 9x10^9/L (4x10^9/L - 11x10^9/L) and C-reactive protein (CRP) of 18mg/L (<4mg/L). A CT neck, chest and abdomen scan revealed circumferential thickening of the distal oesophagus, with oesophageal malignancy excluded on subsequent gastroscopy and biopsy. MRI of the brain and neck demonstrated abnormal thickening and enhancement in the right posterolateral nasopharyngeal mucosa with infiltrative pathology involving the right para-pharyngeal space, longus colli, carotid space, jugular foramen, right skull base, and clivus  meeting and a CT of the skull base and sinuses was performed to ascertain the feasibility of endoscopic biopsy via the sphenoid sinus. This demonstrated significant regression of the right-sided skull base abnormality despite no medical treatment, three months after the initial CT scan. Repeat MRI illustrated consistent findings Figure , favouriUpon completion of a six-week antibiotic course, his dysphagia had improved but dysphonia persisted. The patient was offered an injection of the right vocal cord; however, he opted for conservative treatment due to the COVID-19 pandemic and his wish to reduce his chance of contracting the virus by reducing time spent in public settings. We continue to review him as an outpatient.Pseudomonas aeruginosa infection is implicated as the primary cause of typical SBO [A rare complication of otologic or rhinosinugenic infection, SBO is a potentially fatal clinical entity . Malignaical SBO . Atypicaical SBO ,5. Distiical SBO . Indeed,Patients with SBO often present with a myriad of non-specific symptoms such as unremitting headaches with progression to cranial neuropathies and meningitis. Subtemporal spread of infection at the stylomastoid foramen can result in cranial nerve (CN) involvement, with CN VII being most commonly affected. Jugular foramen involvement may affect CN IX-XI as demonstrated in our case with the patient displaying dysphagia, unilateral vocal cord paralysis, and shoulder weakness. Spread to the petrous apex may result in CN V-VI palsy . MalignaBlood tests generally demonstrate elevated acute phase reactants, often not seen in malignancy alone, thereby aiding the diagnostic process and guiding treatment response. Our patient did not have markedly raised inflammatory markers at presentation.Radiological investigation often requires a multimodal approach. CT is frequently the initial investigation of choice and can demonstrate destructive bony erosion. However, this is not consistently present in biopsy-proven cranial osteomyelitis . Thus, sManagement of SBO requires an MDT approach to eradicate foci of infection and attenuate potential exacerbating factors. An extended course (up to six months) of antibiotics and/or antifungals, guided by culture and sensitivity analyses, is typically the mainstay of treatment. Clinicians should also seek to optimise management of patient co-morbidities including diabetes and immunodeficiency conditions where present . SurgicaDue to similarities in the presentation, clinical, and radiological findings, distinguishing SBO from a neoplastic lesion can be challenging. Diagnosis is primarily guided by multimodal radiological, biochemical, and histopathological investigations. Management requires a multidisciplinary team approach with medical and occasionally surgical intervention required.


Intraosseous schwannomas are extremely rare in the humerus, and less than five cases have been reported previously in the literature. This is the first report of its origin in the proximal humerus with pathologic fracture. We herein present this case to discuss the reason for its rarity and share our experience of management.A 55-year-old female patient presented with pain in the right shoulder, which was caused by tripping and falling over a board. Radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) showed considerable tumor in proximal humerus, which connected with a fracture. For this suspected tumor, we performed two operations. Pathological examination demonstrated typical picture of a schwannoma, showing whorls and interlacing fascicles of schwannoma spindle cells. Immunohistochemistry, the tumor cells were diffusely positive for S-100 protein, SOX-10 and CD68, while they were completely negative for desmin, DOG-1, AE1/AE3 and P63. The Ki-67 index was about 10%. No mitoses or features of malignancy were identified. The final diagnosis of intraosseous schwannoma was made. The treatment for intraosseous schwannoma with pathologic fracture includes excisional biopsy, curettage, bone allograft, and fracture fixation. The patient recovered well. After the surgery, the patient gradually regained mobility and the pain subsided. There was no recurrence after 6 months of follow-up by X-ray.Although very rare, intraosseous schwannoma should be taken under consideration in the differential diagnosis of benign-appearing osseous tumor in the proximal humerus with pathologic fracture. Schwannoma is a neurogenic tumor that arises from a local proliferation of schwannoma cells in the peripheral, cranial, or visceral nerve. Intraosseous schwannomas account for less than 0.2% of primary bone tumors , and theA 55-year-old female patient was referred to our hospital with right shoulder pain caused by tripping and falling over a board on the same day. She had pain and restriction of movements of her right shoulder joint. Her history was notable for having antecedent pain in the right shoulder with restriction of overhead movements for about 1 year. She denied previous shoulder injury, or surgery. On presentation, the patient complained about right shoulder pain, swelling and ecchymosis. On palpation, tenderness was noted all around the shoulder. The skin of the shoulder was intact, and there was no evidence of warmth, erythema, or induration. Both neurological and vascular examinations were normal.Radiographs of the right shoulder showed a large, well-defined osteolytic tumor, which gave an appearance of endosteal scalloping and trabeculated contours on the edge of the bone lesion, involving the proximal humerus Fig. A, B. No Computed tomography (CT) showed considerable well-defined osteolytic lesion with cortical ballooning and thinning. The density of the tumor was homogeneous and had invaded into the cortex. An intramedullary mass elevating the periosteum was seen at the axial slice bone window and a fracture was seen at the coronal slice bone window Fig. C, D.Magnetic resonance imaging (MRI) of the right shoulder showed the tumor had invaded into the cortex and the bone lesion with associated soft tissue edema. The lesion was isointense to muscle on T1-weighted images Fig. A, C, andBecause of uncertainty regarding the histological origin of the tumor, we performed an open biopsy. The operation was performed using a standard deltopectoral approach to access the proximal humerus. Intraoperative the anterolateral cortex of the proximal humerus was elevated . After exposing and removing the upper bony sheath, we found that the tumor was a well-encapsulated soft grayish-yellow colored mass Fig. A. The paPathological examination demonstrated typical picture of a schwannoma, showing whorls and interlacing fascicles of schwannoma spindle cells Fig. A, B, andThen the patient was scheduled 10 days after the biopsy for an extended curettage, bone allograft, and fracture fixation, using the same approach. Intraoperative, a complete and meticulous curettage was performed, the cavity was filled with allograft bone Fig. B, and thThe patient recovered well. After the surgery, physiotherapy was started the day after the operation and a sling was given for comfort. The patient gradually regained mobility and pain subsided. There was no recurrence after 6 months follow-up by X-ray.Intraosseous schwannomas are rare benign neoplasms of the bone of which fewer than 200 cases have been described in the world literature . In all Clinically, intraosseous schwannoma may be present for years before becoming symptomatic, and pain may be present in about 50% of the cases, whereas no symptoms are present in about 25% . They arPreoperatively, the possibility of intraosseous schwannoma was not considered in our case because of its rarity and nonspecific clinical and radiological findings. The typical radiographic appearance of intraosseous Schwannoma is a well-defined lytic lesion, sclerotic margins, lobulated or trabeculated contours, cortical expansion, and absence of central calcification , 11. ComPathologically, intraparenchymal schwannomas have similar appearances to soft tissue schwannoma and demonstrate two types of cell arrangements, alternating cellular (Antoni A) and myxoid (Antoni B) areas . ImmunohIt is remarkable that the tumor in our case showed higher CD68 staining. Generally, the degree of inflammation measured by the expression of CD68 showed a positive significant correlation with tumor size and tumor growth index . This isKi-67 is a monoclonal antibody that provides a means of evaluating the growth fraction of normal and neoplastic human cell populations. A Ki-67 index of less than 3% is expected for a typical schwannoma. schwannomas with an index of greater than 3% are presumed to be actively proliferating and pose a theoretically higher risk for regrowth or recurrence . HoweverFinally, the recommended treatment for intraosseous schwannomas with pathologic fracture includes excisional biopsy, curettage, bone allograft, and fracture fixation. In our case, there was no evidence of recurrence and have a good functional outcome.


