This article reports on the clinical features, diagnosis, and management of ossifying fibroma in the nasal cavity of a 2-year-old horse. Ossifying fibromas (OFs) are rare, benign, fibro-osseous neoplasms that occur more frequently in the rostral mandible of young horses (termed equine juvenile mandibular ossifying fibromas) but rarely in older horses. The occurrence of OF in young animals suggests developmental disorders or trauma as etiological factors. The local recurrence of OFs is common if they are not completely surgically excised, but metastatic spread is unusual. The presented case remained clinically asymptomatic until the mass obliterated the whole nasal cavity, causing severe breathing difficulties. The exact mass location was revealed using diagnostic images—namely, radiographs and computed tomography (CT) images. A concurrent problem of an underdeveloped and hypoplastic last premolar tooth of the maxilla was diagnosed. Because the mass was well-demarcated, the horse underwent standing surgery to remove the mass and the tooth. Histopathological diagnosis of ossifying fibroma was confirmed. The patient recovered uneventfully and remained free of disease at the 2-year postoperative follow-up.A 2-year-old mare of an unknown breed was referred to the clinic due to undetermined breathing difficulties. Physical examination revealed painless swelling rostral to the nasoincisive notch and a large, firm mass protruding from the left nostril. Radiographic examination of the head revealed a mass occupying the left nasal cavity and a displaced and hypoplastic last premolar of the left maxilla. The CT scan showed a well-demarcated heterogeneous mass measuring 22 × 9 × 5 cm (length × height × width) in the left nasal cavity attached to the roots of the displaced tooth and conchae. The surgery was performed on the standing horse. Firstly, due to the oblique position of the displaced tooth, the extraction was performed extra-orally through the trephination and repulsion of the maxillary bone. In the next step, a direct surgical approach was chosen for the caudal part of the mass via the osteotomy of the left nasal bone. The mass was bluntly separated from the conchae and removed through the nostril using Fergusson forceps. The histopathological characteristics of the mass led to the diagnosis of ossifying fibroma. The horse recovered completely in seven months, without recurrence after two years. There are no clear-cut data on the incidence of tumors in the skeletal system in horses. Only in one paper was the rate of occurrence reported to be below 1.5% . T. T23]. TThe endoscopic examination of the right nostril revealed the rightward bending of the nasal septum; an examination of the left side was unavailable due to the presence of the mass. Computed tomography of the head was performed under general anesthesia in dorsal recumbency. The patient was sedated with detomidine (0.02 mg/kg) prior to anesthetic induction with diazepam (0.1 mg/kg) and ketamine (2.2 mg/kg). Anesthesia was maintained using isoflurane . CT images were acquired with a Revolution 750 CT scanner, GE Healthcare Corporation, Chicago, IL, USA . Two-dimensional tomographic sections were viewed using the RadiAnt DICOM 2020.2.3 software. Multiplanar image reconstructions allowed for the identification of the exact location of the mass, which extended from the level of Triadan 208 to the rostral part of the nasal cavity. The space-occupying lesion was well defined, heterogeneous, and measured approximately 22 × 9 × 5 cm (length × height × width) with internal zones of calcification . The masSurgery was performed using the following steps: extraction of the deciduous teeth intra-orally, extraction of Triadan 208, and removal of the tumor. All procedures were performed in a standing position during the same anesthetic protocol.The horse was sedated using detomidine (0.02 mg/kg IV) and butorphanol (0.01 mg/kg IV), maintained with constant infusion rates for detomidine (0.02 mg/kg/h) and butorphanol (0.01 mg/kg/h) diluted in saline, delivered by an infusion pump. The dose was adjusted according to the horse’s behavior. Maxillary cheek teeth were anesthetized with a left infraorbital nerve block using 5 mL 2% lidocaine hydrochloride . The lefExtensive damage to the apex of the alveolus created an oronasal fistula measuring approximately 2 cm in length by 1.5 cm in width. In the initial treatment, lavage and debridement were performed. In the next step, surgical gauze with iodoform was immersed in a semi-liquid paste of plaster of Paris then compressed slightly and placed in the fistula .To remove the mass, it was necessary to make an additional dorsal approach through the osteotomy of the nasal bone to release the caudal connection between the mass and nasal conchae . After tThe skin and subcutaneous tissues were sutured as previously described . Part ofAfter surgery, the horse received an administration of procaine penicillin  and streptomycin (8 mg/kg IM), which was continued postoperatively for 10 days. During the first week, flunixin meglumine (1.1 mg/kg) was administered intravenously as anti-inflammatory therapy. After maxillary tooth extraction, the fistula was lavaged with physiological saline solution, debrided, and plugged with iodoform gauze immersed in plaster of Paris to allow granulation and to prevent the persistence of an oronasal communication. Three, four, and nine days later, under sedation (detomidine 0.02 mg/kg IV and butorphanol 0.01 mg/kg IV) the plug was replaced and the fistula was lavaged and debrided. Sixteen days after initial surgery, a polyvinyl siloxane plug (PVS) was placed in the alveolus. The PVS plug was changed once a week under sedation, as previously described. To improve the healing process, during each procedure fistula irritation with surgical gauze and a miniature tube brush was performed, and a new dental impression material plug was molded and inserted. Eight weeks later, endoscopic examination revealed that the oral opening of the fistula was filled with granulation tissue and mucosa, but the persistence of a 2 mm-diameter oronasal communication in the apical region of the alveolus was detected.The apical part of the plug was remodeled and adjusted to the alveolus. The plug was frequently loosened, necessitating its replacement and resulting in the contamination of the nasal cavity with feed. In the 12th week of treatment, the plug was modified by adding a small plastic sleeve into the PVS packing material, to which a nylon thread was attached. Free ends were fastened to a button fixed on the surface of the maxillary bone . AdditioThe results of the treatment should be considered satisfactory, despite the long-lasting complications associated with the presence of a connection between the nasal and oral cavity. The fistula healed and, consequently, closed within 7 months after the surgical procedure. Histopathology revealed the benign proliferation of fibrous connective tissue superficially a, with tTo date—i.e., 2 years after surgery—no recurrence was observed, and the horse does not show any disturbing symptoms.The exact etiology of ossifying fibroma is unknown. Most OFs are found in young animals and have been reported to be present already at birth . In humaThe most frequent location of OF is mandibular, involving the premolar and molar region . OF in aComputed tomography (CT) overcame the limits of radiography, allowing for the good visualization of the size, localization, and impact on surrounded structures; it also provided the veterinary surgeon clear indications for the planned surgery ,40. HoweThe horse’s temperament and behavior allowed the surgery to be conducted as a standing procedure; therefore, the cost of the procedure and the risk of postoperative complications of standing up due to hemorrhage were significantly reduced. Surgery started with the dental extraction of Triadan 208. In this case, a dorsal approach to the roots through the external maxillary bone trephination and repulsion was recommended and more appropriate than the lateral approach through the buccal soft tissues (buccotomy) because of the oblique position and displacement into the nasal cavity .The persistence of oro–nasal fistula was a problematic complication. Probably in the initial period of treatment, the polyvinyl siloxane plug was incorporated too high, which prevented the alveolar closure of the upper part by granulation tissue. A later problem was keeping the packing material firmly in the alveolus. It was necessary to modify this method by adding a small plastic sleeve into the PVS packing material, which was attached by nylon thread to the button fixed on the surface of the maxillary bone. This method allowed the alveolar material to be maintained for a long time. The only observed side effect was that skin inflammation occurred due to the sutured button.To release the mass completely, it was necessary to make an additional excision of a nasal bone osteotomy. A direct approach to the nasal cavity via osteotomy over the nasal bone was described and is recommended for conditions such as an ethmoid hematoma, paranasal sinus cyst, and neoplasia, or in cases in which the preoperative diagnosis is uncertain ,48,49. TOFs tend to recur if they are not completely excised, and follow-up radiography is advised to monitor any re-growth ,38. As aIn conclusion, signs of early mass growth are unspecific and cause a delay in diagnosis. A preliminary diagnosis of ossifying fibroma can be made from its clinical appearance, its site of development, the age of onset, radiography, and CT, with subsequent definitive diagnosis after histopathology. Total removal is considered ideal for OF and is reported to reduce recurrence and improve the outcome.In this paper, computed tomography played an important role in the diagnostic procedure. Surgery was successful because the mass was well circumstanced. A direct approach to the nasal cavity through a bone appeared to be a good technique for tumor removal from the nasal cavity. In the presented case, the extraction and removal of the tumor was achieved, though the oronasal fistula represented the most challenging problem. A satisfying outcome was achieved using a modified PVS plug, but a significant improvement in complete closure was noticeable after the application of an autologous bone graft.


