We present a rare case of an 81-year-old woman presenting with acute left nasal blockage caused by a large nasal mass of unknown origin. The mass was subsequently diagnosed as diffuse large B-cell non-Hodgkin lymphoma (NHL). Nasal/paranasal space involvement in NHL is uncommon, representing only 0.2%-2% of cases. In this case, the nasal NHL mass exhibited a favorable prognosis, in contrast to previously reported sinonasal lymphomas with poor outcomes. The patient underwent excisional biopsy and was treated with 3 cycles of R-CHOP chemotherapy, resulting in complete resolution of the mass confirmed by a follow-up CT scan and no signs of disease after 1 year. Differentiating sinonasal lymphomas from other neoplasms can be challenging due to their variable morphology and location. Diffuse presentations of sinonasal lymphoma can aid in distinguishing them from discrete lesions associated with other sinonasal neoplasms. However, differentiation from acute invasive sinonasal infection remains difficult. MRI can help identify lymphomas through the characteristic hypointense T2 signal and diffusion restriction, with the combined use of CT to aid in differentiating masses of unknown morphology. Nonetheless, squamous cell carcinoma, which mimics lymphoma features on MRI, poses additional challenges to accurate identification. This case highlights the rarity of nasal NHLs, their potential for excellent prognosis, and the importance of diverse imaging techniques in their diagnosis and differentiation from other sinonasal pathologies. Non-Hodgkin lymphoma (NHL) of the head and neck are relatively common, accounting for roughly 1/3 of all cases of extranodal disease. However, cases involving the nasal/paranasal space are much rarer, accounting for 0.2%-2% of the disease burden This case report is significant for multiple reasons. The improbability of developing a new primary cancer in the nasal region is notable given the patient's history of resolved breast cancer and longstanding IgM monoclonal gammopathy of undetermined origin with limited bone marrow involvement. The new primary diffuse B-cell lymphoma mass developed in the nasal cavity and accounts for a very small proportion of nasal neoplasms. Nasal lymphomas are primarily T-cell in origin, whereas our patient's mass was of B-cell origin. The case report is also important, given the large differential list and difficulty with detection that is present with these nasal lesions, and awareness and vigilance is needed to ensure positive patient outcomes especially given the higher mortality rate if these lesions are not caught early.An 81-year-old woman presented with acute left nasal blockage to the local hospital. Physical examination was overall unremarkable except for a soft tissue mass affecting the left side of the face that was distorting the left nostril. There was also formation of nodular lesions along the left upper lip, below the nostril, and medial canthus of the left eye. There were no signs of cervical, supraclavicular, axillary, femoral or inguinal lymphadenopathy. No signs of hepatosplenomegaly. Computed tomography (CT) demonstrated a large 5.5 cm left nasal mass expanding the nasal cavity, extending to the left aperture and medial orbit . ExcisioWe present a rare case of nasal lymphoma that demonstrated excellent prognosis. Previously published case reports of sinonasal lymphoma had poor outcomes ,5,6, seeGiven the variable morphology and location of sinonasal lymphomas, distinguishing these neoplasms can be very challenging. In general, diffuse presentations of sinonasal lymphoma can be distinguished from other sinonasal neoplasms, which mostly present as discrete lesions. It was challenging confirming this nasal lymphoma diagnosis because they are rarely identified, have similar appearance to other neoplasms, and their unlikely tumor origin given the presenting location. Our case report adds important data to the literature of rare nasal lymphomas seeing as this particular lymphoma had such a positive response to treatment despite its rare presentation.


Malignant mesothelioma is a very rare diagnosis. Malignant mesotheliomas arise from surface linings of pleura, peritoneal cavity, or tunica vaginalis and pericardium with pleural malignant mesotheliomas being the most common. The incidence of brain metastases has been very low with malignant pleural mesotheliomas, but to date, there have not been any cases reported of brain metastasis with malignant peritoneal mesotheliomas. We present a patient diagnosed with malignant peritoneal mesothelioma and was successfully treated with immunotherapy for over two years but later presented with brain metastases. Although the patient had a surgical resection followed by brain radiation, he died three months after his diagnosis of brain metastases. Immunotherapy has revolutionized the treatment of malignant mesothelioma, and patients are living longer than before. We present this patient to increase awareness of brain metastases with malignant peritoneal mesothelioma. This case also highlights that we need to investigate different treatment options for brain metastases in patients with malignant mesothelioma as conventional treatment options like surgical resection and brain radiation are not very effective.  Malignant mesothelioma is a rare disease. Of all mesothelioma cases, 85% originate from the pleura and only 15% originate from the peritoneum [A 59-year-old man presented with abdominal pain and weight loss in May 2020. He was found to have a Liver mass measuring 11.5 x 8 cm on the CT abdomen. Ultrasound-guided liver mass biopsy revealed sarcomatoid carcinoma. It was strongly positive for AE1/AE3, GATA3 and CK7 but negative for calretinin, S100, CK20, TTF-1, CK20, p40, CA-19-9, CDX2. The immunostains were favoring sarcomatoid malignancy but were non-specific. Given an overall negative positron emission tomography (PET) scan except for a large perihepatic/hepatic soft tissue mass with substantial metabolic activity, the diagnosis of localized cholangiocarcinoma with sarcomatoid features was considered. In preparation for surgical resection of the mass, he underwent diagnostic laparoscopy which revealed omental and peritoneal carcinomatosis. Biopsies raised the suspicion of malignant peritoneal mesothelioma. He underwent partial hepatectomy for optimal debulking and pathology confirmed malignant peritoneal mesothelioma given its positivity for D2-40. Hyperthermic intraperitoneal chemotherapy (HIPEC) was considered but was not offered due to unclear diagnosis at the time of surgical resection. Given lymphovascular invasion and gross residual disease, systemic therapy with cisplatin and pemetrexed was initiated in July 2020. After three cycles of chemotherapy, his cancer progressed locally, and in September 2020 ipilimumab and nivolumab were initiated based on CheckMate-743 clinical trial. He received nivolumab (3 mg/kg intravenously once every two weeks) plus ipilimumab (1 mg/kg intravenously once every six weeks). He had an excellent response to treatment. In June 2022, he was found to have worsening peritoneal implants and he underwent complete surgical resection which was followed by a single agent Nivolumab. Unfortunately, in Jan 2023, he presented with acute headaches and was found to have a left cerebellar mass (Figure Malignant mesotheliomas are very aggressive tumors. They originate from serosal surfaces such as the pleura, peritoneal, pericardium, etc. The histological subtype determines the aggressiveness of the tumor with sarcomatoid being the most aggressive . MalignaBrain metastases with malignant pleural mesothelioma are very rare. No cases have been reported of brain metastases with malignant peritoneal mesothelioma. With the use of immunotherapy, patients with malignant mesotheliomas are living longer. Unfortunately, the median survival of patients with brain metastases due to malignant mesotheliomas is about three months. This case highlights the importance of recognizing brain metastases early with malignant peritoneal mesothelioma and looking for different treatment options than conventional surgical resection and brain radiation.


