One of the most concerning causes of abdominal pain affecting children is acute appendicitis. However, there are benign conditions that can closely mimic appendicitis in children. In this article, we present a case of a child admitted for possible acute appendicitis and determined to have a condition known as omental infarction. The patient was managed medically and made a full recovery without surgical intervention. The aim of this case report is to review omental infarction and present a way of differentiating this disease from appendicitis, utilizing imaging, with the goal of avoiding surgical intervention. We also discuss the presentation and imaging findings of and another closely related condition—epiploic appendagitis. It is important to differentiate appendicitis from these 2 conditions as they can be often managed medically without surgical intervention. Clinically, omental infarction often presents similarly to acute appendicitis with right lower quadrant (RLQ) tenderness, leukocytosis, elevated C-reactive protein (CRP), and anorexia. Differentiating between the two pathologies is difficult, and the majority of omental infarctions are diagnosed during surgical exploration of the abdomen for possible appendicitis revealing a normal appendix and necrotic omentum.An overweight 9-year-old Hispanic male with no significant past medical history presented to the emergency room with 2 days of mild, persistent RLQ abdominal pain and tactile fevers for 1 day. The pain was initially intermittent, nonradiating, and mild on the pain scale, and was relieved by Pepto-Bismol. On the day of admission, the pain became constant, moderate, and was aggravated by walking, causing the patient to limp. Over the prior 2 days, he continued to attend school despite his abdominal discomfort. However, his mother noted that, while normally an avid eater, he had been avoiding food and had a reduced appetite. He complained of some nausea on the day of admission, but denied any prior nausea, emesis, or change in bowel habits.On physical examination, the patient had stable vital signs and was in no acute distress. His abdomen was soft and nondistended. There was mild tenderness, localized to the RLQ, without peritoneal signs. He had no tenderness at McBurney’s point and negative psoas and Rovsing signs. An obturator’s test did elicit mild pain. Laboratory workup showed a leukocytosis 14 400 cells/µL with elevated CRP 109.6.In the absence of classic signs of appendicitis with high inflammatory markers, the patient underwent computed tomography (CT) imaging to look for other intraabdominal pathology and to rule out appendicitis. Abdominal CT revealed a normal appendix and moderate inflammation of fatty structure surrounding the anterior ascending colon with mesenteric edema and pelvic ascites. These findings and a benign appendix suggested omental infarction versus epiploic appendagitis. However, CT findings of the latter would more likely show fatty inflammation of an oval-shaped paracolic mass, although definitive differentiation based on imaging may be difficult.The patient was hospitalized and placed on intravenous fluids. Pediatric surgery was consulted, who supported a diagnosis of omental infarction. No surgical intervention was recommended. The patient was placed on complete bowel rest with serial abdominal examinations to rule out progression to overt appendicitis, given the location of the pain in the context of leukocytosis with elevated CRP. Serial abdominal examinations showed slow improvement in his discomfort over the next 24 hours with no need for pain medication. After 24 hours of inpatient stay, our patient was able to walk and even jump without significant pain. Abdominal examination showed decreased tenderness of the RLQ compared with admission and no peritoneal signs. The patient was started on a clear liquid diet and advanced to regular diet, which he tolerated without any nausea or vomiting. He was discharged home with the recommendation to take over-the-counter ibuprofen for pain control and to return if symptoms worsened.3 Rotation of the stomach during embryonic development leads to division of the omentum into a greater and lesser sac. It serves a protective function for the intestinal tract in cases of infection or injury such as a bowel wall perforation. Inflammation of the bowel causes adhesion to the omentum, thereby containing the disease process and preventing peritoneal spread.The omentum is a fold of peritoneum containing vasculature, lymphatics, and fat arising from the intestinal mesentery.4 Omental infarction is an uncommon and underrecognized cause of abdominal pain in children. Obesity is a significant risk factor in the pathogenesis of omental infarction. The relative paucity of intraabdominal fat and omental mass, especially in early childhood, is likely the explanation for lower incidence in children .4 Omental infarction is estimated to be the cause of acute abdominal pain in children 0.1% of the time.5While omental infarction has been well described in the adult literature, only a few case reports exist describing its presentation in children.6 In the majority of cases, there is involvement of branches off the right gastro-epiplopic vessels, causing localized pain of the right lower abdomen.3 In secondary omental infarction, torsion is due to trauma, surgical intervention, or abdominal pathology such as the presence of a cyst or tumor.6In both adults and children, infarction and necrosis of omental tissue due to torsion or thrombosis of omental vasculature leads to acute, sterile inflammation and pain.7 This is related to the hypothesis that an increase in fat of the redundant omentum may predispose it to twisting. Alternatively, there may be a relative ischemia of the extra fatty tissue leading to thrombosis.4Risk factors for primary omental infarction in children include being of male gender and overweight, body mass index >85th percentile. Since obesity seems to be the most important risk factor for the development of omental infarction, the increasing rates of childhood obesity may explain the increasing prevalence of omental infarction in the recent literature.A diagnosis of omental infarction requires a high index of suspicion when a pediatric patient presents with atypical findings for acute appendicitis. In the case of our patient, his abdominal pain was not as severe as seen in appendicitis, reaching a maximum level of moderate pain on the pain scale, and the progression of his pain was very slow over the 2 days prior to presentation. His pain was constant and localized to the RLQ from its onset. On physical examination, he lacked the classic signs of appendicitis. This led to a consideration of other possible causes, using imaging with the aim of preventing a surgical procedure. In this case, we were able to identify a normal appendix on CT imaging as well as the inflammation surrounding the ascending colon. This led to the diagnosis of omental infarction, a benign and self-limited condition, which allowed the patient to be managed without surgical intervention.4 Failure to improve or worsening of symptoms is an indication for surgical resection. Primary surgical intervention of the infarcted tissue can speed recovery and decrease the risk of abscess formation, but is not necessary.4The disease process is self-limited and management is conservative with bowel rest, pain control, and intravenous hydration. Most patients will improve progressively over the course of days.16 Compared with classical appendicitis, children with omental infarction present without fevers, gastrointestinal symptoms like nausea and vomiting, or pain originating periumbically.4Differentiation of omental infarction from acute appendicitis is difficult clinically, and imaging can be key in establishing its diagnosis. Children present with acute-onset lower abdominal pain, which progressively worsens but remains localized. The pain is right-sided in 80% of cases. Children may also have leukocytosis, elevated CRP, and anorexia.8 It will show a well-circumscribed, inflammatory mass located between the anterior abdominal wall and right colon with a normal appendix.9 Size of the mass varies depending on the patient’s weight. Similar to other inflammatory pathologies of the abdomen, fat stranding is present. However, compared with appendicitis or diverticulitis, there is greater fat stranding relative to bowel wall thickening since the pathology originates within the fatty omentum and the bowel wall is often spared.10 The inflammatory mass may adhere to the parietal peritoneum and a free effusion may be seen.11CT is highly sensitive (90%) and is considered the gold standard for the diagnosis of omental infarction.12 Abdominal ultrasound is only reported to be 60% to 80% sensitive, but is highly specific for the diagnosis of omental infarction, and it does not require radiation exposure.13 Furthermore, ultrasound can be used to follow the patient for infarct resolution in cases of conservative management. Ultrasonography would show an oval-shaped, noncompressible, hyperechoic mass within the omentum at the point of maximal tenderness.14 The mass may adhere to the abdominal wall depending on severity of inflammation, and free peritoneal effusion may be present.11 Visualization of a normal appendix on ultrasound can exclude appendicitis immediately.2 In cases where the ultrasound shows a possible omental infarction, but an appendix cannot be identified, low-dose CT imaging can be used to confirm the presence of a normal appendix. Alternatively, in one study, when the appendix was not identified on ultrasound, patients were taken for diagnostic laparoscopy in order to avoid CT ionizing radiation.2In the case of children, CT imaging is not preferred due to ionizing radiation exposure, and abdominal ultrasound becomes our best tool.15 Epiploic appendagitis can occur primarily due to torsion of the appendage or spontaneous thrombosis of a vein or, secondarily, due to a localized inflammatory process such as appendicitis or diverticulitis.1517 Patients present with a subacute lower abdominal pain, left-sided in 60% to 80% of cases, without nausea or diarrhea.18 White blood cell count and CRP are usually normal, though may be mildly elevated.15 Due to its more common left-sided presentation, epiploic appendagitis is more often mistaken to be diverticulitis than appendicitis.19Another mimicker of acute appendicitis in children worth mentioning is epiploic appendagitis, a similar benign process due to infarction of an epiploic appendage. These are 0.5- to 5-cm long, fat-filled, peritoneal sacs off the colonic wall thought to have a protective function for the colon.16 CT imaging will also show the ovoid, paracolic mass with a fatty core surrounded by fat stranding. Adjacent bowel wall inflammation is not usually present.1921 The mass is smaller in size, given the size of an epiploic appendage compared with the omentum, and abuts the colon.19 Epiploic appendagitis is also managed conservatively with nonsteroidal anti-inflammatory drugs for pain control. Surgical intervention is avoided unless conservative management fails or a complication such as obstruction or abscess develops.15Imaging results are very similar to those seen in omental infarction. Diagnostic laparoscopy may be the only definitive way to differentiate the pathology, but is not necessary for management of the disease. Ultrasound would reveal an oval-shaped, noncompressible, hyperechoic mass.Omental infarction is an uncommon cause of acute abdominal pain in children, and its presentation can mimic the more prevalent and serious condition of acute appendicitis. Earlier diagnosis of this benign disease using a high index of suspicion and proper imaging can prevent a potentially unnecessary surgical procedure in children. It should be suspected in overweight children with localized RLQ abdominal pain in the absence of other findings consistent with typical appendicitis.