Fetal oropharyngeal teratoma (OPT) is an extremely rare disorder. This generally originates from the upper jaws that are connected to the hard palate. Pregnant women with fetal OPT usually present with oropharyngeal mass and polyhydramnios. Ultrasound can help in the pre-natal diagnosis of this condition, although magnetic resonance imaging (MRI) is useful for further characterization of the lesion. Because of severe obstruction to airways, OPTs are associated with high morbidity and mortality rates during peripartum period. We present here a case of fetal OPT with imaging characteristics with respect to the antenatal diagnosis. Oropharyngeal teratoma (OPT) is an extremely rare congenital teratoma, occurring in 1 in 35,000-200,000 of live births . EarlierOPT usually presents with oropharyngeal mass associated with polyhydramnios . The levA 21-year-old pregnant gravid 1, para 1 women with no significant past history presented during 27th weeks of pregnancy with lower abdominal pain and increasingly abdominal girth. There was no family history of malformation or any hereditary disease. Clinically, there was suspicion of polyhydramnios. No biochemical screening test for aneuploidy (including AFP) had been performed during the second trimester. On USG, a pedunculated polypoidal mass was seen protruding from the mouth of the fetus and freely floating in the amniotic cavity Figure . The masTeratomas are tumours consisting of all three layers of germ cells and account for around one-third of all neonatal tumours . They caClassically, a case of OPT presents with oropharyngeal mass, polyhydramnios and elevated maternal serum AFP level ,8. An OPMaternal serum AFP is a commonly used test during second trimester to assess a possible neural tube defect. An elevated level of AFP in maternal serum can lead to sonographic investigation and diagnosis of OPT ,8. AFP lOPT, as in our case, frequently causes polyhydramnios due to the foetus' inability to swallow the amniotic fluid. Polyhydramnios is also a significant factor for prognosis, since it indirectly suggests the degree of airway obstruction and the extent of tumour invasion. Moreover, polyhydramnios is often associated with an increased risk of pre-term birth, pre-term premature membrane rupture and neonatal respiratory distress. Palatal clefting is also often caused by these tumours; however, there was no cleft in the palate of our case .In general, USG is sufficient to diagnosis OPT in utero. Fetal MRI has complementary role and may be particularly helpful in determining the need for an EXIT procedure to be performed on a fetus . By defiOropharyngeal teratomas are a rare fetal tumour that can be diagnosed with the use of ultrasounds in utero. For the further characterization of tumour and post-delivery management, such as ex-utero intrapartum treatment (EXIT) procedure, MRI may be helpful. However, the prognosis of this condition is extremely grave and death can occur immediately after birth due to severe respiratory distress. Nevertheless, parents can be reassured that they are not at increased risk of bearing another child with the same lesion.


Hepatolithiasis (intrahepatic stones) is rare in adolescent patients and requires complex management strategies to prevent recurrent infections and progression to hepatic fibrosis. Surgical management is often required. In cases of unclear etiology, further work-up is indicated to provide insight into future management. In this report we describe an extensive stone analysis.A 20-year-old Caucasian female presented with known hepatolithiasis and multiple prior recurrent bouts of abdominal pain requiring hospitalization. Magnetic resonance cholangiopancreatography (MRCP) demonstrated an abnormal left-sided hepatic biliary ductal system dilatation. She was treated surgically with a formal left hepatectomy and preservation of the caudate lobe. The right ductal system had no stones or evidence of inflammation, and her bile and stones cultures were negative for organism growth. An extensive analysis demonstrated stone composition primarily of cholesterol.Adolescent presentations of hepatolithiasis are rare and considerations in the differential diagnosis include primary sclerosing cholangitis, bile acid transporter defects, and other known genetic diseases. This case is unique because only the left half of the intrahepatic ductal system had evidence of stone disease and the bile was sterile. A detailed stone analysis demonstrating cholesterol supersaturation provides additional context though the etiology remains unclear in this case and will require lifelong follow-up.Early-onset hepatolithiasis is rare and requires expert management, and in some cases definitive surgical management with life-long follow-up. Extensive stone analysis and genetic testing can be performed to help identify disease etiology in unique cases. The prevalence of hepatolithiasis is highest in East Asia and rare in Western countries . Moreove2A 20-year-old Caucasian female with a strong family history of early onset gallbladder disease first presented to our center with known hepatolithiasis and recurrent bouts of severe abdominal pain requiring multiple hospitalizations. She was first hospitalized at the age of 13 for right upper quadrant abdominal pain found to have choledocholithiasis with intrahepatic and extrahepatic biliary duct dilatation. She underwent endoscopic retrograde cholangiopancreatography during her admission had a subsequent cholecystectomy with no evidence of cholelithiasis. In the following years, she experienced recurrent bouts of severe abdominal pain without any fever or chills and multiple MRCP studies that demonstrated abnormal left hepatic biliary ductal system dilatation. At the time of her presentation to our center, she was noted to have a dominant stone impacted at the origin of her left main hepatic duct with a left sided dilated ductal system. She was taken to the operating room for a formal left hepatectomy. Intraoperatively, she was found to have palpable stone disease throughout her left liver with a large stone aggregate at the origin of the left hepatic duct. Choledochoscopy of the right sided ductal system demonstrated normal biliary epithelium without inflammation or stones. She was treated by formal left hepatectomy and preservation of her extrahepatic biliary tract. Her preoperative symptom of abdominal pain completely resolved, however, her recovery was complicated by the development of pruritus two weeks after discharge.An MRCP showed isolated and dilated biliary ducts from the caudate lobe with eventual resolution of her symptoms. Bile culture samples from the operative procedure were negative for organism growth. Pathology demonstrated numerous (up to 0.5 mm) yellow tan calculi filling the entire dilated left biliary ductal system and fibrosis and inflammation of the bile duct walls, as seen in the section of left liver lobe . The hepMaterial analysis of the stones was performed using Micro X-Ray Computerized Tomography (Micro-XCT) for density and internal structure, and Scanning Electron Microscopy (SEM) for ultrastructure. Elemental analysis was performed using Electron Dispersive X-Ray (EDX) Spectroscopy. Micro-XCT of stone cross section (not shown) demonstrated low mineral density throughout the specimen and a hollow core. SEM of the surface of whole specimens and of the core of fractured specimens demonstrated the stones were made almost entirely of smooth plates . EDX of 3This case report illustrates a unique presentation of hepatolithiasis for several reasons. While most patients are diagnosed with hepatolithiasis in the 5th or 6th decade of life, presentation in adolescence is rare. Primary considerations in the differential diagnosis include primary sclerosing cholangitis (PSC), recurrent pyogenic cholangitis, bile acid transporter defect, and Caroli disease. PSC is a chronic cholestatic liver disease of unknown etiology characterized by inflammation and fibrosis of intra and extrahepatic bile ducts leading to progressive stricturing and dilatation of the biliary ducts. Given the extensive stone disease and diffuse involvement of the liver specimen, this diagnosis is unlikely. In addition, PSC generally affects the entire biliary tract and is not isolated to one side of the liver as in our patient. Recurrent pyogenic cholangitis, which is endemic in East Asia, remains unlikely given the patient’s lack of travels to that area and Caucasian descent. Moreover, her frequent hospitalizations occurred without systemic signs of infections and her bile was sterile. A bile acid transporter defect, such as ABCB4/MDR3, can present with hepatolithiasis at a younger age, but the absence of significant disease in the right hepatic duct system argues against this as a cause [The stone analysis, while not revealing of a definite diagnosis, might help point in the direction of the etiology. The stones collected from this patient were composed primarily of cholesterol. Cholesterol is commonly found as a major component of stones in the extrahepatic ducts and gallbladder but it is rarely found as the main component in intrahepatic stones . In the Our patient will need close clinical follow-up as she remains at high risk of developing intrahepatic stone formation in her remant right liver. A life-time of interval liver function tests, and cross-sectional imaging is strongly recommended to detect early recurrent disease to prevent progressive indolent liver injury and ultimately liver failure. Indeed, occasionally in patients with recurrent pyogenic cholangitis, liver transplantation as a salvage therapy is required .4Presentations of early-onset hepatolithiasis is rare, particularly in Western countries. Definitive surgical management is required in complex cases. In cases with unknown etiology, further work-up is indicated and can include stone analysis and genetic testing. If indicated, life-long follow-up should be incorporated, as is the recommended management in this case. A detailed family history, genetic testing, and extensive stone analysis may be performed to help characterize disease etiology in unique presentations.The authors declare that they have no conflicts of interest.UCSF PROF PATH Pre-Doctoral Grant to support his research.Jorge Mena received the Ethical approval exempted by 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.Jonathan Freise: data collection, manuscript writing, design of study.Jorge Mena: performed stone analysis, manuscript writing and revision.Kwun Wah Wen: evidence collection, manuscript revision.Marshall Stoller: supervision of stone analysis, design of study.Sunita Ho: supervision of stone analysis, design of study, manuscript revision.Carlos Corvera: managed patient and performed the surgery, design of study, manuscript revision, corresponding author.1.Name of the registry: n/a.2.Unique Identifying number or registration ID: n/a.3.Hyperlink to your specific registration (must be publicly accessible and will be checked).Carlos Corvera.Not commissioned, externally peer-reviewed.