Soft tissue sarcomas (STS) are often described as asymptomatic, rapidly expanding masses, particularly in the extremities or trunk. Undifferentiated pleomorphic sarcoma (UPS), a high-grade variant of STS, ranks as the second most prevalent subtype in the United States. It predominantly affects males between their fifth and seventh decades. Its often benign symptomatology, however, can lead to initial misdiagnosis and subsequent mismanagement. We present the case of a 57-year-old Caucasian male, previously in good health, who experienced a recurring subpectoral lesion causing discomfort and mass-related effects. Initial management included incision and drainage, which provided temporary relief. The biopsy revealed a diagnosis of grade 3 UPS. The lesion's recurrence two months later was accompanied by local invasion into adjacent skin and musculature as well as metastasis to the right hemiliver. A comprehensive understanding of UPS among medical professionals is vital for accurate diagnosis and facilitating prompt intervention to prevent avoidable complications and optimize patient outcomes. With age, cancer diagnoses become more prevalent. Sarcoma, a less common cancer type, constitutes roughly 1% of adult malignancies . SurgicaThe etiology of UPS remains a topic of ongoing discussion. Recent investigations have revealed that the cells originate from a mesenchymal lineage, bearing a close resemblance to mesenchymal stem cells ,6. GenetA previously healthy 57-year-old Caucasian male presented to the emergency department due to a painful, right-sided chest wall mass that progressively enlarged over one year. He worked in lawn care and attributed the lesion's growth to the trauma of his backpack rubbing against his chest. The lump was drained a few months earlier while he was overseas and was noted to contain red-tinged fluid. Since his return, the mass continued to grow and has caused significant pain and numbness over his right chest and right shoulder. He denied having fever, chills, night sweats, drainage, and unintentional weight loss. Family history was contributory for non-Hodgkin's lymphoma in his mother, which was diagnosed in her late 70s.Physical examination revealed a large, firm, immobile mass in the anterior right chest wall associated with engorged vessels. There were no signs of infection, overlying skin changes, or palpable lymphadenopathy. The range of motion in his right upper extremity was within normal limits.A computerized tomography (CT) scan of the chest demonstrated a heterogeneous mass measuring 13.7 cm x 8.6 cm x 11.5 cm under the right pectoral muscle, with no associated adenopathy or signs of inflammation Figures . There wAfter discussing treatment options with a multidisciplinary team and the patient, surgical intervention was chosen over preoperative biopsy due to the patient's discomfort with the tumor. The procedure involved draining the right subpectoral chest wall mass, which revealed sanguineous fluid, blood clots, and necrotic tissue. The capsule was removed with 1 cm margins, and results from pathology indicated a grade 3 undifferentiated pleomorphic sarcoma with a positive vimentin stain.Following surgery, the patient began treatment with doxorubicin and cisplatin. He returned to the emergency department two months later due to a syncopal episode at the infusion center. Assessment at that time revealed recurrence of the right retropectoral mass, measuring 9.3 cm x 14.1 cm x 12.8 cm, with invasion into surrounding musculature and skin. Additionally, a hypodense mass, measuring 2.1 cm x 2.5 cm, was detected in the posterior aspect of the right hemiliver. The patient was referred to oncology for further management. He completed six cycles of chemotherapy before he was lost to follow-up.UPS often masquerades benign conditions, leading to potential misdiagnoses and mismanagement. Recognizing this rare condition is crucial for timely and effective treatment. As its exact pathogenesis remains unclear, tailored therapeutic options are limited . Recent The staging of UPS utilizes the tumor, node, and metastasis (TNM) system . GradingThe current chemotherapeutic regimen for UPS involves doxorubicin, ifosfamide, and mesna, which focuses on inducing cellular damage through DNA alkylation and free radical formation ,14. HoweUPS is an uncommon, high-grade STS associated with a poor prognosis. The tendency to omit UPS from the differential diagnosis, often due to STS being of low order in the differential diagnosis tree, commonly results in diagnostic oversights. Educating healthcare providers about this aggressive and challenging-to-identify cancer is crucial to ensure timely and appropriate patient care, leading to improved treatment outcomes. Furthermore, additional research into UPS genetics and molecular pathways is necessary for the advancement of tailored chemotherapeutic options.


Phyllodes tumor (PT) is a rare tumor that can present as benign, borderline, or malignant. These tumors arise from the breast stroma, similar to fibroadenomas. Phyllodes tumors and fibroadenomas often have overlapping features in both radiological imaging and pathologic analysis. As a result, these two lesions are often difficult to differentiate and require the correlation of multiple modalities, including clinical context, radiologic imaging, and histological evaluation. This article presents a case of a borderline phyllodes tumor in a 51-year-old female, with the inclusion of its radiologic and pathologic images and performed treatment. The goal of this article is to provide a review of the clinical presentation, diagnostic imaging and pathology features, treatment, and management of a phyllodes tumor and compare and contrast this against the more common fibroadenomas, in order to provide aid for differentiating these two breast lesions. Phyllodes tumor (PT) is a rare fibroepithelial lesion that accounts for 0.3-0.9% of all breast tumors . This maPT typically presents as a painless, rapidly growing mass , rangingThe World Health Organization (WHO) classifies PTs as either benign, borderline, or malignant, with benign being the most common, representing 60-75% of PT cases . These cA 51-year-old woman was found to have a left breast mass on a routine mammogram screening. On physical examination, a 4 x 4 cm mass was seen at the 8 o’clock position without associated edema, dimpling, rashes, or nipple discharge. Furthermore, no axillary or supraclavicular lymphadenopathy was palpated on physical examination.Mammography demonstrated an equal-density, oval-shaped mass with indistinct margins in the lower inner quadrant Figure . The ultBiopsy results showed a fibroepithelial neoplasm, favoring a PT. Surgical excision was recommended, and the patient underwent a lumpectomy with sentinel lymph node biopsies Figure . The finWhile most breast carcinomas involve the ducts or lobules, PTs involve the breast stroma, similar to fibroadenomas . As a reCysts are classified as BI-RADS 2, indicating a benign lesion and requiring no further workup. Fibroadenomas are typically classified as BI-RADS 3, indicating a likely benign lesion and requiring a follow-up ultrasound within six months. The lesion in this patient's case was determined to be BI-RADS 4B, indicating a moderate suspicion for malignancy and required further workup with biopsy. This category assignment was likely due to both the suspicious imaging findings and the clinical context of a large mass in a 51-year-old female. Clinical context, as in this patient's case, is often the only diagnostic signal that this lesion is a possible PT as opposed to fibroadenoma since these lesions can present similarly on radiologic imaging modalities .Fine-needle aspiration cytology (FNAC) is unreliable in discerning between benign PTs and fibroadenomas , with a If a patient is diagnosed with either a benign or a borderline PT, imaging for tumor staging does not need to be performed . If a maThe diagnosis of a PT should be considered in all middle-aged women who present with a rapidly growing, palpable breast mass with limited associated symptoms. While PTs, especially benign PTs, present similarly to fibroadenomas, a combination of presentation, imaging modalities, and biopsy may be used to enhance diagnostic certainty for differentiating these tumors. This case brings further attention to the presentation, diagnostic evaluation, and appropriate treatment plan for a PT that is challenging to differentiate from the more common fibroadenoma.