A heterogeneous group of tumors can affect the posteromedial chest wall. They form diverse groups of benign and malignant (primary or secondary) pathologies that can arise from different chest wall structures, i.e., fat, muscular, vascular, osseous, or neurogenic tissues. Chest radiography is very nonspecific for the characterization of chest wall lesions. The modality of choice for the initial assessment of the chest wall lesions is computed tomography (CT). More advanced cross-sectional modalities such as magnetic resonance imaging (MRI) and positron emission tomography (PET) with fluorodeoxyglucose are usually used for further characterization, staging, treatment response, and assessment of recurrence. A systematic approach based on age, clinical history, and radiologic findings is required for correct diagnosis. It is essential for radiologists to be familiar with the spectrum of lesions that might affect the posteromedial chest wall and their characteristic imaging features. Although the imaging findings of these tumors can be nonspecific, cross-sectional imaging helps to limit the differential diagnosis and determine the further diagnostic investigation . Specific imaging findings, e.g., location, mineralization, enhancement pattern, and local invasion, occasionally allow a particular diagnosis. This article reviews the posteromedial chest wall anatomy and different pathologies. We provide a combination of location and imaging features of each pathology. We will also explore the role of imaging and its strengths and limitations for diagnosing posteromedial chest wall lesions.  Chest wall tumors are uncommon causes of thoracic neoplasms, which are less common than soft tissue or bony neoplasms elsewhere. Unfamiliarity with the complex posteromedial chest wall anatomy and radiologic features of related neoplasms is a diagnostic dilemma for radiologists . These tThe posteromedial aspect of the chest wall has complex anatomy due to the presence of intercostal nerves, sympathetic chain, and vascular structures. Many neoplasms originate from these structures . Some ofPrevious studies mostly focused on the assessment of malignant lesions of the chest wall. None of them specifically evaluated the lesions of the posteromedial chest wall ,10,11. OOsseous/cartilaginous parts: 12 thoracic spine vertebrae, 12 ribs, and intervertebral discs.Muscles: Intercostal muscles , subcostalis, and transverse thoracic.Nerves: intercostal nerves, dorsal root ganglions, and sympathetic trunk.Vascular tissues: Intercostal vessels feed above components.Subcutaneous fat: beneath the superficial fascia and builds the padding for underlying muscles and bones.Superficial fascia and skin: acting as protecting layers ,12.In this article, we focus on the posteromedial segment of the thoracic wall. The medial aspect of the posterior chest wall consists of multiple components detailed below :Osseous/Chest wall neoplasms are heterogonous lesions, and there is a lack of universally accepted classification. So, these neoplasms are usually classified according to the tissue of origin Chest radiography is usually the first imaging modality performed when chest wall lesions are clinically suspected, although it can provide some nonspecific information . More spOn the other hand, recent advances in deep learning and artificial intelligence (AI) provide the ability of automatic classification, disease detection, and segmentation. Chest radiography and CT scan are excellent candidates for developing deep learning algorithms . AI has Radiologic characteristics of malignant bone tumors are summarized in Chest wall osteosarcoma is a high-grade tumor accounting for 10–15% of primary chest wall malignancies, which can arise from rib or scapula with an extrapleural component. It has a poor prognosis as the lung and lymph nodes metastases are more frequent than extremities osteosarcoma .A sclerotic lesion with higher central calcification is the most common appearance of osteosarcoma on radiography. Cortical destruction, expansile remodeling, and periosteal reaction are other common findings. CT can show soft-tissue destruction with variable types of calcifications such as cloudy, ivory-like, or dense  1,2]. O,2. O1,2]Chest wall Ewing sarcoma is the most common primary chest wall tumor in children, typically arising from ribs or, less frequently, scapula, clavicle, and sternum. Painful chest wall mass with fever and malaise are the most common presentations .On CT, Ewing sarcoma appears as a destructive paraspinal soft tissue mass with internal necrosis and hemorrhage. Calcification is rarely reported, and the soft tissue component is usually larger than the osseous component . It appeChondrosarcoma is the most common primary neoplasm of the chest wall accounting for 30% of malignant lesions . It deveThe typical CT appearance is a well-defined destructive mass with a mixture of soft tissue and mineralized components with stippled, dense, flocculent, rings, or arcs patterns. The invasion of adjacent structures has also been described . On MR iMultiple myeloma (MM) is an infiltrative bone marrow disorder and concurrent bone lesion predominantly involving the axial skeleton, including vertebral bodies, skull, pelvis, and ribs .Multiple myeloma radiologic features are osteolytic lesion with endosteal scalloping, diffuse osteopenia, multiple small lesions with mottled appearance, and osteoporotic fracture. In contrast to bone metastasis, the sclerotic halo is absent in MM, explaining the lower accuracy of scintigraphy compared to skeletal survey. Whole-body low dose CT was recommended as the initial survey for diagnosing osteolytic lesions of MM, which improved identification of extraosseous involvement and cortical disruption. STIR and T2-weighted imaging are the most sensitive sequences for depicting marrow signal changes. The T1-weighted sequence is useful for the evaluation of marrow infiltration ,22.Solitary plasmacytoma (SBP) of bone is an uncommon plasma cell neoplasm with localized bony growth. There are few case reports on solitary plasmacytoma of the rib ,24. Its radiologic appearance varies from purely non-expansile osteolytic to multicystic mass with bony expansion. CT may reveal extrapleural mass with a well-circumscribed margin and “soap bubble” appearance in advanced cases a,b. MRI Radiologic characteristics of benign bone tumors are summarized in An aneurysmal bone cyst (ABC) is an uncommon benign bone tumor that consists of multiple blood-filled cysts, which can present as a primary tumor or as secondary changes of other bone tumors ,16,27. TABC’s imaging appearance on radiography and CT is a well-defined expansile osteolytic lesion with thin marginal sclerosis, typical fluid-fluid level, and internal septation . T1-weigFibrous dysplasia (FD) is a developmental bone lesion caused by immature bone and marrow fibrous tissue replacement. It affects patients during the first and second decades of life. Rib is the most commonly affected site ,16. Fibrous dysplasia presents as a well-defined intramedullary osteolytic lesion with fusiform bony expansion and endosteal scalloping with preservation of cortical contour a. IncreaChest wall giant cell tumor (GCT) originates from the subchondral region of tubular or flat bones, e.g., clavicle, ribs, sternum, and vertebrae. It usually affects patients during the third or fourth decade of age, with a female predilection. Thoracic vertebrae is the most common location for spinal GCT after sacrum ,30. On CT, GCTs manifest as osteolytic lesions, bone expansion with cortical thinning, heterogeneous soft-tissue attenuation, and area of hemorrhage or necrosis with no internal calcification a,b 30]..30]. MRIEnchondroma is the most common benign rib neoplasm after fibrous dysplasia, accounting for 15–20% of benign rib tumors. It typically arises from the costochondral or costovertebral junction due to its cartilaginous nature . CT reveals focally expansile well-demarcated osteolytic lesion with or without cortical bulging. MRI helps depict enchondroma, especially when matrix calcification is vague on CT. Enchondroma has pronounced hypointensity on T1-weighted images as opposed to adjacent hypersignal fatty bone marrow. Hyaline cartilaginous content [rich in water] results in hyperintensity on T2-weighted images, and internal calcification foci produce hypointensity on all sequences ,32.Chondromyxoid fibroma is a rare benign cartilaginous tumor that contains various proportions of fibrous, myxomatous, and chondroid components ,6. It inCortical expansion with lobulated border, abundant peripheral sclerosis, and rarely internal calcification are the main radiologic appearances of chondromyxoid fibroma on radiograph and CT ,33. CortChondroblastoma is a rare, relatively benign bone neoplasm with a characteristic intercellular cartilaginous matrix and internal foci of calcification. It is usually found in the epi-metaphyseal regions of long bones. However, few cases of rib involvement have been reported ,34. It iThe main radiologic appearance of chondroblastoma on radiograph and CT is an oval or round well-circumscribed lesion with internal matrix mineralization ,34. It aPaget’s disease is a chronic bone disorder characterized by abnormal osseous remodeling with three phases: lytic, mixed lytic and blastic, and sclerotic. It occurs in patients older than 40 years old with a male predilection. Rib involvement happens approximately in 1–4% of cases .Imaging findings vary among different stages of the disease. The initial lytic active phase display osteolysis with no marginal sclerosis. While late blastic phase reveals cortical thickening and trabecular coarsening with bony enlargement. CT scan is useful in better delineation of the classic Paget’s disease triad: osseous expansion, cortical thickening, and trabecular coarsening  35,37].,37.35,37Spondylodiskitis is an infectious process that initially affects the anterior portion of the vertebral bodies and then spreads to the adjacent intervertebral disk via medullary spaces . StaphylPyogenic spondylodiskitis presents with loss of vertebral end plate definition and marrow edema. It displays hypointensity on T1-weighted images and hyperintensity on T2-weighted and STIR images. Various types of disk post-contrast enhancement  may be detected . AbscessTuberculosis spondylodiskitis has a more gradual and chronic clinical course, which leads to multi-level involvement and paravertebral cold abscess formation with well-circumscribed thin wall. Subligamentous spread of infection to adjacent vertebral levels, relative preservation of intervertebral disk, and kyphotic angulation (gibbous deformity) are other imaging findings. CT scan is more sensitive in delineating calcification within paravertebral cold abscess, end plate erosion, and bony fragment visualization  39,42].,42.39,42Neurogenic tumors of the chest wall can arise from the intercostal nerve, spinal nerve roots, and even from the distal branch of the brachial plexus. They consist of benign and malignant groups, including Neurofibroma, Schwannoma, and malignant peripheral nerve sheet tumors .Schwannoma is an encapsulated slow-growing peripheral nerve sheet neoplasm typically occurring in patients between 20–50 years old ,16. ChesSchwannoma presents a well-defined homogenous mass on CT scan with attenuation similar or less than muscle. The “Fat-split” sign caused by adjacent surrounding fat is indicative of its non-infiltrating growing pattern. It also shows remarkable post-contrast enhancement except for areas of necrosis or cystic changes . On MR iNeurofibroma is another slow-growing peripheral nerve sheet neoplasm that affects patients in their 20s to 30s with equal male and female prevalence. Localized Neurofibroma, which includes approximately 90% of cases, is not typically associated with neurofibromatosis type 1 (NF1). However, the majority of cases with plexiform type have underlying NF1 ,16.The main CT findings are well-circumscribed mass with smooth margin, soft tissue attenuation, possible internal calcifications, and adjacent rib erosion. Neural foraminal