We report a 35-year-old-male orchidectomized because of a painless left testicular mass. Reactive left inguinal lymphadenopathies were visualized by post-operative ultrasound while findings compatible with orchiepididymitis with necrosis, testicular abscess or underlying neoformation process were found by contrast-enhanced CT. The pathological diagnosis of the surgical piece allowed the diagnosis of pure testicular yolk sac tumor (YST). While YST is a part of mixed non-seminomatous germ neoplasms in up to 79% of cases in the post-pubertal age , the purDiagnosis of pure YST, post-pubertal type, should be made only after meticulous microscopic examination rules out other germ cell components . In our


Soft tissue sarcomas of the upper extremities are very rare tumors. Due to the complex anatomy of the arm, the management of the soft tissue sarcoma becomes very challenging for the operating surgeons. Nonetheless, a large portion of the patients can be treated in a limb-sparing manner ,if surgical expertises are present .We report a case of 30 years old lady with soft tissue sarcoma of right arm operated in an another hospital, came to our institute with pain in the operated site and positive histological margins. The patient had feeble radial and ulnar artery pulses. We had done a MR angiography of that limb and it showed no flow from mid arm level in the brachial artery, but presence of collaterals around elbow joint. We had removed the residual tumor and also excised 14 cm of right brachial artery. On opening the brachial artery, tumor thrombus was seen along the whole length of the excised segment. The defect was reconstructed with reverse great saphenous vein graft taken from left leg. Post-operative period was uneventful. Doppler ultrasonography done at 6 and 12 months later showed good flow in the grafted segment with minimal narrowing of the anastomosis sites. Due to high incidence of local recurrence, amputation is the ultimate outcome of most of the upper extremity sarcomas in earlier days.This 30 years old lady from a remote village of Assam, India had a mild pain at the right forearm for last 2 years. She developed a small swelling in that region which gradually increased in size. She took treatment from local doctors, but not getting relieved of her pain and swelling. She then came to Guwahati city for better treatment and visited one of the private hospitals. Biopsy was done there along with CT scan. Biopsy came out to be a soft tissue sarcoma. She was operated in that hospital and discharged 5 days after surgery. Immediate post-operative period was uneventful. She again developed pain at the surgical site one month after the surgery. She was prescribed pain killers, but not getting relieved of her pain. After 6 months of this on and off pains, she was fade up and came to our institute. She was worked up extensively at our institute by the surgical oncology team. MRI of the arm showed residual disease and haziness around the neuromuscular bundle at the right arm. All pre-anesthetic work ups were done and the patient was put for surgery. Consent was taken regarding the consequences following brachial artery resection including amputation and requirement of great saphenous vein graft.The patient was intubated and operated under general anesthesia in supine position. Scar of previous surgery was excised. On exploration, it was found that tumor was in close proximity to the neurovascular bundle. On tedious dissection, we were able to separate the tumor from the median nerve, but it was not possible to separate the tumor from the brachial artery. We had to excise 14 cm of the brachial artery. There was tumor thrombus inside the lumen of the brachial artery. After that, we had marked the course of great saphenous vein on the left leg. With careful dissection, we had isolated approximately 16 cm of the great saphenous vein. That segment was cut and placed on a saline filled tray after marking the proximal and distal end .That isolated vein segment was transferred to the right arm after reversing its ends. First, we had done anastomosis of the proximal end near the shoulder joint and next at distal end near the elbow. Anastomosis was done with 9-0 ethilon round body under microscope . Both ulth post-operative day. For follow up, we advised the patient to come to surgical oncology/plastic surgery OPD at 2nd and 4th week and subsequently at 3rd, 6th and 12th month. We carried out a Doppler USG of the right upper limb at 6th and 12th months, which showed good flow at the great saphenous graft with minimal narrowing of anastomosis sites. Patient had no active complaint at the end of 12 months follow up.We had discharged the patient on 7et al. described a series of 105 cases of extremity and retroperitoneal sarcoma enblock excision along with important vessels and reconstruction with vein graft in a span of thirteen years.13 They have concluded that vascular resection to facilitate excision of soft tissue sarcoma had an acceptable long term patency rate. Although the encasement of the vascular bundle did not represent a contraindication to surgery, there was an association with a high metastatic risk by virtue of the locally advanced nature of the disease and this should be considered when planning treatment.13 Our patient did not have any recurrence during this one year follow up.Soft tissue sarcomas of extremities are very difficult to manage due to its complex anatomy of arm and the tumor involves many vital structures. Radaelli et al. described a series of 15 cases of primary vein graft in free tissue transfers, while the mean length of the grafted vein was 10.8 cm. They mostly used cephalic vein as graft.14 Free flap success rate was 100% (15 out of 15) in their study. At follow up, Doppler ultrasonography at 6th and 12th month showed patent graft in our case. Donor site morbidity was significant in cardiac bypass patients. A review of the data in the cardiac registry at The Lehigh Valley Hospital  showed 0.6% donor site (leg) related complications in hospitalized patients.15Nemoto 15 In our patient, she did not have any such problems during this one year follow up. Vein grafting is an important tool in reconstructive microsurgery. With judicious patient selection, proper technique of graft harvesting and anastomosis, good patient outcome can be achieved.It may be due to the poor general condition, prolonged hospital stay and associated comorbidity of these patients. The leg problems have included cellulitis, hematomas or seromas, chronic edema, saphenous neuralgia, hypertrophic and unstable scar.


Melorheostosis is a very rare bone dysplasia, especially in the hand. Most cases were diagnosed incidentally, with the lower limbs being the most affected. This is the first Saudi woman with hand melorheostosis.A 33-year-old Saudi female had mild to moderate right-hand pain that started six years ago. Hand examination showed a full range of motion and full hand grip, and there was no tenderness upon palpation. Plain X-ray, unenhanced CT scan, and MRI of the hand showed an appearance resembling dripping candle wax as melorheostosis. The bone scan showed a nonvascular and nonacute lesion. An unenhanced CT scan demonstrated cortical and endosteal hyperostosis involving the proximal, middle, and distal third and fourth phalanges. Multi-sequential MRI of the hand demonstrated cortical hyperostosis involving the ulnar and radial aspect of the right fourth proximal, middle, and distal phalanges.Features in the X-ray, CT scan, bone scan, and MRI confirmed a diagnosis of melorheostosis with associated flexor tenosynovitis. Melorheostosis is a very rare bone dysplasia, especially in the hand with limited reports in the literature. It has no clear etiology with an equal incidence rate among males and females, and its main features involve dermal, soft tissue abnormalities, and the anomalous bone formation -2. The iPatients commonly present with pain, deformities, limitations of a range of motion, contractures, muscle atrophy, and limb swelling . Most caMelorheostosis is diagnosed through standard radiographs, which show a linear area of osteosclerosis along with the affected bones, producing a dripping candle wax appearance . This caA 33-year-old Saudi female patient who was medically free and in her usual state of health until about six years ago started to have mild to moderate right-hand pain. According to her, the pain comes and goes with 4/10 in severity, no aggravating or releveling factors. Pain is not affecting her life. History was negative for weight loss, fever, or night sweats. Hand examination showed a full range of motion and full hand grip, and there was no tenderness upon palpation. Laboratory tests were regular. A plain X-ray of the right hand was obtained in posteroanterior and oblique views, as well as a dedicated lateral view for the ring finger. Wavy hyperostosis was noted involving the ulnar as well as the radial aspect of the fourth proximal, middle, and distal phalanges as well as the ulnar aspect of the third proximal and middle phalanges with extension to the soft tissue that showed soft tissue swelling. The appearance resembles dripping candle wax appearance, most likely representing melorheostosis Figure .A bone scan of the hands followed total body bone scan. The left fourth proximal, medial, and distal phalanx and the left third middle phalanx showed intense tracer uptake in the bone phase with no corresponding increased tracer uptake in the flow in blood pool images indicating nonvascular lesions. The rest of the whole body skeleton shows no abnormal, localized tracer uptake. The described lesions were nonvascular and nonacute Figure .An unenhanced CT scan of the right hand was obtained in control, axial, and sagittal reformats and demonstrated cortical and endosteal hyperostosis involving the proximal, middle, and distal third and fourth phalanges. It showed mild adjacent soft tissue bulge. However, the adjacent interphalangeal joints appeared unremarkable with no visible deformity. The above features were suggestive of the melorheostosis Figure .Multi-sequential MRI of the hand was obtained with tumor protocol and demonstrated cortical hyperostosis involving the ulnar and radial aspect of the right fourth proximal, middle, and distal phalanges. There appears low signal in all sequences, and there was a minimal extraosseous extension, especially at the volar aspect with subsequent mild soft-tissue edema and swelling. Less pronounced changes involved the third proximal phalanx and middle phalanx with minimal soft tissue extension and bulge at the ulnar aspect. There was associated minimal joint effusion and synovial thickening at the third and fourth proximal interphalangeal joint as well as features of the flexor tenosynovitis of the ring finger Figure .With a previous X-ray and CT scan, the above features were reported, and a diagnosis of melorheostosis with associated flexor tenosynovitis was given. No active treatment was needed for the patient. She was referred to physiotherapy, which reduced her pain. During her four years follow up at our hospital, there were no changes in her symptoms or the size of her hand, also no change in the radiological images.Leri’s disease or melorheostosis was first described in 1922. It is a rare mesodermal bony dysplasia that may involve surrounding soft tissue -11. PainThe gene mutation in MAP2K1 was discovered in patients who were diagnosed with melorheostosis . Lab invA study has shown that the gene mutation was given in MAPK1, causing “Wax appearance” and suggested that MEK1/2 inhibitors are the future treatment in such conditions . A previDiagnosis of melorheostosis may be confirmed by radiological studies such as X-rays, CT, MRI, and bone scan . Bone scIn the case presented in this study, the patient showed disclosed wavy hyperostosis in both ulnar and radial aspects of the fourth proximal, middle, and distal phalanges. Also, only the ulnar aspect of the third proximal and middle phalanges with extension to the soft tissue and swelling as well. The appearance resembles dripping candle wax, which made the diagnosis for us after excluding other differential diagnoses. The differential diagnosis in such a case should be considered, which are infection like myositis ossificans or malignancy like periosteal osteosarcoma or osteopoikilosis . And forWe present a case report of a rare pathology in unusual site affection with no previous reports in studies or literature in Saudi Arabia. Regardless of the incidence globally, it is recommended for researchers, readers, and physicians to be familiar with good knowledge about the uniqueness of the disease. It is always better to diagnose it early to avoid comorbidity and operative complications. The lack of knowledge and awareness of similar cases of rare diseases could lead to misdiagnosis and unexpected complications.The presented case needed no active treatment; however, in other cases, melorheostosis is a benign dysplasia that can trigger severe morbidity. Melorheostosis morbidity usually tends to be due to pain, contractures, limitation of joint motion, differences in length of limb, and bone deformities. Treatment of melorheostosis includes medical treatment for symptom control and soft surgical treatment complication in tissues .This is a rare case of a 33-year-old Saudi female with mild to moderate right-hand pain that started six years ago. Dripping candle wax appearance was found in plain X-ray, bone scan showed nonvascular lesion, CT scan showed cortical and endosteal hyperostosis of the phalanges, and MRI showed cortical hyperostosis of the ulnar and radial aspect of the right fourth proximal, middle, and distal phalanges. All reported features confirmed a melorheostosis diagnosis.