The sellar region and its boundaries represent a challenging area, harboring a variety of tissues of different linings. Therefore, a variety of diseases can arise or involve in this area . A total of three challenging cases of “chameleon” sellar lesions treated via EEA were described, and the lesions mimicked radiological features of common sellar masses such as craniopharyngiomas and/or pituitary adenomas, and we also report a literature review of similar cases.A retrospective analysis of three primary cases was conducted at the Università degli Studi di Napoli Federico II, Naples, Italy. Clinical information, radiological examinations, and pathology reports were illustrated.A total of three cases of so-called “chameleon” sellar lesions comprising two men and one woman were reported. Based on the intraoperative finding and pathological examination, we noticed that case 1 had suprasellar glioblastoma, case 2 had a primary neuroendocrine tumor, and case 3 had cavernous malformation.Neurosurgeons should consider “unexpected” lesions of the sellar/suprasellar region in the preoperative differential diagnosis. A multidisciplinary approach with the collaboration of neurosurgeons, neuroradiologists, and pathologists plays a fundamental role. The recognition of unusual sellar lesions can help surgeons with better preoperative planning; so an endoscopic endonasal approach may represent a valid surgical technique to obtain decompression of the optic apparatus and vascular structures and finally a pathological diagnosis. The sellar and the suprasellar regions represent a very complex area, harboring a remarkable variety of tissues of different linings, and many diseases can arise from or involve these areas, with a majority of them from hypophysis, both neoplastic or not . Over 90Herein, we report three challenging cases of “chameleon” sellar lesions treated via EEA that mimicked radiological features of common lesions such as craniopharyngiomas and/or pituitary adenomas, with the literature review of similar cases.Figure 2). Intraoperative histological examination revealed the presence of a malignant glial cell tumor. Further resection of the tumor was not performed because the tumor adhered tenaciously to surrounding structures. During the postoperative course, due to the presence of supratentorial hydrocephalus, a biventricular peritoneal shunt with a 130 cm H2O Codman programmable valve was positioned in a second surgery. A path report revealed an IDH1-wild-type glioblastoma. Adjuvant radio and concomitant chemotherapy treatment were started immediately as per the STUPP protocol. The patient died 1 year after the surgery due to the progression of the disease . In 1996 and later in 2006, the patient underwent left and then right orchidectomy for testicular seminoma. Brain MRI showed a huge mass located in the median and paramedian portion of the hypothalamus–chiasmatic region (Dmax 50 cm), with irregular margins infiltrating the uncus–amygdaloid complex in the hypothalamus region and the floor of the third ventricle; the lesion presented a central colliquative necrotic component, and its signal was relatively homogenous with slightly hypointense images in T1 and hyperintense on T2-weighted images, with significant heterogenous post-Gad enhancement. Signs of supratentorial hydrocephalus were noticed. The first radiological impression was compatible with a case of craniopharyngioma. An extended suprasellar endoscopic endonasal approach was run for tumor removal: Upon dural opening, the lesion appeared diffusely infiltrating the infundibulum and third ventricle, and it presented as a grayish-yellow tissue and was highly vascularized  with the third ventricle involvement with heterogenous contrast enhancement compressing the optic chiasm. A pearance . The lespearance . LaboratA 21-year-old man was admitted to our department with a headache and sudden visual loss. Ophthalmological examination revealed 1/30 in RE with diffuse reduction of light sensitivity and bitemporal hemianopia in LE. Endocrinological assessment and lab essays revealed central hypercortisolism. Brain computed tomography imaging demonstrated hyperdense large sellar and suprasellar mass with extension into the third ventricle cavity with the presence of calcifications. MRI showed a heterogenous low signal in T1 images, an intermediate high signal in T2 images, and cystic with calcific components of the suprasellar lesion. It measured ~3 × 2, 4 × 3, and 3 cm in anteroposterior, cephalocaudal, and transverse dimensions, respectively.An extended endoscopic endonasal approach was performed. During surgery, the evacuation of the intralesional blood component of the neoformation localized inside the optic chiasm and infundibulum of the third ventricle was performed, which appeared dislocated below; at the end of the procedure a yellowish granulomatous formation was removed in fragments, of dubious vascularization, but suspected of a possible, already site of previous bleeding and adhering to the ventricular walls. Considering its high vascularity and the difficulty of dissection from the adjacent structures, a subtotal resection of the lesion aiming at optic nerve decompression was achieved . HistopaThe patient's visual acuity improved on postoperative day 3, and MRI showed decompression of the optic apparatus despite a large intra-suprasellar residual lesion. A second-stage surgery was proposed to the patient to obtain a more radical excision, but he refused. The neuro-oncological multidisciplinary team meeting discussed the case, and considering the patient's decision, the patient underwent stereotactic radiosurgery. At the follow-up visit after 6 and 12 months, the residual lesion is stable, and the patient did not develop any new neurological signs maintaining the visual improvement.Tumors of the sellar region account for ~10–15% of all brain tumors, and a large variety of non-neoplastic, inflammatory, vascular, or developmental lesions can be found in this region .Pituitary adenomas constitute over 90% of sellar masses, while the remaining 10% of the lesions includes pituitary-origin tumors, such as craniopharyngiomas, Rathke's cleft cysts, and astrocytomas, and non-pituitary origin lesions, such as meningiomas, germ cell tumors, chondrosarcomas/chordomas, giant cell tumors, epidermoid cysts, and metastatic lesions .According to previous data, rare sellar lesions represent a heterogeneous group of non-adenomatous lesions that deserve special care regarding their surgical and clinical management , 13. A tBrain MRI is routinely adopted for diagnosis and proper identification of sellar lesions details and features; however, MRI appearance of different sellar/parasellar lesions can be very similar though misleading , 15. TheGlioblastoma (GBM) is the most common adult brain tumor, occurring in the subcortical white matter of the cerebral hemispheres . From thSellar and/or suprasellar gliomas are usually low-grade glioma, i.e., optic nerve pilocytic astrocytoma associated with neurofibromatosis NF-1 . AppearaAlbeit gadolinium enhancement MRI is observed in both craniopharyngioma and high-grade gliomas, the latter are less likely to present cystic degeneration and calcifications . In the Neuroendocrine tumor (NET) arises from the neoplastic transformation of enterochromaffin cells . These eUsually, patients with NET do not have specific clinical features, but in presence of functional tumors, they may develop endocrine symptoms from secreting one or more hormones, while non-functional tumors may affect pituitary gland function leading hypopituitarism . In our CT and MRI are not specific radiological investigations for these tumors; as demonstrated by our case, NET presents MRI findings similar and compatible with other more common pathologies of the sellar region, such as pituitary adenoma, meningioma, and metastases . It is kThe cavernous malformation (CM) can affect any cerebral region, but it is more frequent as it tends to affect the subcortical areas of the frontal and temporal lobes, while in the posterior fossa, it tends to involve the pons and the cerebellar hemispheres, however, medulla involvement is