Mycobacterium tuberculosis sensitive to isoniazid and rifampin. First-line antituberculous treatment was given with good response. Mycobacterial cultures were positive on the clinical specimens. HIV infection and pulmonary tuberculosis (TB) were not found.A 72-year-old man with diabetes and hypertension presented with 6 months of night sweats, fever, hyporexia, malaise, 12-kg weight loss, and a rapidly growing fluctuant mass over the sternum. He had received various empiric antibiotics  without improvement. Physical examination showed a cachectic man not in distress. Cervical lymphadenopathy and a 10-cm fluctuant presternal chest wall mass were present; there was a fistula draining non-fetid purulent material . The rem2 Differential diagnosis includes pyogenic abscess due to Staphylococcus aureus and actinomycosis, and where are endemic, histoplasmosis and botryomycosis. Final diagnosis is based on radiological findings and microbiological and histological examination of the debrided tissues, and should include special stains, cultures, and molecular diagnostics. Management is similar to other forms of extrapulmonary TB.3Tuberculosis remains a significant global cause of morbidity and mortality, especially in the developing regions. Primary tubercular sternal osteomyelitis is rarely described. A painful mass over the anterior chest wall and signs of soft tissue inflammation and fistula are typical findings, representing delayed diagnosis. Spontaneous sternal fracture, extrasternal spread, and acute inflammatory response (sepsis or septic shock) have also been described.


Neuroendocrine tumours are epithelial neoplasms with predominant neuroendocrine differentiation. The nasal cavity and paranasal sinuses are rare locations for neuroendocrine carcinomas, and only a few related papers have been published in the literature to date. Here we present the case of a 64-year-old male with neuroendocrine carcinoma of the sphenoid sinus, along with the main MRI findings. A 64-year-old male presented to the otorhinolaryngologist with a 2-year history of a continuous, daily, frontal headache associated with left earache. The patient showed no otorrhoea, hearing loss or bleeding from the ear.T1 and T2 imaging, with moderate and homogeneous contrast enhancement. The lesion occupied the bilateral sphenoid sinus in a symmetrical or pigeon-like pattern, with bone destruction of the clivus and the floor of the sella, involvement of the internal carotid arteries and infiltration of the cavernous sinuses, especially on the right side , moderately differentiated  and poorly differentiated . The prognosis is worse for less-differentiated neoplasms.4 Neoplasms are far less common when only the sphenoid sinus is involved, constituting approximately 2%–3% of paranasal sinus tumours.7Tumours—neuroendocrine included—of the nasal cavity and paranasal sinuses are rare, representing 0.2–0.8% of all cancers and 1–3% of head and neck carcinomas.8 in 1982. This tumour is rare and published literature on the subject is scarce.6 It affects mainly older patients (fifth and sixth decades) and is slightly more frequent in males.1 The most common sites involved are the ethmoid sinuses and the nasal cavity.6 Distant metastases are uncommon, and mostly occur in the brain and spine.4 The most frequent symptoms of sinonasal neuroendocrine neoplasms include nasal obstruction, epistaxis and nasal drainage, which are non-specific, often delaying the diagnosis and appropriate treatment. The majority of patients present with advanced-stage disease.6Sinonasal tract NEC was first categorized by Silva et al2Contrast-enhanced MRI and CT scan are not usually definitive of a primary sphenoid neoplasm, although some findings may be suggestive, especially retrospectively. An MRI provides detailed information on the relationships between the tumour and the surrounding structures; therefore, this technique is superior in assessing dural invasion, and perineural and arterial encasement. CT scans with multiplanar reconstructions, on the other hand, are more useful in characterizing the degree and extent of bony erosion.7 reported 19 cases of small cell NEC of the paranasal sinuses. In this study, the authors describe a symmetrical or pigeon-like pattern in the bilateral sphenoid sinus, suggesting that this may be considered as a specific MRI feature of this subtype of tumour. In the present case, we found the same pattern on MRI (In 2015, Zhu et aln on MRI .1 Only a small number of papers have been published in the literature, making it challenging to identify adequate treatment approaches.6 Pathological differentiation may not be an imperative aspect in the clinical management of this disease.5 Surgery, radiotherapy and chemotherapy, alone or in combination, have been suggested and used in the past.1 Multimodal approaches for NECs of the head and neck have been suggested in recent studies.5There is no consensus on the treatment of sinonasal NECs.NECs of the nasal cavity and paranasal sinuses are rare tumours, and published literature on the subject is scarce.7A symmetrical or pigeon-like pattern in the bilateral sphenoid sinus may be considered as a specific MRI feature of NECs in this topography, as suggested by Zhu et al.Written informed consent was obtained from the patient for publication of this case report, including accompanying images.


Synovial cyst of the proximal tibiofibular joint is a very rare condition, for which there is no consensus regarding treatment. Two macroscopic forms may be encountered: extraneural cysts and intraneural cysts. We present the cases of two patients who had synovial cysts of proximal tibiofibular joint that caused peroneal nerve palsy. We discussed the special features of synovial cysts and reviewed the literature. We considered the best treatment of synovial cysts originating from proximal tibiofibular joint and causing peroneal nerve palsy to be a total surgical removal as soon as possible after the diagnosis is made. However, follow-up is needed because recurrence is possible. It should be kept in mind that despite surgical treatment the neurological symptoms may not recover. Synovial cysts are benign soft-tissue tumors that arise from synovial joints or tendon sheaths. They are usually seen in popliteal and dorsal wrist localizations. The Proximal Tibiofibular Joint (PTFJ) is an unusual localization for synovial cysts, first reported by Lenander in 1891 , 3. Two A 42-year-old man consulted the neurosurgery department complaining of slight back pain and right drop-foot. His physical examination showed paresis of the tibialis anterior, lateral peroneal and extensor digitorum muscles with a muscle strength grade 2. Diagnosis was thought as a lumbar disc herniation and Magnetic Resonance Imaging (MRI) was carried out. It showed bulging of L4-L5 and L5-S1 and no disc extrusion. Electromyographic investigation showed that the common peroneal nerve was affected at the knee level. The patient was referred to our orthopedic department. He had neither knee pain nor history of trauma to his knee. Physical examination of right knee showed no abnormality other than tenderness around the fibular head. He had no palpable mass. The radiography was normal. MRI of the knee revealed a 48×20×12mm soft tissue mass with clear borders localized at the anterior of proximal tibiofibular joint with poor visualization of the common peroneal nerve . IntraopThe second case is about a 29-year-old woman who was admitted to the orthopedic department complaining of swelling and pain at her left knee and total loss of ankle active dorsiflexion. She had symptoms for 2 months and no history of trauma. Physical examination of the knee showed slight swelling at the fibular head but no palpable mass. In neurological examination, all motor functions of common peroneal nerve were lost. MRI showed an 85×24×10mm multi-compartmental cystic formation at the anterolateral side of fibular head and communicating at its superior pole with the proximal tibiofibular joint by a thin 2mm pedicle . Intraopet al. in a study of 645 MRIs knees, found that their prevalence was 0.76% [et al. [According to the recent literature, only 73 cases of peroneal nerve palsy caused by cysts of the Proximal Tibiofibular Joint (PTFJ) have been reported since 1981 . However [et al.  stated t [et al. , 12. We  [et al. . On exam [et al. , 15. If The imaging method for diagnosis and differential diagnosis is MRI , 17. ThePeroneal nerve palsy caused by a synovial cyst of the Proximal Tibiofibular Joint (PTFJ) is a very rare disease which must be considered if the patient presents neurological abnormalities of the lower leg. Although there is no consensus on the treatment of this rare condition, we think that total surgical removal of the cyst is the best alternative if the patient has neurological symptoms. The pedicle should be cut to save the patient from recurrence. Recovery rates are sometimes unclear since they depend on the date of the operative treatment and on the kind of preexisting nerve injury.The authors declare no competing interests.