However, the definitive diagnosis relies exclusively on histological and immunohistochemical techniques. We present a case of a 62-year-old Caucasian female complaining of signs and symptoms suggestive for cholecystitis. On ultrasonography, the gallbladder appeared enlarged and filled with a necrotic mass; thus, the presence of adenocarcinoma was suspected. Multislice Computerized Tomography (MSCT) demonstrated no distant metastasis. An extensive radical cholecystectomy was performed, and histological techniques confirmed a leiomyosarcoma diagnosis. In addition, adjuvant chemotherapy of doxorubicin and ifosfamide was administrated. The patient was on follow-up for 2 years and is doing well till date. The discrimination of gallbladder sarcoma preoperatively remains a clinical and radiological challenge. Although radical resection of the tumor remains the mainstay of the treatment, we believe that adjuvant chemotherapy should be administrated in such cases. However, further studies are required in this field.Leiomyosarcoma (LMS) of the gallbladder is an extremely rare entity. Most reported cases were mistakenly diagnosed preoperatively as cholecystitis with or without cholelithiasis. We believe that our article demonstrates the 5 Primary sarcoma of the gallbladder is an extremely rare diagnosis, and one of its common subtypes is leiomyosarcoma (LMS).This neoplasm was first reported in 1879, while the first detailed description was made by Landsteiner in 1904 , 3.rd in this series. This neoplasm is rarely diagnosed preoperatively. The accurate diagnosis is only established with histological and immunohistochemical techniques after cholecystectomy [Our search through the medical literature revealed only 22 other case of LMS. Therefore, we believe that our case is the 23stectomy .A 62-year-old Caucasian woman was admitted to the hospital complaining of abdominal pain in the right upper quadrant that started a month ago. The pain was severe, nonradiating, and colic. It was exacerbated by eating fatty meals and was responded to heavy analgesics. She also suffered from nausea, bilious vomiting, constipation, fever reaching 39°C that lasted for 10 days, chills, anorexia, and fatigue. There was no history of weight loss, pallor, jaundice, smoking, or alcohol consumption. Formerly, she was in good health as she did not report any previous illnesses or surgeries and her family history was unremarkable.On examination, Murphy's sign was positive and there was tenderness over the gallbladder area with a firm palpable mass.Laboratory workup showed a normal hemogram and liver function tests. On abdominal ultrasonography, the gallbladder measured 8.7 × 4.8 cm and was filled with necrotized mass and all edges of the gallbladder were clear except for the bottom . TherefoAs a result, a provisional diagnosis of gallbladder adenocarcinoma was made and extensive cholecystectomy that involved cholecystectomy, main bile duct resection, and regional lymph node dissection was performed. Intraoperative findings showed no liver metastasis, ascites, peritoneal, or omental deposits. Porta was free, and there was no colonic or duodenal infiltration and no enlarged pericholedochal, paraaortic, or aortocaval lymph nodes.On microscopy, the tumor consisted of diffuse proliferation of pleomorphic spindle to oval tumor cells with marked variation in size and shape and the presence of many abnormal mitoses and large hyperchromatic nuclei . FurtherImmunohistochemical investigations were strongly positive for smooth muscle actin (SMA) and desmin and negative for CK, CD117, and CD34 . Therefo2)+ifosfamide (days 1-3: 2000 μg/m2); repeated monthly for 6 cycles). No serious adverse effect or toxicity has occurred. However, radiotherapy is not available in our city. The patient was on follow-up for 2 years; there was no clinical or radiological evidence of recurrence or relapse as observational MSCT scans were clear for any local invasion or distal metastasis, and the patient is doing well till date.Although there is no sufficient evidence regarding the effectiveness of adjuvant chemotherapy with or without radiotherapy, our patient received 6 cycles of adjuvant chemotherapy as the following regimen:  and mainly in their 6 of life –6, 8.th case in this series [In our search among almost 200 reported PGBSs, there were only 6 cases that were suspected to be malignant preoperatively. Only 4 had the definitive diagnosis of LMS. Thus, our case represents the 5s series . Howevers series , 9.Patients with GB sarcoma suffer from nonspecific symptoms that can be divided into two categories , 10. TheLMS coexists with cholelithiasis in 82% of cases. Therefore, it was related as a primitive factor, although the casual relationship remains circumstantial and unclear [Radiological findings on CT scan and ultrasonography may include a dilated gallbladder, an irregular thickening of the wall, and a necrotizing mass protruding into the lumen , 5. The The differential diagnosis of a solid polypoidal gallbladder mass is wide and includes adenomas, adenocarcinomas, and neoplastic polyps such as cholesterol polyps, inflammatory polyps, and adenomatous hyperplasia , 5. The The extensive differential diagnosis of spindle cell tumors of the gallbladder includes leiomyosarcoma, rhabdomyosarcoma, fibrosarcoma, neurosarcoma, epithelioid angiosarcoma, gastrointestinal stromal tumors (GIST), carcinosarcoma, and primary or metastatic undifferentiated carcinoma , 3, 5, 7Immunohistochemical techniques are the best way to differentiate between sarcomas. The spindle cells in LMS are arranged in a fascicular pattern and have eosinophilic cytoplasm with round to oval nuclei . As prevLMS of the gallbladder has a very poor prognosis with a 5-year survival rate less than 5% , 5, 8, 9The treatment of choice remains radical cholecystectomy, and in advanced cases, regional lymph node dissection should be performed , 5, 8. ALMS of the gallbladder is rare and hard to be differentiated from other malignant subtypes. In most cases, it is falsely diagnosed as cholelithiasis and cholecystitis.Although radical resection of the tumor remains the mainstay of the treatment, we believe that adjuvant chemotherapy should be administrated in such cases. However, further studies are required in this field.


