Idiopathic megabowel is a rare condition. Its physiopathology is still unclear. We report a case of a patient presenting with acute bowel obstruction due to idiopathic megacolon and megarectum that was successfully treated with proctocolectomy.A 65-year-old man, with a history of chronic constipation, presented to the emergency with acute bowel obstruction symptoms.His CT scan on admission showed a very dilated rectum and sigmoid colon filled with faeces. The patient was managed conservatively.Due to the deterioration of his condition. We opted for an emergency laparotomy and it revealed the important dilation of the descending colon, the sigmoid colon, and the rectum leading to a Hartmann procedure.degenerative lesions of the smooth muscle layers were seen on the histopthological report and the diagnosis of rectosigmoid idiopathic megacolon was made.Postoperatively, we performed a rectoscopy that showed a distended rectum full of faeces.We performed a proctectomy with colo-anal anastomosis. He had an uneventful recovery.Idiopathic megacolon is a rare condition. The pathogenesis is still unclear. Surgical treatment is the best option to prevent complications and to improve the quality of life of the patient. •Idiopathic megabowel is a rare condition.•It is characterized by a persistent dilatation of the colon and the rectum.•The physiopathology is still unclear.•Acute bowel obstruction complicating idiopathic megabowel should be treated timely.•Surgical treatment is the best option to prevent complications. Its physiopathology is still unclear. However, It was hypothesized that there are anomalies in the extrinsic and enteric nervous system . It is cThis case report has been reported in line with the SCARE 2020 Criteria .2A 65-year-old man, with a history of chronic constipation, presented to emergency with abdominal pain, vomiting associated with abdominal distension for one week.On examination, he had a tender, distended abdomen. Digital rectal examination revealed hard stool impaction. He had normal haemoglobin and leucocytes count. Renal functions were normal.His CT scan on admission showed a very dilated rectum and sigmoid colon filled with faeces . We evokThe patient was managed conservatively with oral laxatives and enemas.His condition was not improving. Three days later, he complained of worsening abdominal pain. He had tachycardia and abdominal tenderness.We opted for an emergency laparotomy. It was performed by a surgeon with sixteen-years experience. It revealed that the descending colon, the sigmoid colon, and the rectum were very dilated , Fig. 3.He had an uneventful recovery and was discharged after five days.Histopathology showed degenerative lesions of the smooth muscle layers. There were a normal number of ganglia in the myenteric plexus and no hypertrophic nerve bundle. The diagnosis of idiopathic megabowel was made.Postoperatively, we performed a rectoscopy that showed a distended rectum full of faeces. Biopsies were done. Histopathology showed no abnormalities.CT scan showed a dilated rectum full of faeces. , Fig. 5.He undertook re-laparotomy ten weeks after the first surgery. We performed a proctectomy with colo-anal anastomosis.He had an uneventful recovery and was discharged home after one week. He had good functional results after eight months of follow-up.3This is one of the rare cases describing idiopathic megacolon and megarectum. We reported successful surgical treatment for this condition.Our misunderstanding of the pathogenesis of the disease is a weakness of our work. We only treated the consequence of the disease. Further genetic and histopathological studies should be conducted to explain better the pathogenesis of this condition.Idiopathic megacolon and megarectum is described as important distension of the colon and the rectum in the absence of an identifiable reason. Other causes of megacolon such as Hirschprung disease, medications, infections, inflammatory bowel disease, and autoimmune conditions should be ruled out.Idiopathic megacolon can be associated with alterations within the gut wall. It was postulated that a decrease in the number of interstitial cells of Cajal (ICCs), regarded as intestinal pacemaker cells, is seen in patients with chronic constipation and megacolon ,5. AbnorIt was suggested that SEMA3F gene plays a central role in the etiopathogenesis of this pathology .The most frequent symptom is chronic constipation that responds improperly to medical treatment . Both geEarly detection of signs of chronic idiopathic megacolon is essential to avoid complications and to perform a more conservative therapeutic strategy.Acute bowel obstruction due to the stercoral stasis should lead to emergency surgical treatment. Delay of surgery can lead to death. It is most commonly due to a perforation of the dilated bowel and subsequent peritonitis and sepsis or to fluid shift and consequently metabolic and electrolytic abnormalities .Surgical treatment is the only efficient treatment. The different surgical options for idiopathic megabowel are essentially colon and/or rectal resection, pelvic floor procedures, or fecal diversion . Bowel rSurgery is more difficult in patients with megarectum . This isTo date, there are no standardized guidelines for the treatment of idiopathic megabowel. We highlight the importance of timely surgical treatment in presence of acute bowel obstruction. It permits avoiding fatal complications and improving the quality of life of the patient. Further genetic studies with a large sample size should be conducted to better explain the pathogenesis of this condition and to assess standardized guidelines.4Idiopathic megabowel is a rare condition. The pathogenesis is still unclear. It is a diagnostic of exclusion. Surgical treatment is the best option to prevent complications and to improve the quality of life of the patient.Not required.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Hazem Beji and Fatma Najib did the conception and design of the work, the data collection, the data analysis and interpretation, and the writing of the manuscript.Asma Zaiem and Mohamed Guelbi participated in the writing of the manuscript.Wael Rebai and Montassar Kacem did the critical revision of the article and the final approval of the version to be published.Dr Hazem Beji.Dr Wael Rebai.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.Not commissioned, externally peer reviewed.No conflicts of interest.