uncommon . HoweverTo date, only 16 operated cases were reported in the current literature, and total resection was achieved in two cases , 40–44. Maximally safe resection should be performed, including decompression of the optic apparatus and cavernous sinus. Therefore, considering the nature of the lesion and its anatomical extension, an endoscopic endonasal approach (EEA), which allows easier access and feasible debulking of sellar masses, is advocated , 45–52. The recent advancement of the radiological technique is increasingly used by the surgeon, to plan the type of approach and the best treatment modality. Recent studies highlight how machine learning can provide additional information to support clinical decisions for neuroradiologists and neurosurgeons , 41. HisNeurosurgeons should consider the “unexpected” lesions of the sellar/suprasellar region in the preoperative differential diagnosis. The multidisciplinary approach with the collaboration of neurosurgeons, neuroradiologists, and pathologists plays a fundamental role. The proper diagnostic assessment of the sellar masses may help surgeons with better preoperative and postoperative planning, and in this scenario, the endonasal endoscopic approach could represent a fundamental surgical technique to obtain both a proper neurovascular structures decompression and a pathological diagnosis.The presence of unusual sellar and suprasellar lesion features at the MRI associated with a rapidly worsening clinical course, altered hormonal profile, and cognitive disturbances should raise the suspicion of uncommon sellar lesions. From a radiological standpoint, the possibility of a malignant tumor diagnosis should be considered in case of evidence of invasion and infiltration of the surrounding tissues. Progress in imaging studies may help differentiate among the variety of possible lesions involving the suprasellar area. Further research and case series should be carried out in order to improve diagnosis and provide a proper strategy to ameliorate outcomes and ensure the overall survival of these patients.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.IB: concept and design. IB, RF, and LU: data collection. IB and DS: original draft preparation. DS and AE: reviewing and editing. MD, DS, and LC: study supervision. All authors read and approved the final manuscript.


Lymphangiomas are benign tumours, almost exclusively found in children. Primary work-up includes imaging. We report a case of lymphangioma in the leg in an adult patient, initially masked as a myxoma. Our patient underwent ultrasound, computerised tomography, and magnetic resonance imaging, which were suggestive of myxoma. Treatment for lymphangioma varies from sclerotherapy to definitive surgical management. In our case, surgical management was selected under consideration of myxoma; however, histopathology confirmed lymphangioma. Lymphangiomas in adult patients can be masked by other conditions and should be considered as a differential in lower leg swellings. Cystic lymphangiomas are rare, slow-growing, benign tumours of the lymphatic system. They more commonly occur in the head and neck area in 75% of cases, and less commonly in the extremities ,2. Most A 62-year-old female presented with swelling on the thigh without any underlying trauma or surgery. The patient was noted to have a right thigh mass over the past four years prior to presentation with an increase in the size of the mass and discomfort over a period of six months prior to presentation. Her other medical history consisted of cervical cancer, awaiting hysterectomy. On physical examination, the mass was soft, mobile, and measured 12 x 11 cm in size without any palpable inguinal lymph nodes and no sensory or motor deficits was identified. USG showed a right thigh mass measuring 12 x 11 x 6.8 cm. MRI was consistent with a 14 x 11.4 x 7.6 cm well-defined, multi-septated mass. Pre-operative CT scan showed a soft tissue mass in the anterior compartment of the right thigh measuring 15.4 x 12.8 x 9.6 cm. Both CT and MRI were suggestive of anterior thigh myxoma  drain and Yates drain were inserted, which were sequentially removed in the week after surgery. The histopathology confirmed benign cystic lymphangioma. The patient did not have any postoperative complications. The finding of cystic lymphangioma on the lower extremity in an adult patient is extremely rare, especially in the absence of trauma or any other injury ,7. CasesIn the literature, a case of lymphangioma on the thigh in an adult was reported, occurring post-trauma after an accident with progressive worsening over a period of 20 years . A furthSurgical excision shows the lowest recurrence rate contrary to other treatment options for cystic lymphangioma . HoweverLymphangiomas of lower limbs are extremely rare presentations in adults and should be included in the differential diagnosis in the work-up of mass lesions of lower extremities. They can be easily masked by other pathologies, which can lead to inappropriate management decisions. However, in our case, the management was suitable for lymphangioma despite a masked diagnosis.


The floor of the mouth is an important anatomical region of the oral cavity where primary benign and malignant disease processes can originate or secondary pathologies can extend into adjacent spaces. Knowledge of the anatomy is crucial for accurate localisation of pathology and understanding the spread of disease. The sublingual space is the dominant component of the floor of the mouth, bounded inferiorly by the mylohyoid muscle that separates it from the submandibular space. Imaging is immensely important to characterise and map the extent of disease, considering the fact that the bulk of the disease may be submucosal and not visible on clinical inspection.The floor of the mouth is a complex anatomical region for radiological evaluation. The purpose of this pictorial review is to present an understanding of the relevant anatomy and to demonstrate the role and appropriate application of different imaging modalities. This article highlights the imaging spectrum of a wide range of various benign conditions including normal variants and a variety of malignant lesions at different tumour stages, with an aim to establish the correct diagnosis, avoid misinterpretation and help in treatment planning. The pos4 The SLS lies lateral to the genioglossus and geniohyoid muscles and superior to the mylohyoid muscle  is the major dominant deep neck anatomical space and is also referred to as the FOM, divided into bilateral spaces by the frenulum of the tongue.d muscle . The conmuscles7 . Extensi8  and post-contrast MRI8 . The sub7The mylohyoid muscle is an important anatomical landmark in the FOM; it separates the SLS above from the submandibular space below, and it lies superior to the anterior belly of the digastric muscle . This is7 White et al.7 confirmed mylohyoid defects in 77% of their cases; bilateral defects were observed in 67% and unilateral defects in 33%. The herniated salivary tissue is mostly from the sublingual glands and less likely from the submandibular gland, and can present as a mass in 40% of cases, with possible recurrent inflammatory changes9 , ranula, lipoma, post-infective or inflammatory conditions caused by obstructive calculus disease of the submandibular duct with abscesses, sublingual adenitis and Ludwig Angina.4The most common malignancies are squamous cell carcinoma (SCC), tumours of the salivary glands  and lymphoma, which is the third most common malignant tumour.10Ranulas are benign mucus retention cysts of the FOM and submandibular regions that often develop in young people but can also be seen later in life. Because of the absence of true epithelial linings, they are not true cysts and develop as a result of blockage of the sublingual gland ducts (Rivinus duct). The underlying aetiology may be idiopathic or related to previous trauma or inflammation.10 , to demonstrate the benign cystic nature of the lesion, to differentiate it from other cystic lesions of the FOM , to look for integrity of the mylohyoid muscles and above all, for pre-surgical assessment with the aim of complete