Inflammatory myofibroblastic tumor (IMT) is a rare proliferative disease of uncertain etiology, characterized by the proliferation of fusate or epithelioid myofibroblasts admixed with predominantly mononuclear inflammatory cells. IMT is generally considered a benign lesion, although in some cases this neoplasm has shown an aggressive behavior in terms of local recurrence and metastasis. We report the case of a patient with a ten-year history of ulcerative colitis affected by IMT of the transverse colon and by synchronous gastrointestinal stromal tumor (GIST) of stomach.A 59-year-old woman with a ten-year history of ulcerative colitis has been admitted to our hospital with signs and symptoms of acute recurrence of ulcerative colitis: abdominal pain, diarrhea, hematochezia and rectal tenesmus. Colonoscopy showed a left colon with diffuse hyperemia, mucosal erosions and a 2-cm, irregularly shaped, polypoid lesion at the level of the transverse colon. Histopathological examination of the specimen obtained via biopsy of the polypoid lesion has revealed a mesenchymal neoplasm with uncertain characters of malignancy. Due to the severity of the inflammatory bowel disease resistant to immunosuppressive and steroid drug treatment, surgical indication was given.Although the relationship between IMT and Crohn’s disease has been widely reported in literature, the relationship between IMT and ulcerative colitis has never been previously described.To the best of our knowledge, this is the first case of IMT associated with ulcerative colitis reported in literature and the synchronous association with a gastric GIST represents another primacy. The mosMicroscopically, the IMT consists in the proliferation of fusate or epithelioid myofibroblasts admixed with predominantly mononuclear inflammatory cells . The diaSurgical resection is the treatment of choice . To dateWe report a case of inflammatory myofibroblastic tumor in a patient with synchronous gastrointestinal stromal tumor (GIST) and ulcerative colitis.This work has been reported in line with the SCARE criteria .2A 59-year-old woman with a ten-year history of ulcerative colitis, a previous episode of cytomegalovirus colitis and suffering from arterial hypertension and atrial fibrillation, has been admitted to our hospital with signs and symptoms of acute recurrence of ulcerative colitis: abdominal pain, diarrhea, hematochezia and rectal tenesmus. Laboratory analysis showed microcytic hypochromic anemia and neutrophilic leukocytosis. Colonoscopy showed a left colon with a tubulized appearance without haustra associated with diffuse hyperemia, mucosal erosions and a 2-cm, irregularly shaped, polypoid lesion at the level of the transverse colon. Histopathological examination of the specimen obtained via biopsy of the polypoid lesion has revealed a mesenchymal neoplasm with uncertain characters of malignancy. Contrast-enhanced computed tomography (CT) of the thorax and abdomen revealed an inhomogeneous hypodense nodule formation of 2.5 × 1.6 cm in diameter, with intense enhancement in the arterial phase localized to the middle-distal transverse colon .Fig. 1CoDue to the severity of the inflammatory bowel disease resistant to immunosuppressive and steroid drug treatment, surgical indication was given. It was therefore decided to proceed with a total colectomy with terminal ileostomy. The exploratory laparotomy revealed the presence of an unknown exophytic mass in the anterior stomach wall, which was removed. No postoperative complications were reported and the patient was discharged 7 days after surgery. In the following months, a proctectomy with ileoanal anastomosis (J-pouch) was performed. Ileostomy reversal was performed one month after the last surgery.Histological examination of the colon revealed the presence of an ulcerated polypoid lesion of 2 × 2.8 cm in diameter surrounded by a mucosa with increased consistency and velvety surface extended for 3 cm . MicroscThe lesion was subjected to immunohistochemical staining which showed focal positivity for SMA, negativity for cytokeratin, desmin, S-100, Melan-A, CD34, CD117, DOG-1, CD21, CD23, CD1a and ALK. Based on these findings IMT diagnosis was confirmed.Histopathological examination of the gastric lesion revealed a GIST.A surveillance approach was decided, and the thoracic-abdominal CT scan performed 6 months after surgery showed no evidence of disease recurrence.3Historically, the terms "inflammatory myofibroblastic tumor” (IMT), "inflammatory pseudotumor" (IPT) and "plasma cell granuloma" (PCG) have been used as synonyms or interchangeably. Nowadays the common use of the same name to identify these different entities has been criticized . In factAccording to a recent review reporting the most common sites of IMT, colon-rectum is the fifth abdominal site most commonly affected. It is preceded only by liver and biliary tract, spleen, peritoneum and stomach. Jejunum-ileum, duodenum, pancreas and esophagus were reported as less commonly affected sites . The mosTo the best of our knowledge, this is the first case of IMT of colon associated with synchronous ulcerative colitis and gastrointestinal stromal tumor (GIST) of stomach reported in literature.To date, only five cases of IMT – three in liver, one in pancreas and one into the cerebellum - associated with Crohn’s disease have been reported . AlthougHistorically, the term gastrointestinal stromal tumor (GIST) identified a heterogeneous group of neoplasms of the gastrointestinal tract originating from the precursors of the interstitial cells of Cajal . To date4IMT is a rare pathology with uncertain etiology, on the edge between neoplasia and inflammatory proliferative reaction. Although the relationship between IMT and Crohn's disease has been widely reported in literature, the relationship between IMT and ulcerative colitis has never been previously described. To our knowledge, the synchronous association between IMT of colon and gastric GIST represents another primacy in literature.The double uniqueness of association  referred to in this case-report makes it difficult to draw conclusions that can be useful in clinical practice. For this reason, comparison with other future similar case-reports are necessary.All authors have no conflicts of interest to declare.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This study did not require ethical approval as it was exempt in our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Raffaeli Eugenia: Conceptualization, Writing – Original Draft, Writing – Review & Editing, Visualization. Luca Cardinali: Conceptualization, Writing – Original Draft, Writing – Review & Editing, Visualization. Maurizio Fianchini: Visualization. Donatella Brancorsini: Visualization. Piergiorgio Mosca: Visualization. Cristina Marmorale: Visualization, Supervision.This paper is a clinical report, no research involved.Cristina Marmorale.Not commissioned, externally peer-reviewed.


Intra-cranial and spinal foreign body reactions represent potential complications of medical procedures. Their diagnosis may be challenging as they frequently show an insidious clinical presentation and can mimic other life-threatening conditions. Their pathophysiological mechanism is represented by a local inflammatory response due to retained or migrated surgical elements. Cranial interventions may be responsible for the presence of retained foreign objects represented by surgical materials . Spinal diagnostic and therapeutic procedures, including myelography, chordotomy, vertebroplasty, and device implantation, are another potential source of foreign bodies. These reactions can also follow material migration or embolization, for example in the case of Lipiodol, Teflon, and cement vertebroplasty. Imaging exams, especially CT and MRI, have a central role in the differential diagnosis of these conditions together with patient history. Neuroradiological findings are dependent on the type of material that has been left in or migrated from the surgical area. Knowledge of these entities is relevant for clinical practice as the correct identification of foreign bodies and related inflammatory reactions, material embolisms, or migrations can be difficult. This pictorial review reports neuroradiological semeiotics and differential diagnosis of foreign body-related imaging abnormalities in the brain and spine. Intra-cranial and spinal foreign body reactions represent rare medical procedure complications.These entities can be incidentally found or investigated due to clinical manifestations.Local inflammatory reactions, material embolisms, and migrations are possible pathophysiological mechanisms.CT and MRI have a key role in their differential diagnosis.Information concerning previous procedure and employed materials is essential as imaging findings depend on material characteristics.Intra-cranial and spinal foreign body reactions are rare but possible complications of some diagnostic and therapeutic procedures. Due to the frequently insidious onset, nonspecific clinical evolution, and their potential to mimic potentially life-threatening conditions, such as hematomas, neoplasms, radiation necrosis, abscesses, and resolving infarctions, it is important to recognize their imaging findings. These abnormalities can be caused by local inflammatory response either to the post-operative presence of a foreign body in the surgical field or its localization in the central nervous system after mobilization from a different region.These entities can be incidentally found during exams performed for other indications or in relation to clinical manifestations related to their localization. While first-line imaging exams, such as radiographs, might allow for the detection of some foreign bodies, often other modalities are required for their characterization. Computed tomography (CT) has a high spatial resolution and can detect hyperdense or adipose components, including metallic elements. On the other hand, magnetic resonance imaging (MRI) also allows a more accurate assessment of changes in tissues adjacent to the foreign body. Similarly, contrast agent administration aids in the evaluation of inflammation.In this review, neuroradiological semeiotics and differential diagnosis of foreign body-related imaging abnormalities in the brain and spine are presented. Infective complications are not included as there is little overlap in imaging signs with reactive alterations.During cerebrospinal surgery, implements made up by different materials may be employed, such as surgical sponges, bone wax, Teflon for suture or micro-vascular decompression, and catheters. Although inert, their intentional or unintentional permanence in the surgical field can lead to inflammatory reactions, especially for non-absorbable materials –3. This Granulomas can be localized either intra- or extra-axially. Intra-axial ones appear on CT as well-circumscribed masses with capsular enhancement and a variable amount of vasogenic edema in the surrounding brain tissue. MR shows a mass with heterogeneous signal on T1w, central hyperintensity with peripheral hypointensity on T2w images, and post-contrast ring-enhancement , 8. ExtrRegarding more advanced MRI techniques, granulomas show no increase of relative cerebral blood flow on perfusion maps while a mild increase of the choline/creatine ratio has been reported on spectroscopy. These two features are important in the differential diagnosis with neoplastic lesions , 11. In Surgical sponges are classified as absorbable  and non-absorbable (cotton or gauze). The latter may present characteristic imaging findings when containing radiopaque filaments. These appear as curvilinear hyperattenuating structures on CT. In MRI, they are characterized by chemical shift artifacts, though not always easily detectable due to the concomitant presence of blood products and air within the surgical area Fig.  14].Fi.Fi14].Bone wax is a mixture of different oils, such as beeswax, Vaseline, and paraffine, and is used to control bleeding from bone surfaces. Even though it is considered safe, in rare cases, it has been associated to chronic inflammation, fibrosis, and granuloma formation . On CT, Bone wax granulomas more frequently determine compression on adjacent structures, and, in some cases, the associated hypersensitivity reaction may be particularly aggressive Fig. . For insSurgical sutures can be made using a wide variety of materials, including Teflon, steel wires, silk, and cotton . These aTeflon is heterogeneously hypointense on T2w images and frequently detectable in the cerebellopontine angle region, as it is commonly used to treat trigeminal neuralgia and hemifacial spasm caused by neurovascular conflict . UnfortuVentricular shunting is the most frequent treatment of hydrocephalus. It is usually performed by external ventricular drain or placement of proximal ventriculostomy and distal peritoneal catheters, a pressure-sensitive valve, and a reservoir. The proximal catheter is easily depicted with both CT and MRI, with peripheral gliosis frequently detectable and possible subtle enhancement Fig. . One of Diagnostic and therapeutic spinal interventions may also cause inflammatory reactions and lead to granuloma formation. Adhesive arachnoiditis is a rare complication of myelography and fluoroscopy-guided cordotomy, which were frequently performed with Lipiodol in the past years. It consists of a local inflammation of the arachnoid with adhesive radiculitis. This determines a tethering effect of the spinal cord with subsequent rise of intraspinal pressure and cerebrospinal fluid dynamic alterations, leading to syringomyelia and myelomalacia . Early sAmong therapeutic spinal interventions, intrathecal drug therapy is often employed for pain relief in patients who are not responsive to systemic painkillers. Although rare, granuloma formation is possible, in particular when high doses of morphine are used .Vertebroplasty is considered a safe procedure with few complications, even when polymethylmethacrylate leakage occurs. Although rare, it has been associated to radiculitis which could be not only determined by nerve root mechanical compression but also by heat and chemical irritation . PolymetFinally, silicon and polyethylene terephthalate-based devices for intravertebral assisted motion, used as a dynamic stabilizer for untreatable back pain, can lead to granuloma formation mostly due to friction caused by the continuous movements of the lumbar spine. On MRI, thecal sac compression, foraminal stenosis, and fluid collections around the device are usually detectable .Bone wax migration has been described especially after posterior fossa craniotomy where it is used to avoid excessive venous bleeding from emissary veins. When it occurs, a filling defect within the sigmoid sinus both in CT and in MRI is detectable, often extending through the mastoid emissary vein, best depicted with CT and MR angiography. It can often be totally asymptomatic , 30. On Liquid silicon oil is routinely used as an intraocular tamponade agent for retinal detachment treatment. It appears as hyperdense on CT and T1w-hyperintense and T2w-hypointense with a chemical shift artifact on MRI Fig. . On MR sLipiodol is an iodized poppy seed oil which has multiple uses in medicine. It is mostly employed as radiopaque contrast agent or embolic material during procedures like transcatheter arterial chemoembolization or lymphatic embolization. A rare but potentially fatal complication is cerebral Lipiodol embolism. In this setting, CT shows multiple bilateral markedly hyperdense lesions . A rare After cardio-thoracic surgery, non-tissue embolism has been reported. From the study of Torre et al., it emerged that 8 of 24 pediatric patients who underwent invasive cardiovascular procedures had foreign body brain embolism. It was associated to different degrees of chronic inflammation. In this setting, cardiac catheters with hydrophilic polymer coating have been identified as the main source of embolism . Emboli A possible but rare source of embolism is represented by vertebroplasty Fig. . In thesA thorough knowledge of the patient’s clinical history and the surgical procedures he has undergone is essential to make the correct diagnosis of the above-mentioned abnormalities. However, the differential diagnosis can often be particularly complex, and the use of advanced techniques and controls over time can be useful. Sometimes, a surgical revision may be necessary to resolve the diagnostic doubt. In our opinion, pathologies that more frequently can create differential diagnosis problems are granulomas, chronic adhesive arachnoiditis, and embolism caused by cardiovascular procedures.Regarding granulomas, the main differential diagnoses are abscesses, hematomas, and tumors. Their radiological features are quite similar, though abscesses may show internal colliquative tissue and air and present restricted diffusion. Hematomas are usually less circumscribed and quite heterogeneous. Tumors are extremely heterogeneous and may show restricted diffusion, increase of relative cerebral blood volume on perfusion maps, and increased choline/creatine ratio at spectroscopy.The main differential diagnosis of chronic adhesive arachnoiditis is leptomeningeal carcinomatosis. The latter’s key distinguishing feature is its rapid progression, whereas adhesive arachnoiditis may take years to develop.Embolisms caused by cardiovascular procedures are very rare. They might be suspected when atypical findings are depicted such as metal-induced artifacts caused by cardiac valve material or Teflon.Intra-cranial and spinal foreign body reactions are rare but challenging findings as they can mimic other more threatening medical conditions. It is vital for the neuroradiologist to know patient clinical history and especially whether surgical procedures have been previously performed to make the correct diagnosis. Indeed, imaging findings strictly depend on the specific foreign body that has been left in or migrated from the surgical area.In conclusion, though it may not be easy to recognize foreign bodies and related inflammatory reactions, material embolisms, or migrations, it is important to keep in mind these entities among possible differential diagnoses.