widening secondary to tumor extension can be accurately identified on multidetector CT . “TargetThoracic Neuroblastoma is a non-encapsulated tumor that arises from extra-adrenal sympathetic ganglia. The mediastinum is the second most common tumor location after the abdomen that has a better prognosis than other sites.Neuroblastoma appears as an ill-defined paravertebral soft tissue mass on a CT scan with heterogeneous attenuation caused by hemorrhage, necrosis, or cystic degeneration. Internal calcification is seen at least in 30% of cases ,16. MRI Ganglioneuromas are differentiated slow-growing neurogenic tumors originating from sympathetic ganglia that affect young patients. They appear as a paravertebral oval mass with a smooth border and vertical orientation following the sympathetic chain direction. Posterior mediastinum is the most common site of involvement of thoracic ganglioneuroma.It has homogenous or heterogeneous attenuation on CT images with probable internal calcification . MR imaging displays lesions with intermediate signal intensity on both T1-weighted and T2-weighted images with curvilinear or nodular low signal bands, which form the whorled appearance  7,16,43,4316,43.Lateral thoracic Meningocele is a rare condition defined as herniation of meninges through the vertebral column defect or enlarged neural foramina. It can be unilateral or bilateral and is usually associated with neurofibromatosis type 1 . It is mLateral Meningocele presents as a well-circumscribed paravertebral mass with similar attenuation to CSF. CT myelography reveals ipsilateral neural foramina enlargement communicating with subarachnoid space. This is a key differentiation feature from Neurofibroma . On MR iPseudomeningocele or meningeal pseudocyst is an abnormal extradural CSF collection that communicates with the brain and spinal canal. It can be congenital (thoracolumbar), traumatic , or iatrogenic (laminectomy of the lumbar spine). Congenital Pseudomeningocele can be seen in Marfan syndrome or NF1 .The Pseudomeningocele can be differentiated from Meningocele by lack of dura wrapping the collection. The absence of nerve roots within the CSF collection helps in identifying the brachial plexus Pseudomeningocele. On MR imaging, it has similar intensity to CSF with a lack of post-contrast enhancement  25,47].,47.25,47Radiologic characteristics of lipomatosis tumors are summarized in Chest wall fatty tumors are relatively common, and lipoma is the most frequent. It is a well-defined mesenchymal tumor arising from adipose tissue usually seen in patients between 50–70 years old. Most chest wall lipomas are located deeply, involve intramuscular or intermuscular layers, and show larger size with less distinct borders than superficial ones ,8,16,50.On multidetector CT scan, lipomas are homogenous and have similar attenuation to macroscopic fat with approximate −100 HU radiodensity ; other nLiposarcoma consists of lipoblasts with various differentiations. Well-differentiated type is the most common subtype with near 50–75% internal fat component. The less frequent subtypes are dedifferentiated, myxoid, pleomorphic, and mixed subtypes. Chest wall involvement is not common ,2,8.On multidetector CT, liposarcoma has higher attenuation than normal fat secondary to a mixture of fat and malignant cells. Necrosis and calcification are uncommon in well-differentiated subtypes in contrast to the myxoid subtype . On MR iEmpyema necessitance is a chronic pleural space infection that can affect both immunocompromised and immunocompetent people. Empyema leakage to chest wall soft tissues manifests as an extrapleural collection of empyema. Its usual location is the anterior aspect of the chest wall. Mycobacterium Tuberculosis is the most prevalent pathogen, with Nocardia Asteroides, Actinomyces Israelii, Staphylococcus, Aspergillosis, and Blastomycosis spp. being less common ,8,52,53.On CT, a communication between the pleural and extrapleural collection is a pathognomonic finding of empyema necessitans . A peripAsbestos-induced conditions include non-neoplastic and neoplastic pleural and lung diseases ranging from pleural effusion, thickening, plaques to malignant mesothelioma, and lung cancer. Pleural plaques are the most common disease ,49,55.Paravertebral and anterior plaques are better delineated on CT scans than radiography . On MRI,Malignant mesothelioma is the most common primary tumor of the pleura, which is related to prior asbestos exposure with a relatively poor prognosis .Multidetector CT effectively reveals the primary tumoral extension, lymphadenopathy, and extrathoracic metastasis  56]. An. An56]. MR imaging and 18F-FDG PET/CT are useful in further evaluation of chest wall, diaphragm, and mediastinal invasion ,57,58,59Rhabdomyosarcoma is a high-grade sarcoma that mostly affects children and usually appears before 40. Chest wall rhabdomyosarcomas are uncommon tumors with poor prognosis and usually manifest as rapidly growing mass with adjacent bone invasion and nerve compression ,16.CT scan demonstrates homogenous mass with no mineralized matrix invading adjacent bone and soft tissue structures  16]. MR. MR16]. Extramedullary hematopoiesis is a compensatory marrow hyperplasia in conditions with insufficient red blood cell production. Paraspinal areas are less frequently involved than lymph nodes, spleen, and liver. It typically arises from posterior ribs in the lower thoracic and upper lumbar area as unilateral or bilateral masses with no adjacent rib destruction .On CT, it presents as a heterogeneous mass with internal foci of fat and no calcification. Lesions with hematopoietic activity demonstrate heterogeneous intermediate intensity on both T1-weighted and T2-weighted sequences with subtle or no enhancement. However, lesions with no hematopoietic activity might show foci of hyperintensity on both T1-weighted and T2-weighted images due to fat component or hypointensity on both T1-weighted and T2-weighted images secondary to iron deposition  Figure  62,63].,63.62,63Extramedullary plasmacytoma accounts for less than 3% of all plasma cell neoplasms and can occur in any location. It presents as soft tissue masses with nonspecific imaging manifestations .Larger lesions show aggressive behavior such as infiltration and destruction of adjacent soft tissue and encasement of vascular structures. It typically presents as isointense compared to muscle on T1-weighted images and iso to hyperintensity on T2-weighted images ,65.Chest wall neoplasms are a group of heterogeneous lesions, and the posteromedial chest wall is a source of different pathologies due to its complex anatomy. Many of these pathologies can be differentiated by imaging. A comprehensive systematic approach with varying imaging modalities is needed to identify the correct diagnosis or limit the differential diagnosis and determine the appropriate further investigation. This article illustrates the various posteromedial chest wall pathologies and their imaging features. Ill-defined border, heterogeneous enhancement, and local invasion are more suggestive of a malignant lesion. In contrast, well-defined borders and the absence of local invasion or distant metastasis favor benign nature. The pattern of mineralization helps in the differentiation of osseous/cartilaginous neoplasm from other neoplasms. We also explored key imaging features as well as strengths and limitations of each imaging modality. Therefore, the familiarity of radiologists with the imaging features of posteromedial chest wall lesions is crucial and can avoid unnecessary invasive procedures. Future investigation is required using quantitative novel imaging modalities to increase the diagnostic accuracy of radiology. Furthermore, improvement in deep learning and radiomics may increase patients’ benefit from reduced need for biopsy and individualized treatment options.


Dermoid cysts are benign congenital lesions that usually appear on the surface of the skull, mainly on the anterior fontanelle. Diagnosis is usually made in the first months of life by physical examination and imaging studies such as CT, MRI, or ultra sound (US) Doppler. It is important to distinguish it from other similar lesions that represent greater surgical complexity, morbidity, and mortality. In this work, we show the principle differential diagnoses, the diagnostic approach, and the surgical technique used in the resection of the dermoid cyst located over the anterior fontanelle. Congenital dermoid cysts (CDCs) are benign lesions that originate from the entrapment of the surface ectoderm along the lines of embryonic fusion . They usThe most common differential diagnosis of these lesions, described in the literature, are epidermoid cyst, encephalocele, lipoma, cephalohematoma, hemangioma, and sinus pericranii . MRI, CTA three-month-old infant with no significant past medical history presented with a subcutaneous soft mass over the anterior fontanelle noted from the first month of life. The patient was born without complications and has no relevant prenatal history. Physical examination showed a well-defined mass of 3 cm diameter, covered by undamaged skin located in anterior fontanelle, soft consistency, barely depressible, with no changes in overlying skin coloration, and minimum transillumination was appreciated. The lesion was neither pulsating nor painful Figure .On neurological examination, he did not present delay for age or alterations in neurological development. Ultrasonography showed a subcutaneous hypoechogenic cystic lesion without vascularization. CT scan confirmed the localization of the lesion above the anterior fontanelle and the absence of involvement of underlying encephalic structures Figure .Findings were suggestive of a congenital inclusion cyst of the anterior fontanelle, and surgical removal was achieved without complications. The histological analysis showed the presence of keratin, hair follicles, sweat, and sebaceous glands delimited by a layer of stratified squamous epithelium Figure . Also, tSurgical techniqueWe made a coronal-oriented linear incision on the cyst, including skin, subcutaneous cellular tissue, and aponeurotic galea Figure . At the In this paper, as well as describing the clinical case and the surgical technique of a patient with a dermoid cyst of the anterior fontanelle, we mention the diagnostic importance of these types of malformations, and its wide range of alternative entities, since some lesions may be simple to handle and do not endanger the life of the patient, and others, like sinus pericranii and encephalocele, do become more complex. We present a table showing the differential diagnoses of a mass at the level of the anterior fontanelle Table .This differentiation can be carried out through imaging studies such as CT or MRI, which would confirm the extracranial position . On CT, The definitive diagnosis of these types of lesions is made with histologic study, in which we can observe the presence of hair follicles, sweat glands, and sebaceous glands .The surgical management of this type of lesion is mainly due to aesthetic reasons, however, we describe the surgical technique that, although it may seem simple, there are structures  that we must take into account to avoid a poor outcome in our patient .These lesions have an excellent prognosis and the chance for recurrence is rare .Early and precise diagnosis of these types of lesions is very relevant to distinguish them from complex diseases that can become more challenging for us to deal with in the operating room. The use of imaging tools such as CT, MRI, and/or Doppler US, is essential when making the presumptive diagnosis of these types of cysts, so we can ensure an appropriate surgical approach, to preserve vital structures in our patients. We encourage all healthcare physicians to use the technology available in their health centers, so the wide range of differential diagnoses can be reduced to those that do not endanger the patient's life. The surgical technique exposed in this paper can be performed at any standard operating room and does not require the use of advanced tools.