excision of the sublingual gland.12  duct is a common site for intraductal calculi with the potential of causing post-obstructive suppurative adenitis and abscesses  are related to salivary ductal calculus disease or odontogenic causes.bscesses . Through19 as demonstrated in The FOM is also involved in other acute infections of the neck spaces, like Ludwig’s angina, which is a serious progressive acute bacterial infection, originating commonly from mandibular molar tooth infection. This disease entity is more common in diabetics and immunocompromised patients, and the infection can progress rapidly, causing airway compromise. Imaging demonstrates extensive cellulitis, predominantly involving the submandibular, submental and SLSs with a lesser likelihood of underlying abscess formation,20 Recent studies have, however, also established the role of MRI in deep neck infection as a more accurate imaging modality because of its high soft tissue resolution.20 The major limitation is the availability of MR imaging in emergency settings.Ultrasound is helpful for the assessment of superficial abscesses in the submandibular region, nodal disease and duct calculi. In acute settings, contrast-enhanced CT neck (from the base of the skull to the superior mediastinum) is the imaging modality of choice for confirmation and localisation of the abscesses, which appear as rim-enhancing fluid collections , pre-sur22Squamous cell carcinoma is the most common malignancy of the oral cavity (more than 90%), most frequently involving the oral tongue and mucosal lip, followed by the floor of mouth . Other malignant conditions affecting the FOM are the minor salivary gland tumours , lymphoma and rarely, sarcomas.21 as demonstrated in Malignancies of the mandible and submandibular gland can also invade the FOM,24 MRI is also very sensitive for detecting early bone marrow infiltration and establishing perineural spread of disease, which is particularly a concern for adenoid cystic cancers.25CT and MRI are complementary imaging techniques to characterise and evaluate the extent of disease. MRI is an excellent technique and imaging of choice, with particular reference to the assessment of the depth of tumour invasion, which is a crucial prognostic marker for T-staging of oral cavity cancers.26 depth of invasion and tumour size are the criteria for T1 to T3 staging, full-thickness osseous destruction of the mandible and maxilla for T4a staging and invasion of the masticator spaces and skull base, and encasement of the internal carotid arteries for T4b staging  2018, staging .26 ImagiBOX 1T-staging of the oral cavity cancers.25On imaging, SCC tumours typically appear as poorly defined, heterogeneously enhancing masses, most likely with cystic and necrotic components . Figure 28Lymphomas contribute 14% of head and neck malignancies and the vast majority are non-Hodgkin lymphomas (96%). Lymphoma of the oral cavity is generally uncommon and constitutes only 5% of oral malignancies. Primary non-Hodgkin lymphoma of the mandible is extremely rare, accounting for only 0.6% of extranodal lymphomas and 8% of mandibular malignancies.At imaging, these rare FOM lymphomas present as characteristically bulky, homogeneous soft tissue masses with a varying degree of significant contrast enhancement and pronounced restriction of diffusion. The osseous abnormalities can appear as ill-defined lytic destruction or an infiltrative pattern with invasion and widening of the inferior alveolar nerve canal. Typical radiological findings are presented in 29Interpretation of the imaging findings in the presence of post-treatment changes is often a diagnostic challenge. It is crucial for the radiologist to be aware of the time gap between the completion of treatment and imaging, as follow-up imaging is performed at least 3 months after the completion of the treatment and significant imaging variations may be present because of radiotherapy-induced oedematous changes. Furthermore, it is crucial to understand the various types of surgical procedures  that impact the imaging findings.18F-FDG PET/CT has a very high negative predictive value for excluding recurrent disease in comparison to CT and MRI (29 as illustrated in MR imaging can pose a significant challenge in the differentiation of recurrent or residual disease from post-treatment changes. Although  and MRI , PET imaPrecise understanding of the anatomical landmarks of the FOM and imaging findings of various benign and malignant conditions is crucial for diagnosis and assessment of the pathways of disease spread, T-staging of cancers, treatment planning and disease surveillance.


Seborrheic keratosis is a common benign epidermal lesion that typically occurs in the elderly population. Its occurrence in childhood and adolescence is rare and can pose a diagnostic challenge for clinicians and dermatopathologists. We report a case of a 16‐year‐old boy with multiple brown, black oval‐shaped stuck‐on lesions on his face, which were diagnosed as seborrheic keratosis based on histological findings. The patient had no significant medical history or family history of seborrheic keratosis. In this report, we discuss the differential diagnoses of seborrheic keratosis‐like lesions in childhood and adolescence and explain why they were not compatible with our case. We also review the available treatment options. Our case emphasizes the need for dermatologists to consider seborrheic keratosis in the differential diagnosis of cutaneous lesions in young patients. It is characterized by well‐circumscribed, pigmented, waxy, and verrucous papules or plaques, commonly located on the face, trunk, and extremities excluding palms and soles. The incidence of SK increases with age, and it is rarely seen in children and adolescents.2A 16‐year‐old boy presented with multiple sharply demarcated, waxy, brown‐black, oval‐shaped lesions on his face measuring up to 1 cm in diameter Figure .3senile keratosis is not a suitable synonym for seborrheic keratosis.There have been few studies on SK in childhood or adolescence. Gill et al. studied 170 Australian people aged 15–30 years and mentioned that 23.7% of participants had at least one SK. Accordingly, they declared that the term 4Although SK is commonly seen in older adults, it can also occur in younger individuals, particularly in those with a familial history of the condition. Seborrheic keratosis is rarely seen in childhood or adolescence, and when present, it can pose a diagnostic challenge for clinicians and dermatopathologists. The differential diagnosis of SK in children and adolescents includes a variety of other benign and malignant skin lesions that may resemble SK clinically or histologically, such as acrokeratosis verruciformis of Hopf and epidermal nevus.In our case, the lesions were only located on the patient's face, specifically on his cheek, chin, and posterior to his left ear. This is in contrast to the acrokeratosis verruciformis of Hopf, which typically presents with lesions on the limbs and trunk. Furthermore, our case did not have the linear or whorled shape typically seen in epidermal nevi, making that diagnosis unlikely.5Treatment for SK is typically not necessary, as the lesions are benign and do not pose any health risks. However, if the lesions are causing cosmetic concerns, they can be removed via cryotherapy, electrocautery, or surgical excision.6SK is a common cutaneous lesion found in elderly individuals; however, it should not be excluded from the differential diagnosis list for skin lesions in young people. Differential diagnoses for SK in the young age group include acrokeratosis verruciformis of Hopf and epidermal nevi, but our case was not compatible with these diagnoses due to the location and shape of the lesions. Treatment for SK is typically not necessary but can be done for cosmetic reasons.Pooria Zare: Data curation; investigation; writing – original draft. Mazaher Ramezani: Conceptualization; supervision; writing – review and editing.None.None.This case report is ethical according to the world medical association declaration of Helsinki.Written informed consent is obtained from the patient to publish this report.