Actinomyces spp. Although abdominopelvic actinomycosis, which involves the colon and the pelvic organs extensively, has been frequently reported, abdominopelvic actinomycosis presenting with colon perforation and hepatic involvement concurrently has yet to be reported.Actinomycosis is a rare chronic invasive disease caused by A 55-year-old woman presented at the emergency room with squeezing epigastric pain. Palpation of the abdomen revealed a hard mass with no acute peritoneal signs. Vital signs were normal range except for tachycardia. Initial laboratory testing revealed leukocytosis, anemia, elevated C-reactive protein (CRP), hypoalbuminemia; and normal AST/ALT and BUN/creatinine. CT scan of the abdomen-pelvis revealed a microperforations of the sigmoid colon, abscess in the left lower quadrant and hepatic lesion. Furthermore, there was a large infiltrating conglomerated mass invading the urinary bladder, left adnexa, sigmoid, left inguinal canal and left pelvic wall area. Ultrasound revealed an intra-uterine device (IUD). All these findings initially raised a suspicion of malignancy such as advanced cancer of the colon with liver metastasis. Despite the rarity of the disease, actinomycosis were not excluded because of the IUD found on ultrasound. Parenteral antibiotics and percutaneous drainage of abdomen abscess as well as fasting with total parental nutrition were prescribed for sigmoid perforation and abscess. After 10 days of conservative treatment, no remarkable change was detected in conglomerated mass invading pelvis. Furthermore, the finding of newly developed mechanical small bowel obstruction warranted surgery. Exploratory laparotomy was performed for the removal of perforated colon, obstructive small bowel and organs involved and postoperative histology confirmed a diagnosis of colonic actinomycosis. The patient made an uneventful recovery and was started on a 6-month course of penicillin.Abdominopelvic actinomycosis presenting with colon perforation and hepatic involvement is extremely rare; however, it is clinically similar to advanced colon cancer with liver metastasis, therefore, complicating the preoperative diagnosis. A diagnosis of abdominopelvic actinomycosis should be considered in patients with a history of IUD and chronic abdominal pain, along with an abdominal mass or cutaneous abscess. If surgery is indicated, preoperative empirical antibiotic therapy for actinomycosis and frozen biopsy during surgery may be considered. Actinomyces israelii is the most prevalent species, anaerobic gram-positive bacteria that normally colonize oral, digestive and urogenital tracts in humans [Actinomycosis is a rare chronic invasive disease and n humans . Breach n humans . Abdominn humans . When itn humans . AlthougHere, we report a severe case of abdominopelvic actinomycosis with sigmoid colon perforation and hepatic lesion mimicking advanced colon cancer with liver metastasis.A 55-year-old woman with no specific medico-surgical history presented at the emergency room with a 1-day history of squeezing epigastric abdominal pain. Patient also complained of a thick turbid yellowish discharge in the left inguinal area that was intermittently drained for some years.Vital signs were normal range except for tachycardia . Palpation of the abdomen revealed a wood-like hard mass in the left lower quadrant with minimal tenderness and no acute peritoneal signs warranting emergent surgery. A visible scar was noted in the left inguinal area without any discharge.3), anemia (hemoglobin concentration of 6.9 g/dL), elevated C-reactive protein (CRP) 32.05 mg/dL , hypoalbuminemia ; and normal AST/ALT and BUN/creatinine. CT scan of the abdomen-pelvis revealed a microperforation of the sigmoid colon, abscess in the left lower quadrant, a hepatic lesion and bilateral hydronephrosis. Furthermore, there was a large infiltrating heterogenous hyperattenuating conglomerated mass invading the urinary bladder, left adnexa, sigmoid, left inguinal canal and left pelvic wall area  and fasting with total parental nutrition were prescribed for sigmoid perforation. Because there was a huge left abdominal abscess (11X8X3cm) that could spread to other spaces and cause generalized peritonitis, the imaging-guided percutaneous abscess drainage was performed.After 10 days of conservative treatment, a repeat CT scan of the abdomen-pelvis showed improvement in abdominal abscess and liver lesion. However, no remarkable change was detected in conglomerated mass invading pelvis. Furthermore, the finding of newly developed mechanical small bowel obstruction warranted surgery.Exploratory laparotomy was performed for the removal of perforated colon, obstructive small bowel and organs involved. Abscess of the sigmoid colon involved the uterus, adnexa, loop of small bowel and distal colon with severe adhesion between the mass and pelvic organs including the uterus, small and large bowels, and bladder. The abscess compressed the left ureter and caused ureteral dilatation. En-bloc excision of the mass was performed using Hartmann’s procedure, bilateral salpingo-oophorectomy, small bowel resection and appendectomy. The gynecologist decided not to resect uterus because of severe fibrotic adhesion in the pelvis and transvaginal IUD removal failed repeatedly due to severe adhesion.Actinomyces spp. failed to grow in preoperative cultures, postoperative permanent histology confirmed a definitive diagnosis of colonic actinomycosis, which showed the granular colonies of bacteria, commonly termed sulfur granule, with aggregates of filamentous bacteria and neutrophils  is also a very rare form of abdominal actinomycosis and often, it is a secondary infection following abdominal infection. HA constitutes 15% of abdominal actinomycosis, and 5% of all actinomycosis –11. The In the present unusual case, the patient presented with signs and symptoms mimicking advanced colon cancer with liver metastasis. Few studies have demonstrated other clinical features such as mimicking colon cancer, large mass with perforation, hydronephrosis and involvement of adjacent tissues. However, there are no reports showing all the features including colon perforation, rectal stricture, hydronephrosis, ascites and hepatic involvement.Abdominopelvic actinomycosis does not produce the characteristic disease signs or symptoms and usually manifests as a slowly growing mass, which may be associated with altered bowel habits, nausea, vomiting and cramping pain . PatientSeveral reports show abdominopelvic actinomycosis mimicking malignancies , 17. DueActinomyces species show very low yield, histopathological examination is the most utilized diagnostic method worldwide, which is generally conducted after surgical intervention due to an initial diagnostic error [In addition, because the preoperative diagnosis is rarely considered and is established only in less than 10% of cases, the diagnosis is based on clinical manifestations and imaging findings , 21. Sinic error , 12, 22.ic error , 24.In our case, colon perforation with liver lesion resembled advanced colon cancer with liver metastasis. Radiologically, actinomycosis was considered, but colon cancer with liver metastasis was not excluded.Actinomyces spp. are usually extremely susceptible to beta-lactams, and especially Penicillin G or amoxicillin. Clindamycin, tetracycline, and erythromycin are alternatives in cases of allergy to penicillin [Treatment of abdominopelvic actinomycosis depends on the extent of the disease and the patient’s condition. Long-term treatment with penicillin is the standard medical therapy for uncomplicated cases . Indeed,nicillin . Piperacnicillin . The neenicillin .Treatment of HA mainly involves surgical or puncture drainage, hepatic resection, and postoperative treatment with anti-infectives , 20.This particular case is interesting in several aspects.First, although preoperative antibiotic therapy was administered only for 2 weeks, a significant reduction in inflammation due to actinomycosis was detected during surgery. The bladder and ureter, which were expected to be sacrificed, were preserved. Ureteral dilatation and hydronephrosis were resolved following insertion of a temporary double-J stent, and antibiotic therapy as reported previously –29.Second, the exclusion of malignant tumors in frozen biopsy during surgery also facilitated the demarcation of the extent of surgery. In most of the previous cases, abdominopelvic mass was considered as a malignant tumor before surgery, and the diagnosis of actinomcycosis was made after surgery , 28–31. Therefore, we recommend the use of preoperative empirical antibiotics and exclusion of malignant tumors during surgery via frozen biopsy. Such a strategy reduces the extent of surgery and postoperative complications in patients, with actinomycosis indistinguishable from malignant tumor before surgery.In conclusion, abdominopelvic actinomycosis presenting with colon perforation and hepatic involvement is extremely rare; however, it is clinically similar to advanced colon cancer with liver metastasis, therefore, complicating the preoperative diagnosis. A diagnosis of abdominopelvic actinomycosis should be considered in patients with a history of IUD and chronic abdominal pain, along with an abdominal mass or cutaneous abscess. If surgery is indicated, preoperative empirical antibiotic therapy for actinomycosis and frozen biopsy during surgery may be considered.A diagnosis of abdominopelvic actinomycosis should be considered in patients with a history of IUD, even though concurrent hepatic mass was detected.If the patient’s condition allows, the use of preoperative empirical antibiotics should be considered for at least 2 weeks to decrease the extent of surgery and postoperative complications.If surgery is indicated, exclusion of malignant tumors via intraoperative frozen biopsy facilitated the determination of the extent of surgery.