Laparoscopy is a relatively new surgical approach in developing countries. Migrated foreign bodies into the body cavities could be very distressing to patients, relations and caregivers. There are paucity of migrated Steinmann pin and laparoscopic retrieval methods in literature.An innovative approach of laparoscopic retrieval of migrated sharp foreign body (Steinmann pin).A two-port technique was used to retrieve the pin. These ports consisted of optical supra-umbilical port (10 mm) and left iliac fossa port of 10 mm. They were aligned in the direction of sharp end of the foreign body, to aid retrieval of the Steinmann pin.This procedure was performed on a 34-year-old man who presented with migration of Steinmann pin into abdominal cavity.He had open reduction of old unreduced left posterior hip dislocation. A Steinmann pin with a diameter of 4.5 mm and length of 140 mm was passed through the greater trochanter to the acetabular roof. The protruding end of the pin ought to have been bent. Three weeks post-surgery, the pin migrated.Physical examination revealed vague tenderness over supra pubic region. A hard pointed object was palpable in the right iliac fossa. Abdominal X-ray and ultrasound were suggestive but not definite for pin location.A sharp Steinman pin was retrieved from the abdominal cavity using laparoscopy.Migration of Steinmann pin is unusual. Laparoscopy is an innovative approach to foreign body retrieval. This could help reduce the morbidity that may be accompanied by other modalities such as open approach. It has been used in rare and difficult disease conditions . Foreign2An innovative approach of laparoscopic retrieval of migrated Steinmann pin (sharp foreign body).3A 34-year-old man presented with migration of Steinmann pin into the abdominal cavity 3 weeks post operation.He underwent open reduction of old unreduced left posterior hip dislocation. The reduction was maintained by insertion of a 140 mm long by 4.5 mm in diameter Steinmann pin. The pin was passed through the greater trochanter to the acetabular roof. Three weeks post-surgery the pin migrated.Initially, he was asymptomatic. However, on the 8-week post operation, he started complaining of vague lower abdominal pain. He had no history of haematuria, haematochezia, and change in bowel habit. Also, no history of nausea, vomiting or abdominal distension.Physical examination revealed vague tenderness over supra pubic region. A hard pointed object was palpable in the right iliac fossa suggestive of the foreign body. The surgical incision site had healed primarily.Investigations done showed that serum electrolyte, urea, creatinine and complete blood count were all within normal range. The abdominal ultrasound scan demonstrated a hyperechoic structure (Steinmann pin) with acoustic shadow. It could not localize the foreign body. Plain abdominal radiograph showed presence of pin. The pre-operative and post-operative radiographs at time of migration were as shown in Patient was prepared and planned for emergency diagnostic and therapeutic laparoscopy.4A two-port laparoscopic technique was performed to retrieve the pin. The ports consisted of optical supra-umbilical port (10 mm) General anaesthesia was used. The patient’s position was supine initially. Aseptic protocols were routinely observed. Supra-umbilical port was created using direct trocar access. Carbon dioxide gas was used to achieve pneumoperitoneum. The pre-set pressure was 12 mmHg. A 30° telescope was inserted and a diagnostic laparoscopy carried out. Intra-abdominal organs and bowel were essentially normal. The patient’s position was then changed to right lateral.The Steinmann pin was seen intra-operatively, lying longitudinally in the left para-colic gutter. 5A sharp Steinman pin measuring 4.5 mm in diameter and 140 mm in length was retrieved from the abdominal cavity. The visceral and other intra-abdominal structures were normal.Patient was discharged 48 h post-operation, in a clinically satisfactory condition. His outpatient follow-ups were uneventful.6The use of Steinmann pin after open reduction of old unreduced hip dislocation is a common practice in orthopaedic surgery .There are reports showing Intra-abdominal migration of pins and wires after fixation of proximal femoral fractures and hip surgeries ,5. The pClinically, localising the migrated pin may be challenging. Plain abdominal radiograph done A and B iLaparoscopy appeared to be the gold standard as it is both diagnostic and therapeutic.Some authors reported retrieval of sharp orthopaedic instruments ,7 and reThe major morbidity following open retrieval has been significantly reduced by laparoscopic retrieval. The authors encourage bending of the protruding part of pin during insertion or to use alternative pins to prevent migration.7Migration of Steinmann pin is unusual. Laparoscopy is an innovative approach to foreign body retrieval. This could help reduce the accompanying morbidity that may occur using other modalities such as open approach.No Conflict of interest.No Source of Funding.Exemption of Ethical approval was given because no identifiable patient’s parts were seen and case was performed as emergency.Written and signed consent to publish as case report was obtained from the patient.POI - performed the procedure, conception, drafting of the manuscript and design and have given final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.NEB - Assisted the procedure, design and drafting the manuscript and also agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Acquisition of data, or analysis and interpretation of data and drafting the manuscript.NE - Conducted the imaging studies, acquisition of data, or analysis and interpretation of data, including interpretation of radiological images.SLH - Acquisition of data and revising it critically for important intellectual content.Innovation and Case report.PO Igwe.Not commissioned, externally peer-reviewed.


Proximal femoral focal deficiency is an extremely rare congenital anomaly with an incidence of 1.1–2.0 in 100,000 live births. It is a dysplastic phenomenon with predilections for the proximal two-thirds of the femur leading to limb length discrepancies.We report two cases of proximal femoral focal deficiency, which is a rare entity.Case 1A 4.5-month-old baby Annang tribe girl was referred in April 2019 to our Radiology Department, University of Uyo Teaching Hospital, Nigeria for lower limb radiographs. This was on account of her shortened left lower limb from birth despite uneventful antenatal history. An examination revealed bulky left thigh with abduction of her left hip joint.Radiographic evaluations showed absent left femoral capital epiphysis, with deficient proximal left femur. A diagnosis of proximal femoral focal deficiency was made. Sadly, the parents and baby failed to honor future orthopedic consultations on intimation of sequential management protocols.Case 2A 4-month-old baby Ibibio tribe girl was similarly referred in August 2019 to the same Radiology Department for lower limb conventional radiographs due to short left lower limb that was noticed from birth. An examination showed shortened left lower limb in external rotation. Her right and left lower limbs measured 27 cm and 23 cm, respectively, with landmark taken from anterior superior iliac spine to tip of medial malleolus. A diagnosis of proximal femoral focal deficiency was made. Corroborating radiographs showed shortened and hypoplastic left femoral shaft but preserved femoral capital epiphysis. Coincidentally, the parents have not brought back their baby to our orthopedic clinic.The discovery of two cases of proximal femoral focal deficiency, a rare entity, from referrals for conventional radiography in our Radiology Department encourages literature documentation. Such recognition will facilitate early institution of management, thus ensuring meaningful childhood growth. Proximal femoral focal deficiency (PFFD) is a subset of a broader group called congenital femoral deficiency. PFFD is also known as congenital proximal femoral deficiency (CPFD) . It is aPFFD is a dysplastic phenomenon with a spectrum of femoral involvement. This ranges from hypoplastic shortened femur to total absence of proximal two-thirds of femur. Severe affectation may even culminate in femoral agenesis . Patho-aAlthough a rare and sporadic case, it is intriguing, but serendipitous, on our part to have two cases of PFFD in our hospital in less than 6 months. This, therefore, necessitates adding to the existing literatures on PFFD, especially with a dearth of such reports in West African sub-region [We aim to report two cases of unilateral focal femoral shortening identified between April and August, 2019 at the University of Uyo Teaching Hospital (UUTH), Uyo, Nigeria.A 4.5-month-old baby Annang tribe girl was referred by our Orthopedic Unit, UUTH, Uyo to the Radiology Department of the same hospital in April 2019. This referral was for radiographic evaluations of her lower limbs with inclusion of the pelvis. The main clinical presentation was a history of shortened left lower limb from birth with gradual progression of deformity. She was a full-term spontaneous vertex delivery of a non-consanguineous marriage. There was no antenatal history of maternal diabetes, non-prescribed drug intake, or perinatal exposure to radiation. There was no history of trauma to or fall of her mother during the antenatal period. There was no positive family history of previous similar occurrence. Her four older siblings do not have any shortened limbs.On physical examination, her left thigh was bulky with flexion, lateral rotation, and abduction of the left hip joint see Fig. . The ranRadiological evaluations showed deficient proximal left femur with lateral bowing of its residual shaft. The left femoral capital epiphysis could not be visualized vis-à-vis the contralateral side see Fig. . On repoA 4-month-old baby Ibibio tribe girl was referred in August 2019 to our Radiology Department, UUTH, Uyo, Nigeria from the Orthopedic Unit for plain radiography of her lower limbs; this was on account of her short left lower limb noticed from birth. Her parents said that her left lower limb was getting progressively shorter but she had no other abnormalities. Antenatal history, past medical history, and family history were not remarkable. There was no history of trauma to the mother during pregnancy or perinatal exposure to radiation. Developmental milestones had been normal so far.On physical examination, she appeared otherwise normal and well nourished. Both her lower limbs were actively mobile. Her left lower limb was shortened and in external rotation see Fig. . Her rigPlain radiographs of her thigh and lower limbs showed shortened and hypoplastic left femur with preserved left femoral capital epiphysis. Her left femur had normal configuration but had a shorter shaft than the contralateral femur. The shaft of her left femur measured 9.41 cm whereas the shaft of her right femur measured 11.88 cm (see Fig. On receipt of the radiographs, the possible plans of management were discussed with her parents. Unfortunately, they have not kept any further appointments. Recent telephone communications in December 2019 with the parents revealed that the child has been left to her fate. This is because of the parents’ belief of spontaneous limb lengthening.PFFD, as mentioned earlier, is an extremely rare congenital anomaly with few case reports in the literature . TherefoThe diagnosis and classification of PFFD have been majorly based on conventional radiographic features . As suchThere are known risk factors for PFFD. Some of the inciting teratogenic agents for PFFD are hypoxia, ischemia, diabetes mellitus, irradiation, microbiological agents, chemical toxicities, hormones, mechanical injuries, thermal injuries, thalidomide exposure, and trauma to the fetus between the fourth and eighth weeks of gestation , 3. InteOn clinical examination, PFFD shows as limb discrepancies with short bulky affected thigh. Significant variability in the clinical presentations is based on the degree of femoral deficiency . The lowThe diagnosis of PFFD requires the presence of a shortened femur with proximal femoral deficiency. Deficiency of iliofemoral articulation, leg length discrepancy, limb malrotation, and varus deformity at the sub-trochanteric level may also be seen . These fThe multi-planarity and non-ionizing characteristics of MRI make it the more definitive and preferred modality for evaluation of PFFD. Usually, coronal and axial sections suffice , 18. MRIPFFD poses a significant challenge to effective treatment . It demaSince the most apparent functional deficit in PFFD is shortened limb, as mentioned previously, this creates room for non-surgical treatment. Thus the first step in most treatments of a child with PFFD coincides with the time when the child is ready to stand . The chiBroadly, surgical management of PFFD could be limb lengthening or limb modification. Limb lengthening is a complex reconstruction of the hip and knee joints with limb lengthened up to 25 to 30 cm , whereasLimb lengthening with or without contralateral epiphysiodesis will be appropriate for a child if the predicted limb discrepancy at maturity does not exceed 20 cm, and the hip is stable with relatively good knee, ankle, and foot . OtherwiLimb modification surgery for PFFD includes Van Nes rotationplasty. This rotationplasty or Van Nes’ so-called turn-about procedure is done for patients with severe deformity with the aim of levelling the ankle of the involved side with the knee of the uninvolved side . It is aThe strength of this study revolves around the aforementioned rarity of this condition. The treatment of these cases at early ages would have been of immense contribution to good management and favorable prognosis.The limitation of this study is the fact that the parents absconded with the babies. Although it is their prerogative to seek treatment in any desired place, we lost the privilege of managing these patients, assessing management outcome, and evaluations of childhood growth. We are compelled to rationalize that the parents must have resorted to traditional bone setters. This is a commonplace festering problem in our local clime. They only resort to orthodox bone treatment when faced with complications. We have resorted to advocacy to stem the tide. Another limitation is that radiographic evaluation tends to overestimate the degree of deficiency . The appPFFD is a rare congenital anomaly with a spectrum of affectation of the proximal two-thirds of the femur. The presence of two cases detected at early stages called for literature documentation. Besides, such early detection would have warranted timely intervention with consequent anticipated good childhood growth.