Massive cystic lesions involving a mandible always present a diagnostic and treatment challenge. Unicystic ameloblastoma (UA) is a variant of ameloblastoma encompassing about 6% of ameloblastomas. They represent cystic lesions that reveal clinical and radiographic features of a cyst, but the histopathological features demonstrate a typical ameloblastomatous epithelium lining the cyst. It is a variant of ameloblastoma, usually having clinical and radiographic similarities with dentigerous cysts, hence posing preoperative diagnostic difficulties. Adult treatment protocol cannot be applied to the pediatric population since resection may cause an alteration in craniofacial development leading to functional and esthetical damage, which can directly affect their quality of life. A more conservative approach of enucleating the lesion seems to be a promising treatment modality of UA in the pediatric age group. We present a case of mural variant of UA arising from dentigerous cyst in an 8-year-old male patient. Ameloblastoma is the most common locally aggressive benign tumor affecting the mandible. It has many histological subtypes out of which unicystic ameloblastoma (UA) is comparatively less encountered variant possessing slow growth but locally destructive potential  - 2. UAAn 8-year-old male patient, reported to our institute with the chief complaint of pain and swelling on right back side of the face since 10 -12 days following a fall from a tree. History revealed that the patient was apparently asymptomatic 6 months back with gradual onset of swelling on right side of face. Extra oral examination revealed a diffuse hard and indurated swelling on right side of the face, extending anteriorly from the corner of the mouth to the ramus molar region posteriorly and superiorly extending from the infraorbital region, to inferior border of the mandible. There was associated difficulty in opening the mouth and facial asymmetry. Intraoral examination revealed a mixed dentition, carious primary molars in first, second and third quadrants and a non-tender swelling on lower right posterior region, measuring between 5cm×2cm, obliterating buccal vestibule. Panoramic radiograph, revealed a large well-defined unilocular radiolucency in relation to markedly displaced, developing, unerupted 45 associated with knife-edge patternof root resorption in 85 and 46 . ProvisiSurgical enucleation  by intraoral vestibular incision approach, followed by peripheral osteotomy preserving the inferior border of mandible, under general anesthesia was performed. Defect cavity was packed withiodoform glycerin-soaked gauze for proper granulation . ExcisioPatient was weekly followed up for initial 18 months and thereon at every 3 months; any possible recurrence was monitored by taking regular panoramic radiographs. Each time, surgical defect was irrigated using Betadine followed by glycerin soaked iodoform dressing for six months. During follow up visits the panoramic radiographs revealed a gradually reduction in defect cavity size and subsequentnew bone filling the defect -6. Afteret al. [ UA is a variant of ameloblastoma, first described by Robinson and Martinez   consideet al.  , 5 andet al.  , 5 favet al.  , 5. Thet al.  . Presenet al.  .Based on configuration and extent of ameloblastomatous component within the luminal cyst wall, four histologic subtypes of UAs are identified namely luminal UA subgroup 1), luminal and intraluminal UA (subgroup 1.2), luminal intraluminal and intramural UA (subgroup 1.2.3), and luminal and intramural UA (subgroup 1.3). Amongst these, subgroups 1.2.3 and 1.3 call for a more aggressive treatment approach like a radical resection owing to their high recurrence rates [ , luminalThe treatment of UAs is still being considered very controversial due to the incongruous use of the term “mural proliferation”  , which This case report highlights the role of histopathologic examination and serial section study from multiple sites of representative specimen as the most sensitive tool for precise diagnosis of UAs and also advocates the conservative treatment approach as the choice of treatment in young children combined with close long term follow up with satisfactory results.Authors would like to thank Dr. Harvey Thomas , Dr. Poorwa Sharma ) for their referral and help in enabling the authors to follow up this case.Authors declare that there are no conflicts of interest in this study.


Pericardial cysts are an uncommon, benign condition that can manifest with diverse clinical symptoms influenced by their size and position within the body. Detecting pericardial cysts typically relies on imaging studies for a conclusive diagnosis. Surgical removal remains the definitive treatment approach for addressing pericardial cysts. This case report presents the clinical course of a 56-year-old female with a known case of asthma, and rheumatoid arthritis (RA) which exhibited recurrent symptoms such as shortness of breath and cough with recurrent pleural effusion to be investigated for suspected empyema, encysted effusion, TB, or malignancy, leading to diagnostic challenges. Through a combination of reviewing the case's clinical history, imaging modalities, and diagnostic procedures, including serial computed tomography (CT) and x-rays, the accurate diagnosis of a pericardial cyst sized 4.4 cm x 10.5 cm x 6.2 cm was achieved. In this specific case, recurrent percutaneous pleural aspirations were attempted as a treatment approach for three years. However, despite these efforts, this method proved unsuccessful in effectively managing the patient's condition. Using minimally invasive techniques, video-assisted thoracoscopic surgery (VATS) proved valuable in providing effective diagnostic and therapeutic options with reduced invasiveness. Timely diagnosis, proper monitoring, and patient education contributed to the patient's overall recovery. Pericardial cysts (PCs) are rare intrathoracic lesions that arise from congenital causes or other etiologies such as inflammation, trauma, or complications of cardiac surgery . They haMost PCs, accounting for over 50%, are asymptomatic and are commonly discovered incidentally during medical evaluations or imaging studies . The cliWe present a fascinating case of a female with a large PC situated in an unusual location, mimicking the appearance of a pleural effusion on the left side. This case report aims to present a successful surgical excision of a giant PC.A 56-year-old female presented to King Fahad Specialist Hospital (KFSH)-Buraidah in January 2019 with complaints of shortness of breath (SOB) and persistent productive cough with white sputum for one week. High-resolution computed tomography (HRCT) of the chest reported the presence of a large left encysted pleural effusion. Previous medical reports in other hospitals indicated that she had experienced recurrent pleural effusion for five years without a definitive diagnosis. A thoracentesis of 500 mL was performed to tap the pleuritic fluid; the results were negative for acid-fast bacilli, showing moderate lymphocytes. The effusion was considered to be chronic parapneumonic. Pneumology OPD then followed the patient as a case of parapneumonic encysted pleural effusion and as a known case of asthma. The following month, a CT chest showed a mild pleural effusion on the