The purpose of this article is to present the diagnostic and surgical approach for a giant retroperitoneal sarcoma and to highlight the difficulty of a precise preoperative diagnosis and the extention of surgical resection.A 63-year-old female patient was admitted at our department with light diffuse abdominal pain, fever and gradual increase of abdominal girth. A CT scan showed a giant fatty tumor occupying left hemiabdomen and indirect findings of renal damage, probably sustained by ureter stretching and urine stasis. At surgical exploration, no cleavage plane was discovered between the mass and the surrounding organs. The severe pielonephritis and the apparent intraoperatively involvement of surrounding tumour structures lead to an aggressive surgery. An “en-bloc” resection of tumor mass, left colon, spleen, pancreatic tail, left annex, left kidney and adrenal gland was performed. Histology revealed a well differentiated liposarcoma with large areas of high grade of dedifferentiation.Liposarcoma is an histologic subtype of soft tissue sarcoma and the most common type of sarcoma arising in retroperitoneum. It is difficult to make an accurate preoperative diagnosis through a percutaneous biopsy. Although it is required to obtain negative resection margins, literature shows that surgical radicality is not a primary endpoint if noble structures are strictly close. In some cases surgery must be more aggressive because of the apparent organ involvement or damage.This is a rare case of a giant liposarcoma involging many organs. Surgery should be tailored according to intraoperative findings and organ damage. LiposarTumor behavior depends on the liposarcoma subtype. WDLS is locally aggressive but does not metastasize, whereas DDLS has the potential to metastasize (20–30% distant recurrence rate). DDLS also has a higher local recurrence rate than WDLS and six times the risk of death .The rarity of retroperitoneal liposarcomas and the variety of histologic subtypes make it difficult to understand and treat this neoplasm . BecauseStudies that have evaluated preoperative chemotherapy followed by surgery have reported inconsistent findings . The resWe describe a case of a giant retroperitoneal liposarcoma and discuss about two still open question: the difficulty of a precise preoperative diagnosis and the extension of surgery.This work is reported in line with the Surgical Case Report Guidelines (SCARE) criteria 2A 63-year-old female patient was admitted at our department. She reported a gradual increase of abdominal girth in the last months, light diffuse abdominal pain in the last two weeks and fever with chill in the last week. No other symptoms were reported. Physical examination on admission revealed a fixed abdominal mass with ill-defined margins occupying the entire abdomen. The patient was hemodynamically stable, HR 90 bpm, blood pressure 130/80 mmHg, oxygen saturation 95%, breath rate was 17, body temperature 37.8 °C and her bowel function was normal. BMI was 26.1. Laboratory tests revealed only a mild leukocytosis. Tumor markers were negative. Contrast enhanced CT showed a huge mass with a peritoneal component of 19 × 25 × 11 cm presenting a lipoma-like aspect with mixed density and pathological contrast enhancement, and a retroperitoneal uneven component of 10 × 14 × 5 cm. The mass displaced left kidney in epigastrium   and mosCT findings suggested a giant fatty tumor, including suspected dedifferentiated areas. Renal infection was probably sustained by ureter stretching and urine stasis. Surgery was decided.A midline xyphoid to pubic incision was performed. Surgical exploration revealed a voluminous mass involving left colon, left kidney, spleen, tail of the pancreas and left uterine annex. No cleavage plane was discovered between the mass and the surrounding organs: so “en-bloc” resection of tumor mass, left colon, spleen, pancreatic tail, left annex, left kidney and adrenal gland was performed  . RadiopIn the first postoperative days a decrease of urinary output occurred and a massive fluid reanimation was necessary. Postoperative anemia led to one RBC transfusion. The rest of recovery was uneventful: normal bowel functions restored in 2nd p.o. day and oral feeding restarted in 3rd p.o. day. Drains were removed in 7th p.o. day and the patient was discharged in 8th.Histological examination showed a well differentiated liposarcoma, with lipoma-like and sclerosing aspects, with large areas of high grade of dedifferentiation (Ki67: 75%). Well differentiated component of the mass involved renal vein and left psoas margin (R1 resection).3Fatty tumors of the retroperitoneum are rare and represent a real dilemma for the distinction between lipoma and well-differentiated liposarcoma. Computed tomography (CT) imaging features that suggest malignancy include large lesion size, presence of thick septa, presence of nodular and/or globular or non adipose mass-like areas, and decreased percentage of fat composition . MoreoveAlmost all liposarcomas occurring in the retroperitoneum are WDLS or DDLS .Because of the difference of biological behavior of these two subtypes it is fundamental to determine the specific cellular population. Actually, liposarcoma present also an intra-tumoural variability and often we find various rates of the two components, describing them as DD/WD liposarcoma. A combination chemotherapy  versus single chemotherapy (single-agent doxorubicin) showed a response rate of 24% and a clinical benefit rate of 44%, higher than previously reported in DD liposarcoma; encouraging results also have been showed in recurrent or borderline-resectable patients who received combination chemotherapy as neoadjuvant therapy, either in DD liposarcoma or in the dedifferentiated cellular population rate of a giant liposarcoma .A retrospective study on 256 patients underwent to surgical resection with pathologic results of WDLS and/or DDLS noted an unexpectedly low subtype-specific diagnostic accuracy of pre- operative image-guided percutaneous biopsy: 64% of DDLS patients and 15% of WDLS patients were incorrectly diagnosed with other types of tumors, and 53% of false-negative DDLS cases were diagnosed as WDLS . AuthorsIn this perspective, the poor accuracy of preoperative biopsy in distinguishing WDLS from DDLS, in the opinion of authors, could lead to avoid percutaneous sampling in the most part of cases, especially in symptomatic patients in which surgery is necessary.Surgical resection with appropriate negative margins is the standard primary treatment for most patients with STS, although close margins may be necessary to preserve uninvolved critical neurovascular structures . In addiAccording to guidelines of NCCN  radical Kirane and Crago  sustain If resections with microscopically positive or grossly positive margins are anticipated, surgical clips should be left in place to identify high-risk areas for recurrence, particularly for retroperitoneal or intra-abdominal sarcomas to help guide potential future radiotherapy .Retroperitoneal liposarcoma tends to infiltrate adjacent tissues and structures with skip areas (satellites): for this reason it can be explained why it frequently recurs  despite complete surgical resection with negative margins ,16.Beyond these recent evidences there are some cases which need a “tailored” surgical strategy. In our case we report an anatomical condition in which an extent surgery is recommended of necessity. If we consider the severe pielonephritis due to the mechanical stretching on left ureter, nephrectomy was necessary. Nevertheless, other structures resected  appeared intraoperatively involved in the fatty mass.In the study by Singer et al. in 2003, the practice of dissecting under the renal capsule and reserving nephrectomy for instances of circumferential hilar involvement was not associated with a reduction in disease specific survival, 5 year OS reported at 92% .Similarly, while aggressive vascular reconstruction is documented to be of low mortality at 4% with 5-year survival 66%, generally vessels can be freed of abutting tumor when not encased ,18.4The surgical strategy adopted in this case, reveals authors’ opinion: an aggressive resection should not be performed “d’emblée”, whereas surgery should be tailored according to intraoperative findings: organ damage or organ engagement.No conflicts of interest.No sources of funding.As this work is a case report, ethical approval was not needed and our report was exempt from ethical approval at our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.Anna Pisapia: preparation of the manuscript, data interpretation, literature analysis.Enrico Crolla: study planning, data interpretation.Rosario Alessandro Saglioccolo: data collection, literature research.Alessandro Perrella: data analysis.Carlo Molino: study concept, data interpretation.All authors read and approved final manuscript.As this is a case report and not a human studies, it is exempt from registering.Carlo Molino, MD.Not commissioned, externally peer-reviewed.