Fecal retention in the blind loop of end to side colonic anastomosis can lead to fecaloma without significant colonic distension. Imaging study and colonoscopy examination can assist in making a definite diagnosis. Revision surgery is the last choice when colonoscopic extraction fails. Fecal retention in the blind loop of end to side colonic anastomosis can lead to fecaloma without significant colonic distension. Imaging study and colonoscopy examination can assist in making a definite diagnosis. Revision surgery is the last choice when colonoscopic extraction fails. Her surgical history included segmental colonic resection with end to side colo‐colonic anastomosis six years ago for a complicated diverticulitis. Abdominal examination revealed a large left lower quadrant palpable mass. Clinical presentation was suspicious for colon cancer. Computed tomography of abdomen showed 12‐centimeter colonic fecaloma with colo‐colonic intussusception in the left side of the colon Figures  showed aFecaloma is a rare condition, usually associated with colonic distension and constipation. The postoperative fecolith has been identified after appendectomy. Clinical presentation with constipation, abdominal pain and colon mass on imaging studies often mimics malignancy. A thorough review of the prior operative note, imaging studies, and colonoscopy is diagnostic. In the presented case, fecaloma resulted from blind loop at the colonic anastomosis site. Colonoscopic extraction with carbonated fluid injectionNone declared.Jasbir Makker,MD has managed the patient and critically reviewed the manuscript and images. Hafsa Abbas, MD has managed the patient and reviewed the manuscript. Kishore Kumar, MD has managed the patient and reviewed the manuscript. Peter Bhandari, MD reviewed the manuscript. Harish Patel, MD managed the patient, wrote the manuscript, and reviewed the references.


Gastric diverticula rarely occur in adolescence. In adults, they are predominantly congenital, asymptomatic, and are located adjacent to the gastroesophageal junction on the posterior aspect of the stomach wall. In this report we present a 14-year-old female who underwent laparoscopic gastric diverticulectomy after incidental discovery on magnetic resonance urography. Though gastric diverticula are uncommon in children, 4% of all the identified gastric diverticula are discovered in people less than 20 years of age. Recognition of this congenital malformation is helpful in identifying the correct treatment and avoid potential complications, such as ulceration or perforation . In thisA 14-year-old female presented to our service following an incidental finding of a gastric diverticulum on magnetic resonance urography Figure . HoweverThe patient began omeprazole for her intermittent abdominal pain prior to the procedure and was instructed to continue the medication after surgery. In the operating room, a 2 cm infraumbilical incision was made, and electrocautery was used to progress through the subcutaneous tissue. The stalk of the umbilical hernia was isolated, opened, and a 5 mm port was inserted in the fascial defect. Carbon dioxide was infused into the abdominal cavity to a pressure of 15 mmHg. Three additional 5 mm ports were placed in the left and right upper quadrants and right mid-abdomen. The anterior surface of the stomach was free of abnormalities. The lesser sac was opened, and the short gastric vessels were divided using the LigaSure Maryland jaw device . At the gastric fundus, approximately 2 cm distal from the gastroesophageal junction, the wide-mouth GD was identified Figure . Of noteGD are rare compared to diverticula found in other locations throughout the gastrointestinal tract. The literature suggests the overall prevalence ranges from 0.01% to 0.11% in upper gastrointestinal endoscopies and up to 0.02% in autopsy studies . Most paAs was the case in our patient, GD are often discovered incidentally on cross-sectional imaging performed for other reasons but appears to be the source of her intermittent abdominal pain. When located posteriorly, GD seen on CT and MRI may be misinterpreted as left adrenal, splenic, or pancreatic tail pathologies . This isAsymptomatic diverticula do not require intervention; however, conservative treatment with proton pump inhibitors, histamine (H2) receptor antagonists, or antacids can provide temporary relief of symptoms . In all Gastric diverticula, while rare and often asymptomatic, can occur in children with vague abdominal symptoms. Cross-sectional imaging can detect and diagnose these lesions; however, at times they can be confused for other pathologies on these studies. Most GD can be diagnosed on UGI exams but ones with narrow necks may not be detectable if they do not fill with contrast. In such cases EGD can make the diagnosis by direct visualization. To avoid complications, laparoscopic resection is recommended for symptomatic cases or those with bases measuring more than 4 cm in diameter.


Background: Bladder adenocarcinoma (AC) is a scarce histological variant and there are few studies on its proper management. No previous case reports present the management of a urachal tumor and the incidental finding of bladder adenocarcinoma.Clinical case: We present the case of a young woman with nonspecific symptoms, who presented with a prior history of dysuria, bladder tenesmus, suprapubic pain and urinary urgency for one year, which had been treated as recurrent urinary tract infection. A partial cystectomy plus extended lymphadenectomy was scheduled. We found a bladder tumor with characteristics of a urachal tumor and the pathological report indicated a primary bladder AC. The patient had a complete recovery at one year of follow-up.Conclusions: A patient can present with a tumor with urachal characteristics; however, the pathology report can show primary AC. The decision to perform partial cystectomy was an appropriate option for the location of this tumor, with optimal surgical results. Still, a long-term follow-up is necessary. More specific management guidelines are required for the treatment of AC. Within bladder tumors, adenocarcinoma (AC) is a histological variant that represents only 0.5–2% of cases. Its prognosis is the poorest, given that it is diagnosed in more advanced stages due to its rarity. There is little literature about its management and there are no standard treatment guidelines.1.Its association with a history of bladder exstrophy, schistosomiasis and chronic bladder irritation has been described. Due to intramural growth, the symptoms occur later in disease progression and AC is diagnosed in more advanced stages, so the prognosis is worse. Only 5% of cases are diagnosed during the initial stages. Hematuria is the most frequent symptom (60–100% of cases), and irritative symptoms and mucosuria are also common (25–80% of cases)Bladder AC can be classified as primary or secondary, the latter occurring by direct extension or by metastasis from a distant site like the colon, prostate, endometrium, cervix or breast. Strictly, the urachus is not an intrinsic component of the bladder. However, urachal AC is usually described with bladder tumors because they share pathological and clinical features. Therefore, bladder AC can be classified as urachal AC (10–30%) and non-urachal AC (70–90%).2. Histologically, it shows several growth patterns: enteric, morphologically identical to its colonic counterpart; or mucinous, with abundant extravasated mucin, including signet ring cells.Primary bladder AC shows a pure glandular phenotype. It usually arises from the trigone and the posterior wall but can be found anywhere in the bladder. It usually presents as a solitary lesionUrachal AC develops from the remnant of urachus. It presents as a solitary polypoid mass in the dome of the bladder, although it can be seen anywhere along the anterior midline, and it can affect the Retzius space and the anterior abdominal wall. Microscopically, it is very similar to primary AC, the mucinous variant being the most frequent.Here, we report an incidental case of a patient with bladder AC treated as urachal AC who presented good oncological results at one year of follow-up. What is unique about this case is that urachal AC tumor management was proposed because of the clinical findings; however, the urachus was ultimately found to be tumor-free.The patient was a 35-year-old mestizo woman, who works as a junior manager, with no clinical history of hematuria, bladder tumors or prior surgical interventions and no family history of bladder tumors. The patient presented to the urology practice with a prior history of dysuria, bladder tenesmus, suprapubic pain and urinary urgency for one year, which had been treated as recurrent urinary tract infection with broad spectrum antibiotics. The patient presented negative cultures; however, the symptoms did not disappear. A timeline of the major timepoints in the patient’s history, diagnosis and treatment is provided .A physical abdominal and genitourinary exploration was carried out. There were no positive findings upon physical examination and no painful trigger points were found. There were no signs of vulvar irritation or palpable abdominal mass.A bladder screening ultrasound was performed in order to identify any abnormal structure or urinary retention. During the exam the bladder was full, and a bladder dome mass was noted. A unique, polypoid mass with mucoid characteristics of 4.0cm was found using urethrocytoscopy. A lower abdomen contrasted CT scan was performed and a collection/mass was located on the anterior and superior edge of the bladder of 60 by 40mm, which was cystic and solid (density of 30UH) and had peripheral calcifications . FollowiMobile solitary tumors that are away from the base may potentially benefit from partial cystectomy, so a partial cystectomy plus extended lymphadenectomy was scheduled . There wThe surgical intervention was performed by an experienced surgeon without complications. A bladder dome mass of approximately 5cm was resected. In the partial cystectomy pathology report, an invasion of the proximal third of muscle layer was described. Clear surgical margins were reported, and no positive lymphatic nodules were found. There was no evidence of infiltration in the area corresponding to the remnant of urachus. Immunohistochemical analysis showed the tumor tested positive for Cytokeratin 20 (CK20) and Cytokeratin 7 (CK7) that are distributed in epithelia and their neoplasms. However, the