left hemithorax, within the left central fissure and surrounding the left lingula. After three months, the patient was referred from the IM clinic to the rheumatology clinic. The patient respiratory symptoms improved, but she complained of bilateral hand stiffness and pain for five months, increasing in intensity and morning stiffness, and was diagnosed with seronegative RA. After six months, the patient returned with complaints of left pleuritic chest pain, aggravated by the right lateral decubitus position, and persistent SOB. An x-ray showed a suspected mild pleural effusion with obliteration of the left costophrenic angle , the patient visited the pneumology OPD hospital complaining of the same recurrent respiratory symptoms. Her CT report traced the condition as a moderate left pleural effusion with underlying lung collapse, which was misled to be an encysted or free pleural effusion, sometimes disappearing with complete evacuation and reappearing again.At this stage, the case was referred to the thoracic surgery department as a recurrent pleural effusion for pleural biopsy to confirm the diagnosis. Considering the clinical history of the recurrence of the effusion, the nature of the aspirated fluid (clear and watery), echocardiography imaging, and Serial CT results, which showed changes in shape, size, and position over time Figures -2c, a prA postoperative x-ray was done Figure . The patVATS is a minimally invasive surgical technique used in thoracic procedures that eliminates the need for a formal thoracotomy incision . DespitePCs, which occur in approximately one person per 100,000 and comprise 7% of all mediastinal tumors, are benign intrathoracic lesions . These cThe age distribution of PCs needs to be better defined. While there have been reported cases of PCs in individuals younger than eighteen, the literature predominantly consists of reports involving older patients; our patient said their age was 56. There are documented cases of PCs in various age groups, but the overall distribution across different age ranges remains to be determined [PCs commonly arise from congenital causes resulting from the incomplete fusion of mesenchymal lacunae during embryogenesis . This deDiagnosing PCs can be particularly challenging due to their infrequent occurrence, mainly when located outside the typical cardiophrenic angles . Also, tLiterature reviewNina et al. reported a 46-year-old female who presented with symptoms of mediastinal compression caused by a giant PC on the right side. The results of an echocardiogram initially suggested the diagnosis of a PC and were later confirmed by both a thoracic CT scan and nuclear magnetic resonance imaging. The imaging studies revealed a cyst measuring 13 x 9.5 cm. Surgical cyst excision was performed, leading to complete remission of symptoms during a 12-month follow-up period .This report was presented by Kaklikkaya, a case of a giant PC in a 39-year-old male. The cyst, measuring 22 × 15 × 7 cm, exerted pressure on the heart and lungs. Surgical excision of the cyst was performed through left-side thoracotomy. Following the procedure, the patient has remained asymptomatic for about nine years and appears to be in complete remission [Simsek et al. reported a case involving a 28-year-old man initially presenting with acute bronchitis. However, a chest x-ray led to a misdiagnosis of dextrocardia. Further evaluation with thorax CT revealed a large, well-defined mass measuring 6.4x9 cm in the middle mediastinum, suggesting a PC. Serial imaging studies showed no change in the size of the cyst over time, and the patient remained utterly asymptomatic during a 12-month follow-up period. As a result, surgical resection of the cyst was not executed, and conservative management was adopted .Hekmat et al. presented a case of a 24-year-old man who contributed to the emergency department with dyspnea and a persistent cough. Trans-thoracic echocardiogram showed an echo-lucent space adjacent to the right atrium at the right cardiophrenic angle, without any pericardial effusion. The patient subsequently underwent surgery, during which a large cyst measuring approximately 13 × 8 × 5 cm was found outside the pericardium on the right side. The cyst was excised entirely, and the patient was discharged after five days. The pathologic report confirmed the preoperative diagnosis of a PC [In a case by Makar et al., a unique presentation of a large PC was observed in a 43-year-old female patient. The patient presented with breathlessness and pleuritic chest pain, leading to the discovery of a large PC located adjacent to the right atrium. A follow-up CT scan showed a significant mass on the right side, extending into the right chest, measuring 5.1 cm × 9 cm × 4.3 cm. Due to the rapidly worsening symptoms, surgical resection was performed using VATS. The patient suffered the procedure well and experienced no postoperative complications .In a case study conducted by Li et al., a rare case of a large PC in a 36-year-old woman was reported. The cyst was located in an uncommon location, mimicking a unilateral pleural effusion. The diagnosis was confirmed, and resolution was achieved through VATS. During the VATS procedure, it was discovered that the previously presumed loculated effusion was, in fact, a PC. The cyst, filled with brown fluid, measured 10.5 cm × 2.5 cm × 2 cm in size. It originated from the lateral aspect of the pericardium near the left ventricle and was adhered to the lung and pleura. After successfully removing the PC, the patient's symptoms improved. A follow-up chest CT performed six months after discharge showed no evidence of recurrence. Based on this case, the study suggests that VATS is a feasible and safe method for treating symptomatic and large PCs .Although PCs typically have a benign course, complications have been reported, including cyst rupture, erosion into adjacent structures like the right ventricular wall or superior vena cava, cardiac tamponade, mitral valve prolapse, obstruction of the right mainstem bronchus, atrial fibrillation, and even sudden death . SurgicaThe management approach for PCs depends on several factors, including the presence of symptoms, complications, and the size and location of the cyst. In many patients, close monitoring with serial transthoracic echocardiography is sufficient to ensure a benign course and allow for potential spontaneous resolution of the PC. If intervention is necessary, treatment options include percutaneous aspiration, surgical intervention using VATS, or surgical excision -10,14. PWe presented a rare case involving a large PC in an uncommon site (left side). In the described case, the presentation mimicked a recurrent free unilateral pleural effusion, and thus, many attempts were made to perform percutaneous aspiration for further diagnostic workup, but this approach was unsuccessful. The definitive diagnosis was ultimately established through VATS and the process of mini-thoracotomy, which through the PC, was successfully removed. Therefore, VATS played a pivotal role in effectively establishing a precise diagnosis of the PC achieving a favorable outcome for the patient. This less invasive approach reduced surgical trauma, improved postoperative recovery, and proved especially beneficial for a patient with marginal pulmonary reserve.