Choroid plexus papillomas (CPPs) are slow-growing and benign tumors, representing less than 1% of all intracranial neoplasms. They are predominantly located in the lateral ventricles in children, and in the fourth ventricle in adults. Primary CPP over sellar regions is extremely rare. There was previously only one case reported in men.We report the case of a 43-year-old male who initially presented with bilateral temporal hemiapnosia. A brain magnetic resonance imaging (MRI) revealed heterogenous enhanced mass lesion with cyst component compressing upward onto the optic chiasm. A craniopharyngioma was initially suspected. Further endoscopic trans-sphenoidal surgery (ETS) was performed for total tumor resection. After surgery, the patient had visual field improved without tumor recurrence on post-operative MRI in clinical follow-up. Histopathological examination of the lesion confirmed the diagnosis of CPP, with fibrovascular cores covered by a single layer of cuboidal to columnar epithelial cells.CPP is a rare tumor without specific clinical patterns or imaging findings. Therefore, pre-operative differential diagnosis is difficult for this kind of tumor with complete separation from ventricular system. An ETS for total tumor resection provided effective treatment. Choroid plexus papillomas (CPPs) are slow growing, benign tumors, representing less than 1% of all intracranial neoplasms. The tumors are most common in children, constituting 2%-4% tumors in children under 15 years of age , the thiThis 43-year-old male without systemic disease complained of blurred vision progressively for almost six months. Bilateral visual field defects were found under visual field examination. The patient’s high cortical functions were intact. Cranial nerve function was also normal, except for bilateral lower temporal hemiapnosia. Anatomical MRI revealed a mass lesion over sellar and suprasellar regions with heterogeneous contrast enhancement, and a cystic component that caused upward compression of the optic chiasm Figure . EndocriAfter the provisional diagnosis of craniopharyngioma with optic nerve compression, we performed endoscopic trans-sphenoidal surgery (ETS) for tumor removal. We used a standard one-surgeon, two-hand technique via a single nostril, with the endoscope mounted on a pneumatic scope holder. A vertical linear mucosal incision was made with electric cautery near the root of the bony nasal septum. A nasal speculum was placed after dilatation of the space and fracture of the bony nasal septum without destruction of the middle turbinate. Subsequently, posterior septectomy was performed with removal of the anterior portion of the vomer bone using high-speed drills and Kerrison rongeurs. The bony septum inside the sphenoid sinus and the rostrum of sphenoid bone were removed to expose the sella turcica. The floor of the pituitary fossa was removed after confirmation of anatomy via the intraoperative navigation system or lateral skull fluoroscopy. A soft density tumor with some yellowish particles was removed endoscopically with ring curettes over the sellar region. The cystic part of the tumor with old blood content was drained during surgery. The tumor was completely removed with the diaphragm sella intact and without cerebrospinal fluid leakage. The sellar floor was reconstructed using with tissue glue and autologous bone grafts harvested during the approach. The patient had no neurological deficit after surgery. No electrolyte imbalance, diabetes insipitus (DI) sign, or hormone deficiency was noted. The original visual field defect also improved after surgery. Post-operative images indicated no residual or recurrent tumor within the two-year follow-up period Figure .Microscopic examination revealed that the tumor was composed of delicate fibrovascular cores covered by a single layer of cuboidal to columnar epithelial cells Figure . There aThe first case of primary CPP over the sellar region in a female patient was presented in 1992 . IncludiNeuroimaging presentation of craniopharyngioma, our initial diagnosis, is not specific. Craniopharyngioma may be hyperintense, iso-intense, or hypointense on a T1-weighted image, and hyperintense on a T2-weighted image. The high signal intensity of cystic fluid on a T1-weighted image may be caused by high protein concentrations. Cholesterol and triglycerides do not affect the signal intensity on a T1-weighted image, but may cause high signal change on a T2-weighted image . Based oComplete surgical tumor resection is recommended for treatment of CPP -16. An ECPP is a rare tumor without specific clinical patterns on image findings. Primary CPP over the sellar region is extremely rare, especially in men. A pre-operative differential diagnosis is difficult for this type of tumor with complete separation from ventricular system. ETS for complete tumor resection provided an effective treatment.


Burkitt's lymphoma (BL) is a high-grade B-cell non-Hodgkin’s lymphoma, which can be divided into endemic, sporadic and human immunodeficiency-associated subtypes. The sporadic BL typically presents as an intra-abdominal tumour but that of cutaneous or subcutaneous origin is very uncommon. We present a case of sporadic BL arising from the axillary soft tissue and discuss the CT and MRI findings. BL tends to grow very rapidly, so early diagnosis and treatment is crucial. Here, we present an unusual case of sporadic BL involving the subcutaneous tissue of the axilla and discuss the CT and MRI findings.Burkitt’s lymphoma (BL) is a high-grade B-cell non-Hodgkin’s lymphoma (NHL) that often presents with extranodal disease and occurs most often in children and immunocompromised hosts.Plasmodium falciparum malaria. The patient initially noticed a small non-pustular nodule in the right axilla. The axillary lymph nodes were not felt at that time. She was initially diagnosed with an atheroma by the referring physician and underwent excision of the skin lesion 4 weeks prior to admission. Pathological examination was not performed. Physical examination revealed a swollen, painful red lump on her right axilla. Complete blood count results were as follows: white blood cells: 6400 μl−1; lymphocyte count: 2163 μl−1; haemoglobin: 11.3 g dl−1; mean corpuscular volume: 88 fl; platelets: 208,000 mm−3. Biochemical profile was normal except for elevated levels of serum lactate dehydrogenase 1148 IU l−1  and C-reactive protein 1.5 mg l−1 . The patient was seronegative for anti-human immunodeficiency virus antibody and anti-Epstein–Barr virus immunoglobulin M and G. Axial contrast-enhanced CT scan showed a large, poorly marginated homogeneous soft tissue mass in the cutaneous and subcutaneous compartments of the right axilla, and the tumour was slightly enhanced after intravenous administration of contrast medium , doxorubicin , vincristine , dexamethasone , followed by intrathecal chemotherapy with 15 mg of methotrexate and 4 mg of dexamethasone. The patient achieved complete remission and received eight courses of maintenance therapy consisting of cyclophosphamide, doxorubicin, vincristine and dexamethasone. She remains in complete remission at 3 years after the treatment.A 33-year-old Asian female patient was referred to our hospital because of rapidly growing subcutaneous nodules in the right axilla. Her medical history was unremarkable, and there was no family history of BL or infection with t medium . MRI of l muscle . On T2 wntensity . Fat-supancement . Skin thT1 and T2 weighted MRI, and homogeneous contrast enhancement of the axillary tumour with skin thickening and marginal septal enhancement. These MRI findings are compatible with soft tissue lymphoma.5 The enhancement pattern seen in this patient may be related to the infiltrative involvement of lymphoma cells and lymphoedema caused by them.5 However, considering that lymphoma is rarely infiltrative but normally grows as a well-circumscribed mass, we suspect that the skin thickening and septal enhancement may be more related to lymphoedema as a result of the enlarged lymph nodes, leading to impaired lymphatic drainage. These MRI findings are still inconclusive, yet they may aid in narrowing the differential diagnosis of BL. Since CT and MRI findings of axillary BL have not been reported so far, the current case may help radiologists in diagnosing a patient with soft tissue BL in urgent need of treatment. We consider only after showing real images, one can prove that the imaging findings of soft tissue BL are not different from the probable result.In this case, the contrast-enhanced CT scan showed a poorly marginated homogeneous mass in the cutaneous and subcutaneous tissue with axillary lymphadenopathy. These findings were suggestive of a diagnosis of lymphoma or cutaneous infection but were not conclusive. MRI is more sensitive and more specific than CT for the detection and evaluation of soft tissue neoplasms. The tumour had slightly increased signal intensity compared with normal muscle on both In summary, the presence of extranodal involvement, particularly in the cutaneous and subcutaneous tissue, together with an aggressive clinical history in a young patient should be suggestive of the possibility of sporadic BL.BL can involve cutaneous/subcutaneous tissues.T1 and T2 weighted MRI.BL manifestations may show slightly higher signal intensity than muscle on both Informed consent to publish this case (including images and data) was obtained and is held on record.


Pediatric-type follicular lymphoma (PTFL) is a rare neoplasm with features that differ from those of adult-type follicular lymphoma. Compared to patients with adult-type follicular lymphoma, PTFL patients often show an excellent response. Preoperative diagnosis is challenging and, therefore, an accurate diagnosis is based on the findings of postoperative pathological examination and immunohistochemistry.A 13-year-old boy presented with a slow-growing mass on the right side of his neck.The patient was diagnosed with PTFL based on the findings of histopathological examination and immunohistochemistry.The mass was completely resected.After 12 months of postoperative follow-up, the patient achieved good recovery without recurrence.The optimal treatment for PTFL has not yet been defined. However, patients with PTFL always show satisfactory prognoses, regardless of treatment strategy . Clinically, pathological and immunohistochemical analyses are necessary in the diagnoses of PTFL cases, especially for distinguishing PTFL from reactive follicular hyperplasia, to avoid unnecessary treatment. However, albeit rare, when it occurs in children and adolescents, it is often associated with high proliferation rates and is likely to present as localized disease. Pediatric-type follicular lymphoma (PTFL) has distinctive clinical and pathological features. It is a newly recognized variant of follicular lymphoma in the World Health Organization (WHO) Classification. A majority of PTFL patients have been reported to present with localized stage I disease and to demonstrate generally indolent clinical courses, characterized by high-grade cytology, lack of the characteristic t  chromosomal translocation, and low B-cell lymphoma 2 (BCL-2) protein expression. PTFL, a distinct variant of adult follicular lymphoma, is typically observed in patients aged between 3 and 18 years, with a male-to-female ratio of approximately 4:1. It occurs most commonly in the cervical lymph nodes and tonsils; however, extranodal occurrence of PTFL has been reported, such as in the testis, gastrointestinal tract, parotid gland, and dura. Unlike follicular lymphoma in adults, PTFL always has an excellent prognosis, with an event-free survival of 90%. Herein, we report the case of a young male patient with PTFL with BCL-2 protein expression.Follicular lymphoma is a type of neoplasm that originates in germinal center (GC)-derived B cells.2A 13-year-old boy presented to our hospital with a 3 cm-sized mass in the right cervical region. The mass was painless without any inflammatory features. He had no recent history of illness or fever. He had undergone appendectomy at the age of 8 years. Clinical examination revealed a 3.5 × 2 cm-sized mass at the superior border of the right sternocleidomastoid muscle; the mass had medium texture, a clear movable boundary, was nontender, and did not adhere to the surrounding tissues. No other cervical masses were palpated. Ultrasound examination performed at another hospital had shown an abnormal acoustic image of approximately 3 cm in the right cervical region at level II   chromosomal translocation, and weak or negative BCL-2 protein expression. This characteristic was well reflected in our patient, who showed good recovery with no recurrence without any chemotherapy after the 12-month follow-up. Originally, PTFL patients were often treated with chemotherapy. In recent years, a variety of treatments have been used, such as “watch and wait” strategy, targeted radiotherapy, and multiagent chemotherapy.,14,15Despite the high frequency of aggressive cytological features, PTFL patients show excellent prognoses to surgical resection or multiagent chemotherapy, and the recurrence rate is extremely low. It has been reported that the probability of 5-year event-free survival was >90%. An immunophenotypic study suggested that GC-associated markers, like BCL-6 and CD10, seen in PTFL are absent in PNMZL. Furthermore, in PNMZL, the interfollicular areas typically show low Ki-67 proliferation rates.The diagnosis of PTFL can be complicated by the presence of clinical and morphological features that overlap with those of reactive follicular hyperplasia or pediatric nodal marginal zone lymphoma (PNMZL). Preoperative examination, such as B-mode ultrasound or magnetic resonance imaging is helpful; however, the final diagnosis depends on the histological and molecular characteristics. The identification of these diseases is crucial to clinical treatment and prognosis. In contrast to reactive follicular hyperplasia cases, most cases of PTFL show irregularly shaped follicles, attenuated mantle zones, and high levels of proliferation-based markers, like the Ki-67 index.TNFRSF14 and MAP2K1 genes are frequently mutated in PTFL, suggesting that both mutations might play an important role in PTFL lymphomagenesis.,10,17The genetic alterations involved in the pathogenesis of PTFL are yet to be elucidated. Recently, studies have shown that the Since the optimal clinical management is yet to be defined, our report adds value to the literature as it suggests that a “watch and wait” strategy can be a good option. Compared with other malignant tumors, PTFL patients always have excellent prognoses. However, many factors related to PTFL remain to be elucidated, especially regarding its molecular pathology and etiopathogenesis; with this knowledge, we can accurately diagnose and effectively treat this disease.Conceptualization: Hongyu Yang.Funding acquisition: Hongyu Yang.Investigation: Biru Zhang.Software: Biru Zhang.Supervision: Shuai Sun.Writing – original draft: Hanyu Zhang.Writing – review and editing: Hanyu Zhang.