The lesion was itchy without any other symptoms and existed 20 years before our evaluation.A biopsy from the nodule was performed and sent to the pathology department, where the section was stained with smooth muscle actin stain (SMA) and the result was positive.We referred the patient to a surgeon to excise the nodule. The lesion was excised with a 3cm safety margin, the eradication includes also the of the major iliac muscle.After one year of follow-up there was no metastasis nor recurrence.Primary Cutaneous Leiomyosarcoma is a very rare malignancy and it is hard to diagnose without biopsy and pathological examination. •Primary cutaneous Leiomyosarcoma is a very rare tumor.•Accurate diagnosis cannot be made without histological and immunohistochemical examination.•Surgery is the only guaranteed treatment and other methods are still controversial. The term Leiomyosarcoma encompasses a broad spectrum of malignancies with highly variable presentations based on the site of origin, the extremities being the commonest. However, they can remain dormant for a long time .Leiomyosarcoma of the skin is termed “Dermal Leiomyosarcoma”, and categorized into two subdivisions: superficial cutaneous and deep subcutaneous ,5.Both types begin either as primary lesions or metastatic lesions from distant sites. Primary Cutaneous Leiomyosarcoma (PCL) is considered the rarest subtype with a few reported cases in the literature .Generally, assessing the overall risk of this type of cancer remains difficult due to its rarity. It is highly unpredictable and typically associated with a poor prognosis .We report the case of a 60-year-old male patient with PCL located in the left iliac region. The unusual site of origin of this rare PCL makes this a compelling case report.This case report has been reported in line with the SCARE Criteria .2A 60-year-old-male patient presented to the dermatology clinic due to a cutaneous lesion in the left iliac region. His history was insignificant and he had no family or genetic history of leiomyosarcoma. In present history, the lesion was itchy without any other symptoms and existed 20 years before the attendance. In the physical examination, we noted an ulcerative nodule with a 3 cm diameter, moveable with the skin and non-stick with the layer underneath (the muscles) .Fig. 1, liver and renal function test, and blood sugar level were normal. With these clinical findings, Leishmania and squamous cell carcinoma were considered and a biopsy was required. An excisional biopsy was performed and sent to the pathology department, where one section measuring 3 × 9 × 9 was studied, Hematoxylin and eosin (H&E) sections showed ulcerated epidermis. Interlacing fascicles of elongated spindle-shaped cells with blunt-ended (cigar-shaped) nuclei invading the dermis and parts of subcutaneous adipose tissue. The nuclei revealed variable pleomorphism & hyperchromasia with scattered atypical mitosis. All the deep and lateral surgical borders were free of malignancy . The secWe referred the patient was referred to a senior surgeon to excise the nodule. The pathological examination and the surgical operation have taken place in Aleppo University Hospital. The lesion was eradicated with 3cm safety margins. The excision also included the major iliac muscle. Two localized transposition slides were made, after that, a drainage tube was put, and finally, it was closed by simple sutures . The surA general physical examination of the patient including the surgical site to monitor any changes after surgery was performed at each follow-up visit.3LMS is an extremely rare malignancy, it composes about 10% of soft tissue tumors that make up 1% of all malignancies . LMS devCLM is most common in the lower extremities, but it can appear in any part of the body, rarely in the face . Middle-The Aetiology of LMS is not yet completely clear, but several factors are believed to have an association such as radiation, trauma, and lupus vulgaris. Malignant transformation of leiomyoma can also be considered as a possible cause ,16. The In a large case series conducted by Fields and Helwig containing 63 LMS skin lesions. The average size was 1.8 cm when presented . The diaSkin changes such as discoloration and ulceration are common symptoms, in contrast, pain is an uncommon symptom but it should be noted that the presence of pain and rapid growth is a sign of a bad prognosis ,17.Imaging techniques and clinical manifestations can lead to an initial diagnosis but an accurate diagnosis of LMS can only be made with histological findings and immunohistochemical examination . HoweverThe best-recommended treatment for LMS is a wide excision of the lesion with appropriate margins of safety (3–5 cm) and a depth that includes the fascia and subcutaneous tissue . We wentThe prognosis differentiates according to the histological classification in addition to several factors, tumor size more than 5 cm, tumor involves the fascia, high histological grade, high mitotic rate of >20 per 10 high-power fields (HPF), and tumor necrosis of >50% Indicate to bad prognosis ,15. As n4As a conclusion, primary cutaneous Leiomyosarcoma is a very rare malignancy and It is hard to diagnose without biopsy and pathological examination.In our case the patient was 60 year old male with PCL located in the left iliac region with no symptoms besides the itchy feeling in the lesion. Chest, abdomen, and pelvis CT scan with injection were performed to investigate metastasis and there was none. The lesion was eradicated with 3cm safe borders by the surgeon after one year of follow-up there was no metastasis nor recurrence has been noted.


N‐butyl‐cyanoacrylate has been used by urologists and radiologists to treat lymphocele. This modality is an effective treatment with fewer complications.Postoperative refractory lymphocele is often difficult to treat. Recently, interventional radiology with N‐butyl‐cyanoacrylate was performed, and the lymphocele volume gradually decreased.Case 1. A 70‐year‐old man, who underwent retropubic radical prostatectomy and bilateral obturator lymph node dissection, developed postoperative lymphocele. Continuous drainage and multiple rounds of sclerotherapy to reduce lymphocele volume ended in failure. Subsequently, lymphangiography with lipiodol and Case 2. A 75‐year‐old man underwent retropubic radical prostatectomy and bilateral obturator lymph node dissection. After surgery, the patient developed a high‐output lymphocele. The lymphocele volume decreased following lymphangiography with lipiodol.N‐butyl‐cyanoacrylate could provide a new standard treatment for refractory lymphocele.Interventional radiology using lipiodol and  CTcomputed tomographyDVTdeep vein thrombosisIViliac veinIVRinterventional radiologyLClymphoceleNBCAN‐butyl‐cyanoacrylateOLNDobturator lymph node dissectionPLNDpelvic lymph node dissectionRRPretropubic radical prostatectomySLCsymptomatic lymphoceleVTEvenous thromboembolismN‐butyl‐cyanoacrylate is a relatively less invasive procedure.Generally, postoperative lymphoceles are treated with highly invasive surgical procedures. With the advancement of interventional radiology, lymphangiography using lipiodol and Most lymphoceles disappear asymptomatically without treatment. However, some patients require therapeutic interventions, including conservative treatment, percutaneous drainage, sclerotherapy, and surgery.Recently, IVR has received much attention in the treatment of postoperative lymphocele.In this report, we describe the effect of IVR in patients with refractory postoperative lymphocele.We report two cases of lymphocele after RRP and OLND. In both cases, we ligated peripheral sides and sealed rest of the sides using a sealing device at the process of OLND.Case 1 was a 70‐year‐old man with prostate adenocarcinoma of Gleason score 9. He underwent RRP and bilateral OLND. Twelve days after the surgery, he presented at our hospital with a complaint of abdominal swelling and left pedal edema. CT showed a large lymphocele in front of the bladder Fig. , DVT in Case 2 was a 75‐year‐old man with a history of prostate adenocarcinoma of Gleason score 10. He was hospitalized in our department and underwent RRP and bilateral OLND. A drainage tube was inserted into the pelvic region, and a urethral catheter was placed. Five days after the surgery, cystography showed a leak from the vesicourethral anastomosis. Then another week was needed to close the leakage. After removal of a urethral catheter, the fluid volume from a pelvic drain continued to be over 150 mL/day, and lymphatic disruption was suspected. CT images showed three sites of small lymphoceles in front of the bladder Fig. . SixteenLymphangiography with lipiodol causes hydrolysis and saponification of the adipose tissue surrounding the lymphocele, leading to a granulomatous reaction with fibrosis and subsequent lymphatic leak obstruction.NBCA is used as an adhesive for skin sutures, vascular aneurysm treatment, and vascular embolization. Recently, an increasing number of cases has been reported in which NBCA was used for lymphatic embolization.The incidence of lymphocele in patients after RRP and PLND is up to 61%.Tsaur et al. demonstrated a treatment algorithm for SLC Fig. .16 TradiLymphatic leakage in Case 1 did not stop, despite continuous drainage and 13 times of sclerotherapies. Although surgery would have been the next standard treatment, the radiologist performed IVR, lipiodol lymphangiography, and lymphatic embolization with NBCA instead (Fig. Based on our experience with Case 1, when continuous drainage in Case 2 failed to stop the lymphatic leak, lymphangiography with lipiodol was administered directly, without the intervention of sclerotherapy Fig. . As a reThese two cases suggest that a refractory lymphocele patient should undergo lymphangiography using lipiodol and NBCA at an early stage of treatment, because IVR is minimally invasive for patients, and it requires shorter periods of hospitalization.Based on our two cases, when lymphatic leakage in a patient with postoperative lymphocele does not improve despite continuous drainage, lymphangiography should be considered as the next treatment. In some cases, concomitant lymphatic embolization with NBCA should be performed.The authors declare no conflict of interest.Not applicable.All informed consent was obtained from the participants.Not applicable.


Despite the fact that it is rarely found in the appendix during pregnancy, ectopic decidua can, in some cases, cause the occlusion of the appendicular lumen by extrinsic compression due to the expansion of endometrial tissue or due to decidua polyp formation. This condition consequently leads to appendicular inflammation. We report the case of a 27-year-old primigravida woman, 32 weeks of gestation, who presented to our facility with a 2-day history of isolated right iliac fossa pain. The diagnosis of an acute appendicitis was suspected and a planned appendectomy was performed. Microscopical examination showed appendicular deciduosis. The circulating progesterone levels during pregnancy stimulate endometrial decidualization, which is an essential feature for the implantation of pregnancy. It is characterized by hypertrophy of stromal tissue, increased glandular secretion and vascular proliferation.Rarely, can this cell transformation occur outside of the endometrium, and decidual cell groups could be found in the ovaries, uterus and cervix. A rare form of ectopic decidua can be located in the appendix and cause complication with an acute appendicitis. To date, only few cases of deciduosis resulting in acute appendicitis have been reported in the literature.A 27-year-old primigravida woman, 32 weeks of gestation, with unremarkable medical and surgical history, presented to our facility with a 2-day history of isolated right iliac fossa pain.3 and the level of C-reactive protein (CRP) reached 67.7 mg/l. The urine analysis was normal. The abdominal ultrasonography confirmed a viable intrauterine pregnancy and did not show the appendix or any other abnormalities. Magnetic resonance imaging investigation was not available in our institution.No nausea, vomiting or urinary symptoms were reported and there were no similar previous episodes of pain. The body temperature was 38.4°. Abdominal palpation revealed tenderness in the right iliac fossa. The white blood cell count was 22 450/mmGiven the suspicion for acute appendicitis, we decided to perform a planned appendectomy.The intraoperative findings included inflamed appendix. No other peritoneal or pelvic pathologies were identified and a conventional appendectomy was performed.A pelvic ultrasonography performed after surgery, showed normal fetal movements.The patient was discharged on post-operative Day 2, and gave birth to a healthy boy 7 weeks later.The pathologic examination showed an appendix of 6 × 1.5 cm with a constricted lumen suggesting appendiceal obstruction . MicroscThe pathogenesis of ectopic decidua and precise mechanism reactions are not yet fully understood and it is controversial to decide whether it is a physiological reaction or rather a pathological process. Deciduosis may be a de novo development of decidua originated from submesothelial stroma, or a decidual transformation of a pre-existing endometriosis .Commonly, ectopic decidua is a benign condition that is not responsible for any symptoms. It regresses within 4–6 weeks in the postpartum without any treatment but it may reappear in a subsequent pregnancy , 2.However, in some cases it can cause abdominal pain, intraperitoneal hemorrhage, hydronephrosis or hematuria secondary to renal or pelvis involvement, it can rarely cause right iliac fossa pain or acute appendicitis . In thisDeciduosis of the appendix has been rarely reported in the literature. To date only few cases have been reported , 4, 6–8.Regarding the differential diagnosis with malignant tumors, a morphological examination of the removed tissues is the ‘gold standard’. Deciduosis is characterized by nodular architecture, composed of large cells with well-defined borders and eosinophilic cytoplasm . DeciduaDecidual cells are positive to vimentin and CD10. They also have nuclear receptors of progesterone and estrogens, but they are negative to cytokeratin and calretinin [Treatment of appendicular deciduosis is surgery with standard follow up.In conclusion, deciduosis of the appendix resulting in acute appendicitis is a rare pathology. Unlike other sites of ectopic deciduosis that can be managed expectantly, the treatment is appendicectomy. Histological examination is mandatory in order to exclude a peritoneal mesothelioma or a primary or metastatic peritoneal cancer.