Proliferating pilar tumors are rare, benign, exophytic neoplasms, which can closely resemble a squamous cell carcinoma. We describe a patient with a large benign exophytic tumor on the scalp that had been slowly growing over 10 years. While this class of benign follicular tumors is rare, the standard of care is typically excision with clear histologic margins. In this case, this large scalp tumor was surgically excised with clear margins/permanent section margin control using “Slow Mohs” technique, with subsequent repair using a skin substitute dressing, followed by a delayed skin graft. These tumors can also arise de novo and they may clinically resemble a squamous cell carcinoma. PTTs are benign follicular tumors that are classified under infundibular and/or isthmic differentiation, where the infundibular epithelium is indistinguishable from adjacent epidermis. It is characterized histologically as a partially cystic and solid lesion with increased keratinocyte size, abrupt keratinization, and the absence of a granular layer. They are more commonly observed in women over the age of 40, and 90% of cases are located on the scalp. Rarely, PTTs may differentiate into a malignant neoplasm, with the potential for metastasis.2 Wide local excision is the standard of care due to the potential for recurrence and risk of malignant transformation. As these tumors have the potential to grow large and lead to a significant surgical defect, the use of excision with margin control, such as Slow Mohs micrographic surgery technique, has the potential to be tissue-sparing.Proliferating pilar tumor (PTT) is a rare, benign, exophytic tumor that may sporadically proliferate from a preexisting trichilemmal cyst.A healthy 77-year-old woman presented with a 5-cm pink, dome-shaped, eroded exophytic tumor, over her right parietal scalp that had been slowly growing for 10 years . The tumPermanent section pathology revealed a keratinizing tumor with symmetrical architecture and a circumscribed, pushing border. There were multiple areas of abrupt keratinization, cystic ulceration, and calcification, consistent with a benign proliferating pilar  tumor  and 4.Two weeks later, examination revealed desiccated periosteum with no granulation of the wound bed. The outer cranial table was burred to spongy bone (diploë) and covered with a collagen-glycosaminoglycan biodegradable matrix (Integra)  . After 6415 The average size of the tumors was approximately 5 cm in diameter.415Most cases of benign PTTs located on the scalp involve patients who tend to be female and over the age of 55 years, with a few reports of patients being in their 20s.41114 There are no formal recommendations for margin size and depth in removal of either benign or malignant PTTs. Consequently, the margin size among these cases tended to be arbitrary and considered to be surgeon dependent, with some stating 1 cm is sufficient while other articles proposed that 2 cm is ideal as a precaution to avoid local recurrence.41114 Benign PTTs typically grow in size between 2 and 10 cm in diameter, but they have the potential of growing as big as 25 cm; by adding an additional margin size this will only create a larger defect and thus a more difficult closure. In one report, radiotherapy was used to clear several small nodules on the scalp that were considered unresectable, after previous surgical removal.This case report is congruent with the typical patient profile for a benign PTT. Slow Mohs technique with meticulous, mapped, and oriented permanent section margin control, was used to excise the tumor, with histologic examination by a pathologist. A wide excision (with variable margins) is the standard procedure for removing benign PTTs according to the current literature, with over 75% of the case reports opting for this method. “Slow Mohs” technique with mapped permanent section margin control was chosen for this large scalp PTT to ensure clear margins, preserve healthy tissue, and shorten the procedural time for the patient. There are few case reports of Mohs surgery for PTT in the literature. Tierney et al. described Mohs surgery for a PTT, but due to the large defect size, a tissue expander was used for reconstruction. Alarcón et al. described two cases of PTT treated with Mohs surgery, both with free margins after the second stage.Mohs micrographic surgery utilizes precise frozen section histologic margin control to remove skin cancers while maximizing tissue preservation. Mohs micrographic surgery with frozen sections, or a modified Slow Mohs technique with permanent sections, has the advantage of histologic margin control for the removal of scalp PTT. Mohs surgery preserves functionally and aesthetically important scalp tissue, by examining all histologic margins, identifying any potential subclinical extensions of PTT, thereby reducing the risk of PTT recurrence.Complete excision of PTT is essential to avoid tumor recurrence. Rarely, PTT has the potential for malignant transformation, with ulceration, bleeding, rapid growth, infiltration into the outer cranial table, and potential metastases to the cervical lymph nodes.


Angiomyofibroblastoma is a benign soft tissue tumor and a form of genital stromal mesenchymal tumor that primarily affects the vulva. It could possibly affect the reproductive‐aged women's lower genital tract (vagina).Angiomyofibroblastoma is a rare benign soft tissue tumor primarily affecting the vulva in reproductive‐aged women. We report a 67‐year‐old female complaining of a painless mass in her right vulva spreading to the right inguinal region over the past 2 years. The first clinical impression was a canal of Nuck hernia, diagnostic laparoscopy was planned to rule hernia out. The vulvar mass was excised, and a histopathology examination revealed Angiomyofibroblastoma. A mass in the right major labia spreading to the right inguinal. It could possibly affect the reproductive‐aged women's lower genital tract (vagina). Clinically, it frequently appeared as a benign, painless enlargement of the vulva, but rarely other manifestations such as foul‐smelling secretions, menorrhagia, and dyspareunia have also been seen. This tumor's first case series was published by Fletcher et al.In this article, we report a case of AMF. Toward a better understanding of this tumor and its histopathology as well as an investigation of its differential diagnosis, we manage to conduct this article. Our work has been documented according to the CARE guidelines.22.1A 67‐year‐old white married female was referred by a gynecologist to our department for complaining of a painless mass in her right vulva spreading to the right inguinal region without any other symptoms from the past 2 years Figure . The masShe was systemically well on the examination. Her vital signs and abdominal examination were normal. There was an approximately 12 cm painless mass in the right vulva spread to the right groin. The right groin was quite prominent and the hernia was first considered as a diagnosis. No signs of infection or inflammation and lymphadenopathy were observed. Internal genital organ examination was normal. An ultrasound of soft tissue demonstrated a hypoechoic solid mass with specific borders in size of 90*44*55 mm located in the right major labia which was extended to the right inguinal , and estrogen receptors (ER). CD34 for spindle cells was negative whereas on thin‐wall vessels was positive. Based on these features, the pathological impression indicated Angiomyofibroblastoma.2.4The patient visited 1 week after surgery. Her vital signs were normal and there was no evidence of hematoma or infection at the surgical site. In an oncology consultation, it was confirmed that the mass is completely benign and there is no need to perform any other treatments. After 3 months, our patient remained well and asymptomatic.3In this report, we discussed AMF of the vulva in a 76‐year‐old woman that was doubted to be a canal of Nuck hernia. The labia majora is the site of the canal of Nuck hernias, which is caused due to the continuous protrusion of the parietal peritoneum into the inguinal canal.Vulvar AMF is an uncommon, painless, and benign mesenchymal neoplasm with a great prognosis. However, it might turn into malignancy.Although speculative, most scholars believe that the disease may originate from stem cells.The immunohistochemistry profile of AMFs is nearly positive for vimentin, desmin, progesterone, and estrogen receptor. But SMA expression in the tumor cells varies.Even though aggressive angiomyxoma (AA) is the first differential diagnosis that comes to mind, other mesenchymal tumors, hydrocele of the canal of Nuck, Bartholin's cyst, leiomyoma, inguinal hernia, cellular angiofibroma, and fibroepithelial stromal polyp need to be considered either.Like our case, several investigations claimed that ultrasonography might be useful for the diagnosis of AMF since it can identify the exact borders of AMF. Soft tissue with a hypoechoic mass and a partially visible blood flow signal inside the mass can also be provided by ultrasonography. The definitive diagnosis is finally confirmed by postoperative pathological examination. Currently, no drugs are available to treat AMF, and surgery is preferred.Regarding the unknown and different characteristics of vulvar AMF, opinions, and clinical approaches are controversial. For instance, Akhtar et al presented a 25‐year‐old woman with a 1.5–2 cm, painless, cystic lesion over the labia minor that was initially thought to be a Bartholin's cyst which has gradually grown in size in the past 2 months.Due to the small number of patients and limited accessible follow‐up data, the long‐term clinical activity of AMF, the role of hormones on tumor formation, and the consequences of gynecological procedures as risk factors are not yet obvious and further studies need to be done in this field.Negar Einafshar: Writing – original draft. Mahta Shari'at Moghani: Writing – original draft. Mahsa Radboy: Writing – original draft. tooraj Zandbaf: Conceptualization; supervision; writing – review and editing.The authors declare that they have no competing interests.The patient's written consent was obtained for the publication of this case report.