test for carcinoembryonic antigen (CEA), which is a marker of colon carcinoma cells, was negative.The urachus was tumor-free . HoweverThe patient was discharged 10 days after the surgical intervention. Cephalexin 500mg three times a day was prescribed for five days after discharge. The Foley catheter was removed 14 days after surgery. No complications and no urinary fistula were reported. No chemotherapy was administered. No signs of recurrence were observed during a CT scan and urethrocystoscopy performed after a follow-up period of one year.Although the bladder is not a common site of metastasis, secondary AC is more frequent than primary AC. Cancer cells can spread by direct extension or by the hematogenous/lymphatic route. During diagnosis, ultrasound is useful as an initial imaging test; however, CT scanning and MRI provide solid information to determine the extent of the disease, rule out metastases and evaluate if it is potentially resectable. In our case report there was evidence in the CT scan that a collection/mass was located on the anterior and superior edge of the bladder; however, it may have been interesting perform an MRI in order to precisely identify any urachal involvement.A mass in the midline, solid or cystic, with calcifications is considered a major finding indicative of urachal AC. Cystoscopy and transurethral resection of the tumor confirms the diagnosis. Peritoneal carcinomatosis, as well as peritoneal pseudomyxoma, can be a finding in patients with metastatic disease. The analysis of CEA, CA125 and CA19-9 antigen levels should be carried out, which may be elevated in 40%–60% of these patients. The diagnosis of primary bladder AC should be made only after the exclusion of a secondary AC. Therefore, it is necessary to perform colonoscopy, endoscopy, mammography and colposcopy. The histopathological findings are difficult to use to differentiate between the types of AC and immunohistochemistry has limited utility for the differential diagnosis. The diversity of AC means that cytological preparations are a challenge because immunohistochemistry has limited utility.1. In urachal AC, partial cystectomy is the standard procedure, with block resection of the bladder dome, urachal ligament, and umbilicus4. Lymphadenectomy (LD) is necessary when the incidence of lymph node metastasis in AC is high at the time of diagnosis. LD improves survival, time before recurrence and staging. Therefore, performing extended LD would be the most appropriate option in these patients5.The low frequency of AC and the absence of large studies explain the absence of clearly established therapeutic guidelines. In primary AC, radical cystectomy and dissection of pelvic lymph nodes are the first option. However, mobile solitary tumors that are away from the base may potentially benefit from partial cystectomy4. The use of radiotherapy is also not clear in bladder AC. Some studies showed better oncological results with positive nodes and recurrence. Despite this, its advantage in terms of oncological results has not been established with adequate studies. It can be recommended for local control only6.The role of chemotherapy is not yet clear. However, some cohort studies have shown benefit in high-risk patients . This is based on cisplatin and 5-fluorouracilA patient can present with a tumor with urachal characteristics, however, the pathology report can show primary AC.The decision to perform partial cystectomy was an appropriate option for the location of this tumor, with optimal surgical results. Still, a long-term follow-up is necessary.More specific management guidelines are required for AC.All data underlying the results are available as part of the article and no additional source data are required.Written informed consent for publication of their clinical details and clinical images was obtained from the patient. It is an interesting work and an unusual find in that geography. It is valuable in keeping urologists aware of the possibility of such a differential diagnosis.The abstract is not clear, it is not understood why the surgical treatment is noted  and the full text must be read to understand itDuring the discussion, they focused little on the pathophysiology and epidemiology of the type of tumor, I think it should be expanded further because they discussed the diagnosis and treatment options.The conclusions of the work should not justify the findings of the case, but rather contextualize the analysis of the case  However, I make several clarifications:Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?PartlyIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?PartlyIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:General Urology, Andrology, MAle InfertilityI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. The article is well structured and fulfills one of the educational functions.The introduction expresses the reason why it is intended to publish, there is a review of the topic and explains the relevance of the topic.The case description has important antecedents, the interrogation, the physical examination, the diagnostic support studies, and the results.In the discussion, the authors emphasize why the case is remarkable and explains or clarifies the important aspects and compares themselves with other students. In conclusion, the document is suitable for indexing.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:EPIDEMIOLOGY AND PUBLIC HEALTHI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The authors provide a case report on the management of muscle-invasive adenocarcinoma of the bladder with partial cystectomy. As discussed by the authors, this is not standard or recommended treatment for this disease. This treatment strategy has been well addressed in the literature.Background:Schistosomiasis and chronic bladder irritation are associated with squamous cell carcinoma of the bladder (not adenocarcinoma).Case report: It is unclear the duration of followup. It would be useful to know longer-term oncologic outcomes. Specifically, the authors are advocating for partial cystectomy in T2 adenocarcinoma of the bladder without a clear report of the oncologic outcome. I'm not entirely sure of the novelty of this case and its' suitability for publication.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?NoIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?NoIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Urology, urooncologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. This report presents a case of a young woman with adenocarcinoma presented in the bladder. With endoscopic procedures, secondary involvement of the bladder was excluded. Based on imaging findings the presence of urachal carcinoma was supposed, therefore partial cystectomy with extended lymphaedenctomy and the removal of the umbilical remnant and the umbilicus was performed. The pathological examination of the tumor found primer bladder adenocarcinoma.1,2 What was the level of these serum tumor markers before and after partial cystectomy?Serum tumor markers as CEA, CA-19-9, CA125 and CA-724 can be elevated in urachal cancer. However, there is no reliable immunohistochemical marker which can distinguish between urachal and primary bladder adenocarcinoma, some of them can suspect the origin of the examined adenocarcinoma. Were immunohistochemical examinations performed of the TURB tumor sample ? This should be mentioned in the manuscript.Histological examination of partial cystectomy resulted primary bladder adenocarcinoma. What was the TNM-stage of this?In the case of primary bladder adenocarcinoma, radical cystectomy is suggested. In this case, urachal cancer was supposed before surgical treatment, therefore partial cystectomy was performed, however the final diagnosis was primary adenocarcinoma. In the future, is radical cystectomy proposed and if so, when?   The case report is well written, the train of thought is traceable, but there are some diagnostic tools which could suggest the presence of urachal cancer before open surgical treatment. Therefore I have some minor point to discuss: Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?PartlyIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:urachal cancer, urological cancerI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Brown tumor (BT) is defined as osteolytic lesion of an underlying state of hyperparathyroidism. Hyperparathyroidism will activate osteoclasts which initiate active bone resorption foci of lytic-cysts with hemosiderin depositions that pigment it with its characteristic brown pathologic gross appearance. Devastating fractures and injuries can occur to affected bones and surrounding tissue that require emergent intervention and correction.We present a case of a medically free 31-year-old female patient, who presented complaining of unsteadiness and progressive lower limbs weakness over 40 days of duration. Subsequent lab tests showed elevated PTH levels, along with 3.5 × 1.8 cm heterogeneous soft tissue mass involving the right pedicle on T7 level compressing the corresponding level of the spinal cord. Surgical management aimed to decompress the spinal cord and to obtain a biopsy for histopathologic examination which revealed a brown tumor. Neck ultrasound and Sestamibi scan indicated the presence of hyperactive and hyperplastic parathyroid tissue most suggestive of parathyroid adenoma.Various presentations of Brown Tumor depend on the bone affected, despite the rarity of spinal involvement, yet expanding tumors can manifest either with back pain, radicular pain, paresthesia, weakness, paralysis, or incontinence. The highest incidence rates of spinal brown tumors affect adults over the age of 40. Management goals are to decompress the neuronal tissue emergently and to prevent further bony lytic deterioration.The objective of this study is to provide an overview of primary hyperparathyroidism-related spinal brown tumors, presentation, and summary of previously reported similar cases in the literature. •Brown tumors are rare manifestation of today's primary hyperparathyroidism clinical presentation and context when compared with secondary hyperparathyroidism.•Up to 3% of patients with primary hyperparathyroidism develops BTs, the incidence is furtherly declining due to screening and health assessment programs.•Brown tumors are destructive lesions that could be single or multiple at any site involving long bones, hands, mandible, pelvis and ribs, which are way more common sites than the spine.