Extraskeletal osteosarcoma (ESOS) is a rare mesenchymal malignancy, which produces osteoid, bone, or chondroid material and is located in the soft tissue without attachment to skeletal bones and periosteum. One of the things that ESOS originated from mesentery is much rarer.A 75-year female had a history of pain in the left lower abdomen for more than 4 months. Abdominal computerized tomography (CT) and magnetic resonance imaging revealed a large, irregular, and solid-cystic mass (largest diameter was 11.5 cm). The tumor was radically removed during an open operation. It was composed of abundant osteoid and polyhedral-shaped tumor cells with high atypia and high mitotic activity microscopically. The final pathological diagnosis was osteoblastic osteosarcoma, arising from the sigmoid mesocolon with negative margins. A 9-month follow-up by CT exhibited signs of peritoneal metastasis.Given the rarity of cases of mesenteric ESOS, diagnosis mainly depended on pathology findings or should be taken into consideration when the mesenteric mass was found. Its most effective treatment had not been determined, with surgical excision being generally accepted. Ensuring negative surgical margins may be an important factor affecting prognosis. Extraskeletal osteosarcoma (ESOS) is a rare mesenchymal malignancy that usually occurs in the fifth or sixth decades of life, first described in 1941 by Wilson , most frA 75-year-old woman with no history of malignancy was referred to our hospital in August 2020 after experiencing pain in the left lower abdomen for more than 4 months. No history of trauma, previous radiation, or a family history of genetic diseases was identified. There was no history of dark or bloody stools, but she reported a recent change in bowel habits lasting nearly 2 months which was caused by transient constipation that led to frequent use of laxatives. She had a 3 kg weight loss in the preceding months.12/L (3.80–5.10 × 1012/L)) and hemoglobin concentration (92 g/L (115–150 g/L)). Tumor markers such as AFP, CA199, HCG, HE4, and CEA were all normal, but CA125 was markedly elevated: 585.60 U/mL (0–35.0 U/mL). Following abdominal ultrasonography, a solid-cystic and space-occupying mass and blood flow signal can be seen inside. An abdominal computerized tomography (CT) scan revealed a mass adjacent to the left uterine adnexa area and closely related to the sigmoid colon, along with multiple lymph nodes in the pelvic and abdominal cavity. Magnetic resonance imaging revealed a large, irregular, multilocular, solid-cystic, and complex signal mass shadow. The solid part was isointense on both T1 and T2 images. Part of the mass was obviously hyperintense on DWI . Standard blood examination showed a decreasing blood count , also known as soft tissue osteosarcoma, is a rare malignant neoplasm that produces osteoid, bone, or chondroid material but lacks bone or periosteum involvement. Although the first report was described in 1941 . ESOS isESOS should be diagnosed using a combination of clinical manifestations and radiographical and pathological findings and only after excluding the possibility of a primary bone tumor or bone tumor metastatic to soft tissue . CombineSurgery is the main treatment for ESOS. Depending on differences in location, range, and development of the tumor, a simple resection, wide resection, or radical resection can be selected. Besides, preoperative radiotherapy and adjuvant chemotherapy are available to treat ESOS. According to statistics, expanding the scope of surgery can reduce the local recurrence rate but had no significant effect on prolonging the survival time . AccordiWe summarize the reports of ESOS of mesentery that have been published in English to date Table . It incl Extraskeletal osteosarcoma is a relatively uncommon soft tissue sarcoma, especially originating in the mesentery. ESOS growth in the abdominal cavity is relatively insidious, exhibiting typical clinical symptoms. Concurrently, the imaging features of ESOS are devoid of apparent characteristics. ESOS should also be considered when imaging reveals intraperitoneal solid-cystic or calcified masses. Its ultimate diagnosis depends on pathology. There is no agreement on the most effective treatment, and surgical excision is widely accepted. Chemotherapy remains widely controversial. Ensuring negative surgical margins may be an important factor affecting prognosis.


Lichen nitidus is an uncommon lichenoid dermatosis that could be defined as multiple, separated, shiny, pinpoint, pale to skin-colored papules. Palmoplantar lichen nitidus is a quite rare variant of lichen nitidus. It is hard to make a diagnosis of palmar lichen nitidus when there are no lesions elsewhere on the body. There are some dermoscopic features defined for both palmoplantar and non-palmoplantar lichen nitidus that might be useful to facilitate the diagnosis before histopathological examination. Herein, we report a case of a 24-year-old man diagnosed with isolated palmar lichen nitidus with dermoscopic features and histopathological confirmation. A 24-year-old man presented to us with asymptomatic, pitted, hyperkeratotic, grouped papules on his third and fourth phalanges at the palmar aspect of left hand with a duration of four years . His pasThe patient was evaluated in the dermatology clinic of Afyonkarahisar Health Sciences University Medical Faculty.LN is an uncommon lichenoid dermatosis that could be defined as multiple, separated, shiny, pinpoint, pale to skin-colored papules, 1 to 2 mm in diameter. LN usually affects children and young adults without any sex predilection. The etiology of the disease is uncertain.Isolated palmar LN is a quite rare disease that presents with asymptomatic or occasionally pruritic hyperkeratotic pitted papules. Park et al. reported that palmar involvement usually seemed to accompany LN lesions of typical sites and claimed that there have been only 4 cases of LN confined to the palm including their case.There are a few dermoscopic findings defined for LN in the literature. These definitions are quite different between the palmoplantar variant and classical LN. The absence of dermatoglyphics, radial ridges, central depression areas with non-polarised mode; ill-defined hypopigmentation with diffuse erythema, and linear vessels with polarised mode were observed in classical LN.The histopathological main features of LN are well-circumscribed infiltration of lymphocytes, macrophages, Langerhans giant cells, and multinucleated epithelioid histiocytes in the papillary dermis surrounded by the elongated epidermal rete ridges.The presence of white halo-like, well-demarcated structures probably correspond to epidermal acanthosis on histopathology while the brown shadow-like central depressions are considered a reflection of the underlying dense inflammatory infiltrate composed of lymphocytes and epitheloid cells.Many treatment modalities have been tried including topical and systemic corticosteroids, antihistamines, acitretin, UVA, narrowband UVB, and cyclosporin for LN.Isolated palmar LN is a very rare disease most commonly affecting young patients. Dermoscopy is a noninvasive, cheap, and fast method to diagnose the disease and might be used to make the diagnosis and reduce the need for biopsy.This case report was presented as an oral presentation in the International Dermatology, Dermatopathology and Esthetics Academy 2020 Congress.None declared.İrem Nur Durusu: Approval of the final version of the manuscript; critical literature review; data collection, analysis, and interpretation; effective participation in research orientation; ıntellectual participation in propaedeutic and/or therapeutic; management of studied cases; preparation and writing of the manuscript; study conception and planning.Dilara Güler: Approval of the final version of the manuscript; critical literature review; data collection, analysis, and interpretation; effective participation in research orientation; ıntellectual participation in propaedeutic and/or therapeutic; management of studied cases, study conception, and planning.Gülhan Gürel: Approval of the final version of the manuscript; critical literature review; effective participation in research orientation; ıntellectual participation in propaedeutic and/or therapeutic; management of studied cases; manuscript critical review; study conception and planningGülsüm Şeyma Yalçın: Approval of the final version of the manuscript; critical literature review; effective participation in research orientation; ıntellectual participation in propaedeutic and/or therapeutic; management of studied cases; study conception and planning.None declared.


Colonic actinomycosis is rare and can present as an ill-defined intra-abdominal mass that can be difficult to differentiate from colon cancer. This case report aims to share the details of this case and provide diagnostic clues. A 63-year-old female presented with a palpable right-sided abdominal mass. Computed tomography (CT) revealed irregular thickening of the colonic hepatic flexure, and colonoscopy detected no abnormalities. Five months later, the patient returned with an increase in the mass size. Repeat CT revealed lesion expansion, with suspected abdominal wall invasion. Extended right-hemicolectomy with abdominal wall wedge resection was performed, and the histological results were compatible with actinomycosis infection. Colonic actinomycosis is a rare chronic inflammatory disease. Normal colonic mucosa during colonoscopy, with clinical and imaging findings, may help physicians diagnose the condition preoperatively. A palpable colonic mass is a worrisome clinical finding, and one of the differential diagnoses is invasive carcinoma. We report a case of cecal actinomycosis, which is a rare cause of a palpable colonic mass. Even with imaging and physical examination findings, it is challenging to differentiate this condition from cancer . HoweverA 63-year-old female with no underlying disease presented with a palpable mass on the right side of her abdomen. Abdominal computed tomography (CT) was performed at the primary hospital and revealed colonic hepatic flexure thickening . InteresRepeat abdominal CT  revealedAlthough we believed that the problem was not cancer according to the colonoscopic findings, radical surgery was chosen to relieve the patient's symptoms, with acceptable risk owing to the lack of important organ invasion. After discussing surgery with the patient and her family, extended right hemicolectomy with wedge resection of the adjacent abdominal wall was performed as a cancer operation. There were no post-operative complications, and the patient was discharged on day five.The histological results indicated multiple abscesses with actinomycosis granulomas involving the pericolic fat, ascending colon and the resected abdominal wall. Actinomyces. Six of 14 species generate illness in humans, and the most common is Actinomyces Israelii [Actinomycosis is a rare chronic inflammatory disease caused by the bacterial genus Israelii . The orgIsraelii ). PatholIsraelii . HoweverIsraelii .The four clinical forms of actinomycosis are cervicofacial, thoracic, abdominopelvic and cerebral; the cervicofacial form is the most common . AbdominAn intra-abdominal mass usually raises concerns for patients and physicians; mainly when the mass originates from the colon, as is often the case with cancer . In our The confirmatory diagnosis of actinomycosis infection comprises demonstrating micro-organisms from pus or tissue biopsy; however these organisms are difficult to find . CT-guidFor complicated actinomycosis, a long course of 6–12 months of antibiotics is the treatment, and penicillin G is the drug of choice , 5. To oIn conclusion, colonic actinomycosis is rare and difficult to diagnose. With clinical, imaging and colonoscopy findings, the differential diagnoses can be narrowed. Actinomycosis should be suspected in chronic inflammatory mass-forming lesions with normal colonoscopy findings.