Nonoperative management (NOM) has been established as the standard treatment for isolated blunt organ injury in hemodynamically stable pediatric patients. Although delayed splenic rupture or bleeding is a rare complication in NOM, it is an issue that many pediatric surgeons are greatly concerned about. We herein report a rare pediatric case concerning the mechanisms involved in delayed splenic rupture after NOM.A 9-year-old boy with severe abdominal pain was transferred to our hospital. Twenty-one hours before the admission, he had been kicked in the region of his left lateral abdomen. Contrast-enhanced abdominal computed tomography revealed a severe intra-parenchymal hematoma and multiple lacerations of the spleen with a large amount of hemoperitoneum without active bleeding. His condition was diagnosed as a grade III injury on the AAST splenic injury scale. After fluid resuscitation, his vital signs became stable. The patient was treated with NOM in our intensive care unit. However, suddenly after defecation (72 h after the injury), he started complaining of severe abdominal pain and left shoulder pain. His blood pressure dropped to 70/35 mmHg, and he started to lose consciousness. Abdominal ultrasonography (US) revealed increased ascites. Fluid resuscitation and blood transfusion were performed. His symptoms and abdominal US findings suggested that splenic re-bleeding had caused delayed splenic rupture to occur. Emergency splenectomy was performed. The resected spleen was enlarged with a large parenchymal hematoma. The posterior-lateral side of the splenic capsule was ruptured.The mechanism of delayed splenic rupture in our case was considered to be the result of a tear in the subcapsular hematoma caused by stretching the splenocolic ligament related to a bowel movement during defecation. Although delayed splenic rupture or bleeding is unpredictable, it is very important to understand the mechanisms and to educate the family of the children with splenic injuries of the warning signs of delayed rupture or bleeding. Among blunt abdominal injuries in children, the spleen is the most frequently injured organ . NonoperWe herein report on a case of delayed splenic rupture caused by tearing of a subcapsular hematoma. We believe the mechanism causing the splenic capsule to tear involved stretching the splenocolic ligament, leading to colonic peristalsis during defecation.A 9-year-old boy  with severe abdominal pain was transferred to our hospital. Twenty-one hours before admission, he had been kicked in the region of his left lateral abdomen. On admission, the patient’s face was pale, and his Glasgow coma scale was recorded at 13/15 . A physical examination revealed severe tenderness on the left lateral abdomen with moderate abdominal distension. His vital signs were as follows: blood pressure 80/50 mmHg, heart rate 110 bpm, and a respiratory rate of 30/min, respectively.4/ml, hemoglobin (Hb) 9.1 g/dl, hematocrit (Ht) 27.1%, and platelets 33.6 × 104/μl. All of his other laboratory data were within normal limits. After fluid resuscitation, his blood Hb and Ht levels fell to 7.6 g/dl and 22.3%, respectively. He required a transfusion of 1000 ml red blood cells in order to maintain his blood pressure. His vital signs became stable, and he regained clear consciousness.Contrast-enhanced abdominal computed tomography revealed a severe intraparenchymal hematoma and multiple lacerations of the spleen with a large amount of hemoperitoneum Fig. a, b. TheWe treated him by NOM in our intensive care unit. His abdominal pain decreased gradually while resting in bed. His hemodynamic conditions were stable, and further blood transfusion was not necessary. At 70 h after the injury, he started drinking water. Two hours after drinking water (72 h post-injury), he discharged feces. After defecation, he suddenly started complaining of severe abdominal pain and left shoulder pain. His blood pressure dropped to 70/35 mmHg, and he started to lose consciousness. Abdominal ultrasonography (US) revealed increased ascites. Fluid resuscitation and blood transfusion were performed. His symptoms and abdominal US findings suggested that splenic re-bleeding had caused delayed splenic rupture to occur. An emergency splenectomy was performed. The resected spleen was enlarged with a large parenchymal hematoma. The posterior-lateral side of the splenic capsule was torn , and observation. Twenty cases of delayed splenic rupture and bleeding were reported , 5, 7, 8The mechanism of delayed splenic rupture in our case was considered to be the result of a tear in the subcapsular hematoma caused by stretching of the splenocolic ligament. The patient started complaining about abdominal and shoulder pain suddenly after defecation, which led us to suspect that the bowel movement had caused the splenocolic ligament to stretch at the splenic flexure. Also, defecation might cause rising of intra-abdominal pressure that could induce a rupture of the hematoma. There have also been a few reports of splenic rupture as a complication of colonoscopy . One of Given our understanding of the mechanisms involved in delayed splenic rupture, we strongly recommend careful observation of patients after beginning oral intake. It is very important to understand that gastrointestinal peristalsis can cause delayed splenic rupture.We herein report a rare case of delayed splenic rupture in a pediatric patient undergoing NOM of blunt splenic injury. Stretching of the splenocolic ligament during bowel peristalsis can cause tears in a subcapsular hematoma. It is very important to provide information to the family regarding the symptoms and signs of delayed splenic rupture or bleeding.


Lymphangiomas are uncommon congenital malformations that present mainly in the head, neck, and axillar regions in pediatric patients. Mesenteric cystic lymphangiomas (MCLs), which occasionally present with substantial growth and the invasion of adjacent vital structures, are rarely reported in adults. We report a case of MCL in an adult who was treated with laparoscopic-assisted excision.A 40-year-old Japanese man visited his family physician for prolonged periumbilical pain. Plain computed tomography (CT) showed a low-density mass in his left abdomen, and he was referred to our hospital 2 weeks later. His abdomen was flat and soft, and no mass was felt upon palpation. Routine laboratory data showed no abnormalities in the blood cell counts. The levels of tumor markers, such as carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and cancer antigen 125 (CA125), were within normal ranges. Contrast-enhanced CT was performed, and a low-density mass was observed with an irregular outline and poor contrast, as well as involvement of the peripheral mesenteric artery and partial compression of the adjacent jejunum without dilatation of the oral side of the bowel. The patient was diagnosed with lymphatic cysts and observed for 1 month without symptom exacerbation. Follow-up CT showed no increase in the size of the mass but showed apparent invasion of the jejunal wall without bowel obstruction. Magnetic resonance imaging (MRI) showed intermediate intensity on T1-weighted imaging (T1WI) and high intensity on T2-weighted imaging (T2WI). The coronal view on T2WI clearly showed an accumulation of cystic lesions. We performed tumor excision with partial resection of the jejunum in a laparoscopic-assisted manner. Pathological examination showed multicystic lesions with an attenuated endothelial lining, surrounding rich adipose tissue and scattered smooth muscle fibers; the patient was diagnosed with MCL.Immunohistochemical assays supported this diagnosis.This is rare case of MCL presenting in an adult who underwent successful laparoscopic-assisted resection. Mesenteric lymphangioma (ML) should be considered in the differential diagnosis of patients with intraabdominal cysts. Radical excision is optimal, even when the patient is asymptomatic. Laparoscopic-assisted tumor resection is a suitable surgical method for treating MLs located in the peripheral mesentery. Mesenteric lymphangiomas (MLs) are known to be uncommon congenital malformations of the lymphatic system ; 65% of A 40-year-old Japanese man experienced periumbilical pain since November 2013, and although the symptoms were mild, they were prolonged. He visited his family physician in January 2014, who noted mild tenderness in the lower left quadrant. The patient underwent an abdominal CT scan. CT revealed a low-density mass that measured 43 × 40 mm in size in the left abdomen. He was referred to the National Hospital Organization Tsuruga Medical Center in February. His past medical and family histories were unremarkable. On examination, the patient had a height of 179.0 cm, a body weight of 98.7 kg, and a body mass index (BMI) of 30.8 and did not present with anemia, icterus, edema, or malnutrition. His abdomen was flat and soft, with mild tenderness in the lower left quadrant on palpation; however, the mass could not be felt.The laboratory results showed no abnormalities in his blood cell counts; however, an elevation in the serum alanine transaminase , γ-glutamyl transferase , total bilirubin , and total cholesterol  levels was observed. The levels of epithelial tumor markers, such as carcinoembryonic antigen , carbohydrate antigen 19-9 , and cancer antigen 125 , were within normal limits.The patient underwent a contrast-enhanced CT examination 2 weeks after the CT examination conducted by his family physician because in the previous examination, the patient had not been administered a contrast agent. A low-density mass with an irregular outline and measuring 45 × 42 mm in size was detected in the left abdomen at the slightly cranial level of his umbilicus in the plain phase Fig. . The tumThe patient’s abdominal symptom passed without exacerbation, and a follow-up examination was conducted in March. One month later, he underwent a scheduled CT examination, and the mass did not appear to have increased in size Fig. a. EnhancBecause it was expected that depiction of the tumor would be made somewhat more difficult by its location and the body shape of the patient, we conducted a sonography examination in reference to the location and properties of the tumor determined by CT and MRI. The lesion showed a low echo; however, a clear image was not obtained.CT performed by the previous physician and at our institution showed that the tumor was located in the peripheral part of the jejunal mesentery and exhibited slight enteric compression without dilatation of the oral jejunum but no rapid increase in size. The patient hesitated to agree to an immediate operation but did agree to a 1-month observation period. Permeation of the jejunal wall was shown by a second CT examination at our institution performed 1 month later, and from these findings, we highly suspected that the lymphangioma was invading the jejunal wall and thus decided to perform surgery.We made a preoperative diagnosis of lymphangioma invading the jejunal wall, and with the patient’s informed consent, we performed an operation to relieve his symptoms and obtain a definitive diagnosis of the tumor in April.2) gas at 8 mmHg of pressure. An