•Almost half of Primary Hyperparathyroidism-Related Brown Tumors of the spine were found to affect the thoracic region. While sacral region was least to be affected. Hyperparathyroidism is either a primary parathyroid pathology or could be a compensatory mechanism in chronic calcium wasting conditions like chronic kidney diseases; both primary and secondary hyperparathyroidism were found responsible for the abnormal progressive bone remodeling activities seen in brown tumors ,2.The patient had a brown tumor involving the seventh thoracic vertebra T7 with bilateral lower limbs weakness and numbness as a rare first presentation for primary normo-calcemic hyperparathyroidism. We have reported the case presentation, relative physical examination, management, and a literature review covering the 30 reported cases in the literature. This case report was reported in line with SCARE 2020 criteria [1.1We reported a case of a 31-year-old female who is medically free, presented with a history of gait unsteadiness and bilateral lower limbs weakness and numbness of 40 days duration. She addressed difficulties in standing and sitting when she is lying down. Her symptoms were progressive in a manner that affected her productivity and daily activities.The patient denied having difficulties in passing urine or stool. No reported history of fever, weight change, or trauma, and is not on any regular medications or supplements. The patient had no history of personal nor familial history of endocrine tumors. She used to take over-counter supplemental vitamins.Clinically she was slim presented in a wheelchair with difficulty rising up to a standing position. Upon physical exam, the patient's vital signs were within normal ranges. She was awake and oriented. Cranial nerves were intact. Examination of her limbs showed full strength in upper limbs and −4/5 strength on her lower limbs. Deep tendon reflexes were 3+ on knee jerk and ankle jerk. The lower limbs were hypertonic. Babinski test showed upward going toes. Fine and pinprick sensations were intact. Digital rectal examination had normal sensation, normal tone, but weak power. No skin lesions were noted.Her blood tests showed sky-high parathyroid hormone levels of 862 pg/ml . Despite the elevated parathyroid hormone levels, Calcium, phosphorus, vitamin D, thyroid hormone levels and kidney function results were within the normal ranges. Also, a complete paraneoplastic markers assessment turned negative. Subsequently, she underwent parathyroid ultrasound which revealed evidence of well-defined hyperechoic mass lesion in the left anterior neck region, measuring about 2*0.5*0.6 cm. This lesion was highly suspicious for parathyroid adenoma.Whole spine MRI was performed and revealed heterogenous soft tissue mass lesion involving the right pedicle, lamina, transverse process, and inferior articular process of T7, as well as the right posterolateral aspect of T7 vertebral body. This lesion appeared predominantly isointense on T1/T2WI with vivid enhancement on postcontrast images measuring about 3.5 × 1.8 cm. This lesion was shown to compress and displace the spinal cord from the right which causing compressive myelopathy on the corresponding level of the spinal cord .Fig. 1, also known as osteitis fibrosa cystica are well demarcated, benign, rapidly growing lesions of lytic-cysts due to hyperparathyroidism, yet BTs are rare manifestation of today's PTPH clinical presentation and context when compared with secondary hyperparathyroidism. Researchers estimate that up to 3% of patients with PHPT develops BTs, the incidence is furtherly declining due to screening and health assessment programs .Osteoclast-like multi-nucleated giant cells and hemosiderin laden macrophages cells are responsible for the radiological and gross features of brown tumor. The structural texture of brown tumor combine a hemorrhagic, cystic and solid components that constitute the distinctive diagnostic features of BTs on imaging modalities ,7. Brown31 spinal lesions identified as PHPT-related brown tumors were reported in 30 case-reports, among these, 15 lesions (48.38%) were found to affect the thoracic region which is the most common site for PHPT-BTs. The lumbar region is the second most affected site with 8 (25.80%) reported lesions. While the cervical and sacral regions were the least to be affected, 6 (19.35%), 2 (6.45%) respectively.Brown tumor complications exceed the sole risk of pathological fractures following cortical thinning ,9,10, si3Although of the benign nature of brown tumor, it can cause devastating fractures due to cortical thinning. In cases of spinal vertebrae involvement, brown tumors can cause neurologic symptoms of paresthesia, paresis, or paralysis because of spinal compression. In symptomatic cases it is recommended to ensure tumor resection, spinal decompression and stabilization, along with medical or surgical parathyroid intervention to control the underlying cause.This case-report has been reported in line with the SCARE 2020 criteria.This study was not fundedWritten informed consent was obtained from patient for publication of the case report and any related images. A copy of the written consent is available for review by the editor-in-chief of this journal on request.This work was carried out in collaboration between all authors. Authors SMJ and SSD designed the study. Author ISD managed the literature searches, data collection and wrote the first draft of the manuscript. Author OFJ managed the literature searches and completed the final draft. All authors read and approved the final manuscript.It is not applicable.The authors declare that this case report and literature review are not funded.This work was carried out in collaboration between all authors. Authors SMJ and SSD designed the study. Author ISD managed the literature searches, data collection and wrote the first draft of the manuscript. Author OFJ managed the literature searches and completed the final draft. All authors read and approved the final manuscript.Name of the registry: N/a.Unique Identifying number or registration ID: N/a.Hyperlink to your specific registration (must be publicly accessible and will be checked): N/a.Sultan M. Jarrar, MD, Assistant professor of Neurosurgery, Department of clinical neuroscience.Faculty of medicine, Jordan University of Science & Technology PO Box 3030 zip code 22110. IrbidJordan, Telephone: 00962 790033567, Email: smjarrar@just.edu.jo.Not commissioned, externally peer-reviewed.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.


Acute mesenteric vein thrombosis represents a rare but potentially lethal thrombotic event. Its treatment involves prompt and aggressive anticoagulation therapy. In the perioperative setting, management of the underlying thrombus must be weighed carefully against the risk of bleeding. We describe a 57-year-old man who presented with abdominal pain and was found to have terminal ileitis with concomitant superior mesenteric vein thrombosis. Acute mesenteric vein thrombosis (AMVT) represents a rare, life-threatening cause of intestinal ischemia. Individuals with underlying cancer or hereditary thrombophilias are most commonly affected. However, idiopathic AMVT has also been described . PatientUnfractionated or low-molecular-weight heparin represents the mainstay of management for AMVT. The mortality rate for AMVT approaches 50%; therefore, anticoagulation therapy should be administered even in the presence of active bleeding ,5. We deA 57-year-old male with a history of dyslipidemia, diabetes mellitus, obesity, and obstructive sleep apnea presented with a one-day history of abdominal pain, nausea, and vomiting. Physical examination revealed exquisite tenderness to palpation of the right lower quadrant. Complete blood count, complete metabolic panel, lipase, and urinalysis were normal. A CT scan of the abdomen and pelvis with intravenous contrast revealed edematous changes in the distal ileum as well as a filling defect in the superior mesenteric vein (SMV) Figure . The patOn hospital day three, a repeat CT scan was obtained which demonstrated thrombus regression. The ileitis was unchanged as compared to the previous CT scan. Heparin was held in preparation for colonoscopic evaluation.A colonoscopy was performed six hours after anticoagulation had been discontinued. Unexpectedly, the terminal ileum appeared normal. However, a 1.2-cm polyp was identified in the ascending colon; this was resected. The gastroenterology team recommended holding anticoagulation therapy for 48 hours following the polypectomy.The next morning, the patient woke with severe upper abdominal pain. A physical examination revealed marked distention. Laboratory studies revealed leukocytosis  and lactic acidosis . An emergent CT scan was obtained and demonstrated recrudescence of the previously-identified SMV thrombus (Figure Anticoagulation therapy with dalteparin was started one day after the reanastomosis. The patient received total parenteral nutrition and was later advanced to a soft diet. He was discharged in stable condition after a three-week hospital stay. Subsequent workup for inherited thrombophilias - including Factor V Leiden, prothrombin gene mutation, and protein C deficiency - was negative.AMVT classically presents with colicky, periumbilical abdominal pain. Nausea and vomiting are common . PhysicaEmergent anticoagulation represents the mainstay of therapy for AMVT . UnfractThe mortality rate for untreated AMVT is approximately 50%; prompt and uninterrupted anticoagulation therapy reduces mortality to nearly 0% . Thus, tAn underlying etiology for our patient's AMVT or the imaging appearance of ileitis was never definitively established. We hypothesize that disruption of bowel perfusion may have contributed to edema and thickening of the ileal wall, mimicking an inflammatory process. However, there is no known association between AMVT and the subsequent development of colitis or ileitis.AMVT is a rare but potentially life-threatening thrombotic event. Patients typically present with abdominal pain that is out of proportion to physical examination findings. Definitive diagnosis can be established with imaging. Anticoagulation therapy should be administered immediately upon identification of a thrombus and should be continued without interruption for at least three to six months. Indeed, due to the high mortality rate associated with AMVT, anticoagulation should be used even in the presence of active bleeding.