We present a rare case of a primary intradural extramedullary Ewing’s sarcoma/peripheral primitive neuroectodermal tumor (PIEES/PNET) in the thoracolumbar spine and review the current literature. We describe the imaging manifestations, pathological features, surgical methods, and patient survival to shed light on the clinical management of this rare tumor. A 32-year-old man experienced progressive low back pain for more than 1 month. An intradural extramedullary tumor from T12 to L2 was detected on magnetic resonance imaging. He underwent a thoracolumbar laminotomy for decompression, complete excision of the intradural extramedullary tumor, and internal fixation with pedicle screws. A histopathological examination confirmed that the tumor was a PIEES/PNET via an immunohistochemical study of the surgically resected tissues. Postoperatively, the patient received chemotherapy and radiotherapy. No recurrence, metastasis, or failure of internal fixation were noted at a 17-month post-surgery radiographic examination. PIEES/PNET of the thoracolumbar spine is extremely rare. Treatment is difficult because the current literature is sparse and cases are rare. Complete resection combined with chemotherapy and radiotherapy effectively reduces recurrence and metastasis. ES/PNET2A previously healthy 32-year-old man experienced progressive low back pain for more than 1 month. Physical examination showed percussive pain in the thoracolumbar spinous process, but no significant mass was detected. The muscle strength of the right lower limb was grade 4, while that of the left lower limb was grade 5. The right anterolateral thigh felt numb, while the left side was normal. The Lasegue test was positive on the right side and negative on the left. Bilateral Achilles tendon, knee reflexes, and Babinski sign were negative.Spinal magnetic resonance imaging (MRI) revealed a circular mass in the spinal canal of T12–L2 with unclear boundaries. Signaling within the tumor was not uniform, with hypointensity on T1-weighted imaging (T1WI)  and specThe patient underwent thoracolumbar spinal canal tumor resection under general anesthesia. The lamina and spinous process were excised with an ultrasonic bone knife and the dural sac was gently incised with a sharp knife to expose the spinal canal. Intraoperatively, a quasi-round tumor was observed in the spinal canal of T12–L2. The tumor was red and fish-like with a soft texture. The tumor’s capsule was incomplete, its boundary was unclear, and it was adherent to the peripheral nerve roots. The nerve roots were carefully separated from the tumor under a microscope, and the tumor was completely excised . We confImmunohistochemistry revealed: Fli-1 (+), Vim (+), CD56 (+), CD99 (+), Syn (+), weak focal S-100, weak focal CD117, PCK (−), TdT (−), LCA (−), EMA (−), CgA (−), CD34 (−), MyoD1 (−), desmin (−), and HMB45 (−). Postoperative pathology of the tumor tissue revealed undifferentiated small round blue cells, and the pathological diagnosis was PIEES/PNET . On postThe study was approved by the Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. The patient provided informed consent for the publication of this case report.3PNET is a rare and highly malignant tumor of the nervous system and a member of the Ewing’s sarcoma family of tumors. PNET, more common in children and adolescents, has differentiation potential and a short disease course, and mainly occurs in the paraspinal and retroperitoneal areas and the extremities, whereas intraspinal PNET is rare . The maiAt present, imaging of PIEES/PNET mainly involves MRI, and it often presents as a single mass in the spinal canal and extramedullary space ,13. MRI The gold standard for the diagnosis of PIEES/PNET depends on pathological examination. On gross examination, PIEES/PNET has usually a fish-like gray-red mass appearance. Microscopically the tumor is composed of large irregular sheets of small round cells divided by strands of fibrous tissue. Homer Wright pseudorosettes are a frequent finding . In thisPIEES/PNET is a systemic disease. It currently has no unified treatment, and treatment consisting of surgery, local high-dose radiotherapy, and chemotherapy is generally advocated . SurgicaIn summary, PIEES/PNET is a malignant tumor originating from the neuroectoderm. It grows rapidly and is difficult to diagnose early, which depends on histological and immunohistochemical examination. PIEES/PNET progresses rapidly and has a poor prognosis; thus, its treatment regimens require improvement. We reported this case to improve clinicians’ understanding of PIEES/PNET, improve its preoperative diagnosis, reduce misdiagnosis, strive for early diagnosis and treatment, and improve patient prognosis.PIEES/PNETprimary intradural extramedullary Ewing’s sarcoma/peripheral primitive neuroectodermal tumorES/PNETEwing’s sarcoma/peripheral primitive neuroectodermal tumorMRImagnetic resonance imagingT1WIT1-weighted imagingT2WIT2-weighted imaging


Uterine primitive neuroectodermal tumors (PNETs) are rare entities, with only around 70 cases published in the literature. Most of them are diagnosed in advanced stages with rapid progression and poor prognosis. Herein, we present a case of a 71-year-old patient with postmenopausal metrorrhagia and an ultrasound finding of endometrial thickening. The pathological diagnosis after an endometrial biopsy showed PNET. In the study of extension, possible distant dissemination with infiltration of the sigmoid and liver was observed. Chemotherapy treatment was proposed, but not begun due to the rapid progression of the disease. Four months after the initial diagnosis, the patient died of multiple organ failure. While there is no optimal chemotherapy treatment regimen for PNET, some studies have reported encouraging results. It is necessary to publish more studies emphasizing the follow-up and survival of the disease to establish which may be the best treatment option and thus improve the current poor prognosis. Primitive neuroectodermal tumors (PNETs) are included in the family of Ewing's sarcomas . They haWe present a 71-year-old woman with a personal history of rheumatoid arthritis, with no relevant family history. Regarding gynecological history, menarche at 12 years, G3C3, menopause at 50 years. She was referred to a gynecology clinic due to the accidental ultrasound finding of endometrial thickening during the study of recurrent urinary tract infections. The patient reported intermittent and scarce postmenopausal metrorrhagia for five months without any other associated symptoms. She was not using estrogen therapy. The patient did not perform routine gynecological examinations.On examination, she had a body mass index of 32. On gynecological examination, she had an enlarged uterus 12 cm). A Doppler ultrasound was performed, revealing an enlarged uterus with a 66 mm thickened endometrium, with a type two Doppler score on the anterior surface, compatible with the tumor. Also, a loss of the endometrial-myometrial interface was observed  Figure , findingAn exploratory laparoscopy was indicated, which found the uterus totally infiltrated by neoplastic tissue that blocked the pelvis and appeared to infiltrate the sigmoid, liver lesions suggestive of metastasis, and a moderate amount of ascites.Palliative treatment was proposed with chemotherapy based on vincristine, adriamycin, cyclophosphamide, ifosfamide, and etoposide (VAC/IE), but could not be initiated due to presenting symptoms of renal and respiratory failure with secondary sepsis progressing to multi-organ failure. The patient died four months after the diagnosis of the disease.PNETs belong to a group of small round cell tumors that are most commonly found in the central nervous system, soft tissues, and bones. The origin in the female genital tract is rare. The most common location is the ovary, followed by the uterine body , vagina,To date, about 70 cases of uterine origin have been described in the entire literature ,7. The lPNETs of the uterus have been described in all ages, although they are more frequent in adolescent or postmenopausal women . PostmenThe diagnosis of this entity requires histological confirmation and imaging tests or surgery to complete the staging. In the series of 17 cases , 12 of tThe differential diagnosis of uterine PNETs includes tumors that present neuroectodermal elements found in the central nervous system. Diagnosis is based on microscopic and immunohistochemical evidence of neuroectodermal differentiation with markers such as CD99, friend leukemia integration 1 transcription factor (FLI1), and vimentin . In our Given the scarcity of published cases, there is no consensus to establish an optimal treatment regimen in uterine PNET. As a standard, the described treatment has been surgery followed by chemotherapy and/or radiotherapy. Patients treated with surgery and radiotherapy have a relapse rate close to 90% . MultimoAkazawa et al. conducted a search in the medical literature analysis and retrieval system online (MEDLINE) database, obtaining 178 papers, of which finally 49 cases of uterine PNETs were included. They analyzed the chemotherapy regimen that each patient received, concluding that the determining factor for choosing one treatment over another is age. They found that the Ewing sarcoma regimen  was used more frequently in young patients. However, less than half of the patients older than 60 years received any of these mentioned drugs. The frequent use of platinum derivatives did not change according to age groups which are used in half of them along with other chemotherapeutic agents. The initial treatment plan was palliative chemotherapy based on VAC/IE in the case presented. However, it could not be initiated and proven effective due to the rapid progression of the disease.Most of the published works focus on the diagnosis and choice of initial treatment, without referring to the prognosis and survival of the disease. Younger patients have a better prognosis with a 75% survival at two years, compared to 32% in the group of postmenopausal women . In one Although cases have been published where the evolution has been more favorable, the majority, as with the patient in this study, have presented a poor prognosis. There are no data on whether routine gynecological examinations can improve the detection or prognosis of these types of rare diseases. Likewise, the genetic study, although it can provide valuable information, in tumors of this type in the uterus is not very clarifying since, according to the series of cases studied, the presence of recognizable mutations is rare. In order to offer new treatment alternatives, it is necessary to publish all the cases in which this entity is diagnosed, with greater emphasis on follow-up, as well as response to the therapy received. Only that way we will be able to advance in the knowledge of this rare entity.