accessory trocar (5 mm) was placed on the right side of the 12-mm trocar through the E·Z Access device. Using forceps, we removed the omentum from the small intestinal front and found a soft yellowish mass in the mesentery of the jejunum that had invaded the wall of the jejunum  in the umbilical wound and then attached the E·Z Access™ device . A 12-mm trocar was placed through the E·Z Access device, and pneumoperitoneum was established with carbon dioxide , cavernous, and cystic . The capDifferential diagnoses include a wide range of cystic intraabdominal lesions, such as mesenteric cysts, abdominal lymphomas, secondary metastases from an unknown primary tumor, tuberculosis, hydatid disease, small bowel adenocarcinomas, and rare mesenteric tumors, including desmoid tumors, schwannomas, smooth muscle tumors, sarcomas, cystic mesotheliomas, lymphangiosarcomas, and lymphangiomas with myxoid degeneration , 24.To prove the lymphatic origin of the endothelial cells of cysts, we performed immunohistochemical analysis using a representative set of markers consisting of CD31, factor VIII-related antigen, D2-40, CD34, AE1/AE3, and calretinin for the diagnosis of lymphangioma . ImmunohTo treat ML, radical surgical excision is recommended, even when patients are asymptomatic, because ML can grow rapidly and invade adjacent structures, resulting in complications and the risk of sarcoma transformation upon irradiation . HoweverMinimally invasive surgery is a surgical treatment option. A relatively small ML, especially one that develops in the peripheral area of the mesentery, as in our case, is a good indication for laparoscopic-assisted surgery because the peripheral ML lesion can be easily removed from the body through a minimal wound and resection, and anastomosis can be performed under direct observation. A precise preoperative evaluation of the diagnostic images to determine the size, anatomical location, extent, and involved structures as well as the predicted laparoscopic surgical field aids in identifying an appropriate port site and wound length. Losanoff et al.  noted foWe used a pressure of 8 mmHg for pneumoperitoneum during the operation in this case. In our faculties, laparoscopic surgery begins with pneumoperitoneum at a pressure of 8 mmHg to avoid referred pain by diaphragm hyperextension, symptoms of high carbon dioxide in the blood, atelectasis, and phlebothrombosis, and if a good visual field cannot be maintained, we increase the pneumoperitoneal pressure incrementally. Fortunately, we were able to accomplish the intended procedure with a sufficient surgical field of view at 8 mmHg of pneumoperitoneal pressure in this case. However, if necessary, the pneumoperitoneal pressure can be increased to 12 or 15 mmHg to provide a better surgical field of view.The Lapprotector™ and E·Z Access™ devices are useful for laparoscopic-assisted tumor resection because they allow the use of multiple ports with minimal trauma and can also be used in single-port laparoscopic surgery (SPLS). We used two ports (one scope port and one forceps port) to remove the omentum. It seems that the excision of mesenteric tumors with a portion of the small intestine using a laparoscopic technique provides anatomical ease and the advantages of minimal surgical invasiveness, a reduced wound number and length, less postoperative pain, fewer wound-related complications, and improved cosmetic outcomes –32.We report a case of MCL in an adult patient who was successfully treated by laparoscopic-assisted excision. ML should be considered in the differential diagnosis of patients with intraabdominal cystic masses. The optimal treatment is radical excision, even when the patient is asymptomatic. Laparoscopic-assisted tumor resection is a suitable surgical method for treating MLs located in the peripheral part of the mesentery.


Primary lymphoma of bone (PLB) confined to the epiphysis has only been described in four other patients. Due to the rarity of this entity, diagnosis has often been delayed, leading to mismanagement with adverse clinical consequences. We report a fifth case of primary epiphyseal lymphoma of bone located in the left distal medial femoral epiphysis of a 13-year-old boy. Radiographic and histologic features of PLB are discussed, along with a review of the literature and pitfalls of misdiagnosis. The patient initially presented with six months of progressive left knee pain with an associated loss of passive range of motion. Imaging revealed a mixed radiolucent lesion within the left distal medial femoral epiphysis with cortical breakthrough. A core biopsy was performed revealing a blue round cell tumor. Thanks to modern immunohistochemistry techniques, a diagnosis of primary lymphoma of bone was quickly made. The patient thus avoided further surgical intervention and received the appropriate treatment of chemotherapy, with subsequent rapid resolution of the lesion. This case highlights the necessity of including primary lymphoma of bone in all epiphyseal lesion differential diagnoses, especially in the pediatric patient population when aggressive radiographic features are present. Lymphoma, when confined to bone at initial presentation, is referred to as primary lymphoma of the bone (PLB). PLB is most commonly diagnosed in patients over 30 years of age with a slight male predominance –3. PatieSolitary epiphyseal lesions of bone in children are relatively rare and not easily diagnosed. The radiologic differential diagnosis for this age group includes a broad spectrum of tumor and tumor-like conditions . The mosth documented case of epiphyseal PLB, a rare diagnosis which has only been described in four other patients to date [This case report documents an epiphyseal primary lymphoma of bone, diffuse large B-cell subtype, in the left distal femur of a 13-year-old boy. This is the 5 to date –8.The authors have obtained parental informed written consent for print and electronic publication of this case report.A 13-year-old boy with no past medical history presented with six months of progressive left knee pain. He denied any trauma or constitutional symptoms. On physical exam, the patient had a moderate left knee effusion with some warmth and no erythema. There was tenderness to palpation along the medial joint line and a marked decreased passive range of motion, 40-90 degrees. His neurovascular exam was intact with no signs of lymphedema, adenopathy, or instability.Computed tomography (CT) revealed a mixed radiolucent and sclerotic permeative lesion within the left posterior medial epiphysis with medial cortical destruction . There wMagnetic resonance imagining (MRI) demonstrated a nonspecific infiltrative process involving the left distal medial femoral epiphysis, extending proximally along the posterior femoral cortical surface, appearing dark on T1 and bright on STIR and T2 weighted images . The radMetastatic workup including CT chest, abdomen, and pelvis, three phase bone scintigraphy, and fludeoxyglucose-positron emission tomography scans (FDG-PET) were all otherwise unremarkable Figures  and 4.Fluoroscopic guided core biopsy was performed . HistoloBased on the clinical, radiologic, and histologic features, a diagnosis of epiphyseal primary diffuse large B-cell lymphoma of bone was rendered. The patient subsequently received nine weeks of chemotherapy including vincristine, doxorubicin, cyclophosphamide, and prednisone, without rituximab or radiation therapy (XRT), consistent with prior established regimens for primary lymphoma of bone in children .The patient responded well to chemotherapy and his symptoms dramatically improved. At one and a half years after chemotherapy, the patient was in remission and free of pain and had regained full passive knee range of motion. Imaging including MRI and FDG-PET showed a resolving lesion with satisfactory bone remodeling Figures –10.Primary lymphoma of the bone is rare with an estimated 500 cases reported in the English literature –18. One Primary lymphoma of bone presents a diagnostic challenge; therefore immunohistochemical techniques play a major role in solving these diagnostic dilemmas. B-cell markers such as CD10, CD20, CD43, CD45, CD79a, CD99, BCL2, BCL6, MUM-1, and terminal deoxynucleotidyl transferase are helpful in establishing a diagnosis . AdditioTreatment of primary lymphoma of bone is nonsurgical. Surgery is reserved solely as a palliative measure to restore function and alleviate pain in the rare case of a pathologic fracture . R-CHOP A retrospective review from the Moffitt Cancer Center identified 70 patients with confirmed primary lymphoma of bone. These patients had a 3- and 5-year progression-free survival (PFS) rate of 61.2% and 46.9%, respectively, and 5- and 10-year overall survival (OS) rate of 81.1% and 74.7%. Poor prognostic factors included soft tissue extension and multifocality. Researchers at the University of Texas noted a 5-year PFS and OS rate of 80% and 82%, respectively, in their retrospective review of 102 patients with PLB . It is iThere have been a total of five reported cases of epiphyseal primary lymphoma of bone including this report. All five involved male patients, aged 8-16 years, presenting within 2-6 months of symptom onset, three cases involved the distal femur, one case involved the proximal tibia, and one case involved the proximal humerus. Four cases were histologically diagnosed as diffuse large B-cell lymphoma and one was diagnosed as anaplastic large cell lymphoma. Misdiagnosis and delay in appropriate treatment may have detrimental consequences, as is highlighted by one of these patients, an 8-year-old boy who presented with a three-month history of right shoulder pain. This patient was subsequently treated with empiric antibiotics for an assumed osteomyelitis after MRI revealed a hyperintense T2 signal within the proximal humeral epiphysis. Eight weeks later, he began complaining of left lower quadrant abdominal pain. A subsequent abdominal CT scan revealed a large mass extending from the left lower abdominal wall into the pelvis. Open biopsy confirmed anaplastic lymphoma of both lesions. A timelier biopsy performed for this patient may have prevented such progression.We describe a rare case of epiphyseal primary lymphoma of bone in a 13-year-old boy who presented with six months of left knee pain and an associated flexion contracture. This is the fifth reported case in the medical literature, consistent with the demographics of the previously reported cases. Diagnosis should be made based on the clinical, radiographic and histologic findings with treatment guided by a multidisciplinary team involving orthopaedic and medical oncologists, pathologists, and musculoskeletal radiologists. Biopsy should always be performed when aggressive radiologic features are present. With the appropriate treatment, the prognosis is good. Overtreatment of a medically curable disease such as PLB can lead to significant morbidity and disfigurement. Undertreatment without a timely diagnosis and medical intervention can lead to metastatic disease. Although rare, epiphyseal PLB should be included in the differential diagnosis of any epiphyseal bony lesion, especially in the adolescent population.