Cryptosporidium infection. Cryptosporidium is an opportunistic infection that more commonly affects immunocompromised hosts, especially those noncompliant with antiretroviral therapy. Our patient had an uncomplicated hospital course and made a full recovery due to early diagnosis and immediate intervention. We hope to make the medical community more aware of this rare and potentially life-threatening association given the rarity of such a presentation. Early diagnosis and intervention are critical to preventing morbidity and mortality.Small bowel obstruction is a common cause of abdominal pain and accounts for approximately 20% of surgical admissions related to abdominal pain. In the United States alone, there are over 300,000 admissions annually for small bowel obstruction and account for every 15 out of 100 admissions for abdominal pain. If treated appropriately with medical management, over 80% of cases resolve without life-threatening, long-term complications or the need for surgical intervention. The three most common causes including adhesions, tumors, and hernias account for the majority of cases. Less frequently reported causes include infections. We present the case of a 26-year-old male with a history of AIDS who was found to have a small bowel obstruction in the setting of active  Cryptosporidium infection. Cryptosporidium, an opportunistic pathogen, can infect both immunocompetent and immunosuppressed hosts. Although it is well known to be the most common parasitic cause of infectious diarrhea in immunocompromised hosts, its association with small bowel obstruction has been rarely reported in adult patients with HIV or AIDS. There have been case reports linking small bowel obstruction with disseminated histoplasmosis; however, it has not been associated with Cryptosporidium infection [Small bowel obstruction is a commonly encountered clinical condition requiring both medical and surgical attention. Small bowel obstruction can be described anatomically by a transition point, or point of obstruction, that results in proximal bowel dilation as well as distal bowel decompression . The mosnfection .Pneumocystis pneumonia infection and frequent clinic visits for oral pain secondary to oral thrush.A 26-year-old male with a past medical history significant for HIV complicated by AIDS presented to the emergency department after being found to have abnormal routine blood work as an outpatient. The patient acquired HIV through vertical transmission at birth and was largely noncompliant with medical therapy throughout his life. His antiretroviral regimen consisted of bictegravir-emtricitabine-tenofavir (50-200-25 mg) and sulfamethoxazole-trimethoprim for primary prophylaxis. The most recent CD4+ T-cell count was 3 cells/uL (reference: 430-1800 cells/uL) and an HIV viral count of 4,570,000 copies. The extent of noncompliance was also evident by previous admissions for Upon admission, the patient reported that his only complaints included decreased oral intake, nausea, vomiting, and intermittent episodes of loose bowel movements of two-day duration. His vitals on admission were a heart rate of 87 beats per minute, respiratory rate of 18 breaths per minute, oxygen saturation of 100% on room air, blood pressure of 90/52 mmHg, and temperature of 97.6°F measured orally. Physical examination was significant for a cachectic appearance and coarse breath sounds in both lung fields. Otherwise, the abdominal examination was benign as there was no tenderness, rigidity, or guarding. Laboratory findings, as illustrated in Table Shigella, Campylobacter, Salmonella, Giardia species, and Shiga toxins 1 and 2 by polymerase chain reaction. Clostridium difficile testing was also negative. Stool cultures were significant only for normal microflora. Interestingly, Cryptosporidium was detected by antigen testing. The laboratory data corresponded with infection as the white blood cell count remained stable; however, the bandemia worsened from normal on admission to 36% (reference range: 5-11%) at the peak of his symptoms.The patient’s hospital course acutely worsened on day two as nausea and vomiting had become refractory to antiemetic therapy including oral trimethobenzamide and ondansetron. Intravenous antiemetic therapy was limited as the patient had significant prolongation of the QTc interval on electrocardiograms. Nausea and vomiting had evolved to several loose bowel movements. An immediate abdominal X-ray was done that confirmed small bowel obstruction Figure . IntraveThe patient responded appropriately to the standard of care therapy for small bowel obstruction. His symptoms had improved within 24-48 hours after the initiation of nasogastric suctioning, and he reported significant improvement and resolution of symptoms. He was able to tolerate a diet and was safely discharged to a rehabilitation facility.Small bowel obstruction is a commonly encountered medical problem in the United States. Approximately 15 out of every 100 admissions citing abdominal pain are secondary to small bowel obstruction and collectively account for over 300,000 admissions annually . The diaIn some cases, the primary team may elect to perform a small bowel series with diatrizoate meglumine, better known as Gastrografin, as it is a radio-opaque contrast medium that can help identify points of intraluminal obstruction. Diatrizoate meglumine has been associated with a significantly decreased in-hospital length of stay by nearly two days . The effAlthough the etiology of small bowel obstruction is broad, over 80% of cases are due to intra-abdominal adhesions, tumors, and hernias. Less common causes include intra-abdominal inflammation and infection, intestinal stricture, volvulus, gallstones, intussusception, superior mesenteric artery syndrome, and congenital anomalies of the gastrointestinal tract. Regardless of the etiology, the management remains largely the same and consists of intravenous fluid hydration, nasogastric suctioning to promote decompression, management of electrolyte derangements, and prohibiting any oral intake until obstruction resolves. Early diagnosis and intervention are critical as the majority of cases resolve without surgical intervention and have a much lower risk of associated complications . The mosCryptosporidium. Cryptosporidium is a parasitic protist normally known to infect birds, reptiles, amphibians, and fish [C. parvum and C. hominis. Transmission of the parasite often includes direct oral consumption of contaminated water [Our patient was a young male without any comorbidities or surgical history aside from untreated AIDS. The cause of small bowel obstruction in our patient is unclear; however, it is likely related to the acute gastrointestinal infection caused by and fish . The twoed water . Once inCryptosporidium infection. An extensive report was provided by Suh et al. in which they described 23 patients with AIDS who were found to have gastrointestinal histoplasmosis. However, only three of those patients were found to have a small bowel obstruction [Cryptosporidium among patients with HIV, it has not been reported in adult patients to date. We hope to make the medical community more aware of the possible association between active Cryptosporidium infection and small bowel obstruction. Clinical awareness of the potential correlation can lead to early diagnosis and intervention, thus preventing life-threatening complications of small bowel obstruction.At the time of writing, there are no reported cases of small bowel obstruction in adult patients with AIDS and active truction . DespiteCryptosporidium is an opportunistic pathogen and is the most common parasitic cause of infectious diarrhea in patients with AIDS. Our patient had an uncomplicated hospital course due to early diagnosis and intervention. The pathophysiology of obstruction in our patient who had no history of abdominal surgery or risk factors is likely due to bowel wall edema as well as intestinal phlegmon that resulted in mechanical obstruction. We hope to make the medical community more aware of the possible association of Cryptosporidium infection resulting in small bowel obstruction as the course can be rapidly progressive and life-threatening. If treated promptly and early in the disease course, most cases of small bowel obstruction resolve without requiring surgical intervention.Small bowel obstruction remains a common cause of admission requiring both medical and surgical evaluation. Abdominal X-ray and CT imaging remain the ideal imaging modalities of choice to confirm the clinical diagnosis. A small bowel series with Gastrografin has the added benefit of introducing a high osmolar medium that can potentially decrease bowel wall edema while providing useful diagnostic information. Most cases of small bowel obstruction can be traced to abdominal adhesions, tumors, or adhesions. Infectious causes can be seen more commonly in immunosuppressed populations such as those with HIV.


Female adnexal tumors of probable Wolffian origin (FATWOs) are rare gynecologic neoplasms arising from the mesonephric duct remnants. Less than 90 cases have been reported in the English literature. Although most cases of FATWO are considered benign, recurrence and metastasis may occur in very few cases during the course of the disease. Due to the small number of recurrent and metastatic FATWO cases, there are no clear recommendations regarding optimal treatment.A 75-year-old postmenopausal woman, who underwent a mass excision of the right broad ligament three years ago, was found to have a right adnexal mass during a regular postoperative physical examination.Vaginal ultrasound examination revealed a cystic and solid mass approximately 3.6 × 4.4 × 3.8 cm on the right side of the uterus. Three years ago, the mass of the right broad ligament was diagnosed with FATWO in the local hospital. Following extensive immunohistochemistry analysis and after reviewing the histology slides from the primary tumor, the final diagnosis of the mass on the right side of the uterus was recurrent and metastatic FATWO.The patient underwent laparoscopic mass excision, hysterectomy and resection of the metastatic lesion in the small intestine, and then she received 6 cycles of docetaxel and carboplatin-based chemotherapy.The disease has recurred three years after the first surgery in the local hospital. After the second surgery followed by systemic chemotherapy, there is no evidence of recurrence with 24 months of follow-up till now.FATWO is considered a benign entity. However, a few FATWOs have been shown to behave aggressively. Due to only a few reported cases, there are no comprehensive recommendations regarding the optimal clinical management of recurrent and metastatic FATWOs. Complete surgical resection followed by combination chemotherapy is considered to be the most effective therapy for recurrent and metastatic FATWOs. Chemotherapy with docetaxel plus carboplatin, which is most commonly used in malignant cases, may be effective in the treatment of recurrent and metastatic FATWOs. These tumors are considered to have low malignant potential over time, as only a few cases have been found to relapse and metastasize and most of these tumors have a benign course. It has been reported that recurrence and metastasis occur in approximately 11% of cases and they may occur as early as 2 years after diagnosis. Due to the few reported cases, there are no clear recommendations regarding the optimal management of recurrent and metastatic FATWOs. Here, we report a case of recurrent and metastatic FATWO arising from the broad ligament and review the literature on the optimal management and prognosis of this disease, to provide clinicians with a better understanding and management of the disease.Female adnexal tumors of probable Wolffian origin (FATWOs) are rare gynecologic neoplasms derived from mesonephric duct remnants of the female genital tract, with >90 cases reported in the English literature.2Ethical approval and patient consent were acquired and recorded in the patient medical record with witness signature. All ethical approval and consent procedures were approved by the Medical Ethical Committee of West China Second University Hospital, Sichuan University.A 75-year-old post-menopausal G3P2 Chinese woman originally presented in 2015 with a right adnexal mass. At laparotomy, she was noted to have a mass approximately 8 cm in diameter arising from the broad ligament. There was no evidence of any other pelvic or abdominal disease. The patient underwent a simple mass excision combined with prophylactic bilateral adnexectomy in a local hospital. After consultation with two different external expert pathologists, the mass was suggested to be a FATWO. The patient had a good recovery without complications. In October 2018, vaginal ultrasound at our institution during routine follow-up showed a cystic and solid mass approximately 3.6 × 4.4 × 3.8 cm in the right adnexal area. The patient did not have vaginal bleeding, abdominal pain, abdominal distension or other discomfort. There was no family history of breast or ovarian cancer. On physical examination, except for the mass on the right side of the uterus, no other abnormalities were recorded. Laboratory test results, including blood cell counts and tumor markers such as cancer antigen-125, were all within the normal ranges. Pelvic computed tomography (CT) suggested a cystic and solid mass about 5 × 4 cm on the right side of the uterus, with a regular shape and close contact with the wall of the uterus.After a detailed explanation and comprehensive counseling regarding the advantages of a single surgical intervention, laparoscopy was performed. At diagnostic laparoscopy, gross examination showed that there was a solid and cystic mass approximately 5 × 4 cm in size on the right side of the pelvic cavity, which was densely adhered to the posterior leaf of the right broad ligament, the right posterior lateral wall of the uterus and the small intestine. Intraoperative findings showed no obvious ascites fluid. Except for the right posterior lateral wall of the uterus, the posterior leaf of the right broad ligament and part of the small intestine, no obvious tumor invasion was observed in other sites of the abdominal and pelvic cavity. Resection of the tumor mass combined with a total hysterectomy was performed, and peritoneal washing was also undertaken during surgery. The postoperative course was uneventful and the patient was discharged on day 5 after surgery.Gross examination of the excised specimen showed that the tumor mass was mainly solid and partly cystic, and the cut surface of the solid component was gray-white. Pathological findings revealed that the neoplastic cells were diffuse shaped by solid, tubular, and sieve-like pattern, with some cystic changes. Local areas of fibrous stroma divided the tumor into lobules. Most of the cells were square or columnar; the round or oval nuclei were cytologically bland with fine, evenly dispersed chromatin, an absence of discernible nucleoli and a low mitotic index Fig. . Immunoh2) and carboplatin (300 mg/m2) 3 weeks after the second surgery. The patient was regularly reviewed for chest and abdominal CT scans and tumor markers; there was no evidence of recurrence at 2 years after the second surgery. We will continue to follow-up this patient.A medical oncologist was consulted, and additional chemotherapy was recommended. The patient received adjuvant chemotherapy with 6 cycles of docetaxel (80 mg/m3,4–28 These studies involved 28 patients (Table FATWOs are extremely uncommon tumors with low malignant potential and are believed to derive from mesonephric remnants. To date, approximately 90 cases of FATWO have been reported. Although most cases of FATWO exhibit a benign clinical behavior, a few cases have been shown to be aggressive. In recent years, some metastatic and recurrent cases have been reported. We searched the PubMed and GeenMedical databases using the keywords “Wolffian origin,” “malignant,” and “metastatic,”, and found 26 studies published between 1976 and 2017. Hence, early diagnosis may be difficult. Sivridis et al combined the maglignancies described earlier and proposedsdiagnostic criteria for malignant FATWO: tumors >10 cm in diameter, obvious hypercellularity, capsular invasion, capsular rupture and verifiable tumor implants and metastases. Fortunately, most FATWOs exhibit a benign clinical behavior.The clinical manifestations of FATWOs are varied; patients with FATWOs may have abdominal pain or irregular vaginal bleeding as their main symptoms, or feel a palpable mass in the abdomen when the tumor is large enough. Many patients are asymptomatic, and the tumors are found incidentally during imaging studies or laparoscopy for other gynecological disease. Histologically, FATWOs can exhibit a variety of growth patterns, including tubular, sieve-like, solid and diffuse in various combinations. The tubal lumen and sieve-like spaces often contain eosinophilic, colloid-like, PAS-positive substance.,13,20 Although there are some case reports of remission or partial remission following specific adjuvant therapy, the exact effect of radiotherapy, chemotherapy, hormone therapy, and molecular-targeting therapy on malignant FATWO remains to be clarified. Therefore, it is imperative to institute appropriate treatment strategies in patients with malignant FATWO.Due to the rarity of FATWO and the few reported cases, optimal management has not yet been established. However, complete tumor resection, including hysterectomy, bilateral salpingo-oophorectomy, and debulking surgery, is the preferred treatment for FATWO. Most tumor relapses occur in patients initially treated with conservative procedures such as cystectomy or simple tumor resection.,25,28 cisplatin/cyclophosphamide,,16 etoposide/ifosfamide/carboplatin, cyclophosphamide/doxorubicin/cis-platinum, and cisplatin/oxaliplatin/docetaxel (Table  showed that carboplatin and paclitaxel combination therapy produced a good response in patients with recurrent and metastatic FATWO following the failure of imatinib treatment. Atallah et al reported a patient with progesterone receptor-positive FATWO with tumor recurrence after pregnancy. The patient received paclitaxel plus cisplatin chemotherapy, which induced temporary disease stabilization. Qiu et al reported a patient with recurrent FATWO who was treated with cisplatin/oxaliplatin/docetaxel chemotherapy, which resulted in side effects and the patient had recurrent disease 2 months after the second surgery and died ultimately. In our patient, a good response to platinum-based chemotherapy was observed without side effects. In addition, there was no evidence of recurrence at 2 years’ follow-up after the second surgery, indicating that combination chemotherapy with docetaxel plus carboplatin may be effective for treating recurrent and metastatic FATWOs. However, further studies are needed to determine the effectiveness of this chemotherapy regimen.Multiple chemotherapy regimens have been used to treat recurrent and metastatic FATWO, such as paclitaxel/carboplatin, It was reported that the median recurrence time for FATWOs was 48 months with a range of 13 to 96 months, and liver and lung were the most frequent metastatic sites.,20 According to the findings shown in Table The prognosis of FATWO is independent of clinical presentation and histological features, and recurrence can still occur in the absence of aggressive histological findings.4FATWOs are rare gynecologic neoplasms of low-malignant potential which are considered to derive from mesonephric remnants. Although most cases of FATWO have a benign course, some have the potential for recurrence and metastasis, and a few patients have died of the disease within a short time. Due to only a few reported cases, there are no distinct recommendations regarding the optimal management of recurrent and metastatic FATWOs. We reviewed previous cases to determine the best treatment protocol. Complete surgical resection with hysterectomy, bilateral adnexectomy, and debulking of the tumor, followed by combination chemotherapy is considered to be the most effective therapy for recurrent and metastatic FATWOs. Chemotherapy with docetaxel plus carboplatin, which is most commonly used in malignant cases, may be effective in the treatment of recurrent and metastatic FATWOs.Conceptualization: Qiuhe Chen, Chuan Xie.Data curation: Qiuhe Chen, Yangmei Shen, Chuan Xie.Formal analysis: Qiuhe Chen.Investigation: Qiuhe Chen, Chuan Xie.Methodology: Yangmei Shen, Chuan Xie.Software: Qiuhe Chen, Yangmei Shen, Chuan Xie.Supervision: Qiuhe Chen, Chuan Xie.Writing – original draft: Qiuhe Chen, Chuan Xie.Writing – review & editing: Qiuhe Chen, Chuan Xie.


Glomus tumor (GT), which are neoplasms of the glomus body, usually occur in the extremities, particularly under the nail bed. GT occurring in the bladder is very rare and has been reported as sporadic. In the present study, a rare case of bladder GT is reported and its clinical and histopathological characteristics are summarized by literature review.A 57-year-old woman presented with intermittent gross hematuria for 2 years. Urinalysis displayed hematuria. The bladder ultrasound showed an avascular and homogeneous isoechoic polypoid mass with a maximum diameter of 6 mm at the right lateral wall of bladder. The bladder endoscopic examination showed a polypoid lesion, with a smooth surface, located in the right lateral wall. Then, a transurethral resection was performed, its histopathological features indicated a benign GT.GT arising in the bladder is extremely rare, and only four cases have been identified in studies reported in English. It is difficult to diagnose bladder GTs according to their clinical features. The gold standard method used for their diagnosis is histopathology. However, it should also be considered in the differential diagnosis for bladder mass. Glomus tumor (GT) is a mesenchymal neoplasm, composed of a mixture of glomus cells, blood vessels and smooth muscle cells arising from the glomus body. GT can occur in almost any part of the body, but it is most commonly seen in the extremities, particularly in the nail bed . GT occuA 57-year-old woman presented with intermittent gross hematuria for 2 years. She did not report any other symptoms. Physical examination indicated no abnormal findings. Blood cell counts and biochemical tests were within the reference range. Urinalysis displayed hematuria. Therefore, it was suggested that she should undergo a urinary system ultrasound examination. The kidney and ureter ultrasounds indicated no abnormal findings, whereas the bladder ultrasound revealed an avascular and homogeneous isoechoic polypoid mass with a maximum diameter of 6 mm at the right lateral wall of the bladder Fig. . She hasGT, which are neoplasms of the glomus body, usually occur in the extremities, particularly under the nail bed. Localizations other than the extremities have been reported in various systems including the respiratory  –8 the diGT occurring in the bladder is very rare and has been reported as sporadic. To the best of our knowledge, only 4 cases of human bladder GT have been identified in the literature, indicating that the current case is the fifth. The clinical data of these five patients are presented in Table GT is composed of a mixture of glomus cells, blood vessels and smooth muscle cells. GT is usually benign and rarely malignant or atypical. The criteria of malignancy GT are the following: (1) tumor with a deep location, (2) a size more than 2 cm, (3) atypical mitotic figures or apparent nuclear atypia, (4) 5 or more mitotic figures/50 high-power field . The atyIn conclusion, GT arising in the bladder is extremely rare, and only four cases have been identified in studies reported in English. It is difficult to diagnose bladder GTs according to their clinical features. The gold standard method used for their diagnosis is histopathology. However, it should also be considered in the differential diagnosis for bladder mass.