Most paratesticular liposarcomas (PLPSs) are well-differentiated liposarcomas (WDLPSs) with favourable prognoses. As such, the rare occurrence of PLPS often leads to its misdiagnosis as a hernia or hydrocele on physical examination. Curative resection of the tumour may not be possible in cases where PLPSs have transformed into dedifferentiated liposarcomas (DDLPSs) owing to a delay in diagnosis. Herein, we describe a case of unresectable paratesticular dedifferentiated liposarcoma (PDDLPS) with poor prognosis due to delayed diagnosis.A 57-year-old man visited our hospital with a chief complaint of a right scrotal mass, which was diagnosed as scrotal hydrocele but without treatment or follow-up. Eight years later, the patient complained of abdominal distension, and a computed tomography scan revealed the presence of retroperitoneal and right scrotal masses. The right scrotal mass was removed, and histopathology revealed DDLPS. The patient was diagnosed with unresectable PDDLPS metastasising to the retroperitoneum, and the left pleura was treated with doxorubicin. After an initial response, pleural effusion and ascites increased during the sixth cycle of chemotherapy. The patient subsequently received eribulin but died 5 months after the initial DDLPS diagnosis.It is difficult to distinguish PLPS from benign inguinal hernia and hydrocele testis on physical examination. PLPS generally has a considerably good prognosis. However, failure to diagnose WDLPS can be dangerous as it might lead to malignant transformation to DDLPS, which has a poor prognosis. Physicians should consider this malignancy when examining patients with hernias or hydroceles of the inguinal region and should perform ultrasonography or magnetic resonance imaging. Malignant soft tissue tumours usually occur in the extremities or retroperitoneum and rarely in the proximal testicular region , 2. The A 57-year-old-man presented to our hospital with the chief complaint of a painless right scrotal mass. On physical examination, his right scrotum was enlarged, but was painless, elastic, and soft. Thus, it was diagnosed as scrotal hydrops and left untreated. Two years later, a magnetic resonance imaging (MRI) scan showed a mass, 6 cm diameter, in his right scrotum with a high signal intensity on T1-weighted image. There was partial heterogeneity inside the mass, and a diagnosis of lipoma was made , and distant metastasis is extremely rare , 10, 11.Liposarcomas, similar to other malignant soft tissue tumours, tend to occur in the extremities and retroperitoneum , 12, 14.This case showed not only a dedifferentiated component within the paratesticular tumour but also a highly differentiated component. Therefore, it is quite plausible that the PWDLPS transformed into PDDLPS and metastasised to the retroperitoneum and pleura in this patient.First-line chemotherapy regimens containing DXR are recommended for liposarcomas with distant metastases. The response rate of DDLPS is 24%, the median progression-free survival (PFS) is 4 months, and the median overall survival (OS) is 25 months . AlthougOn physical examination, it is difficult to distinguish PLPS from benign inguinal hernia and hydrocele testis; however, PLPS has a considerably better prognosis as most PLPSs are WDLPSs with no possibility of metastasis and possible surgical resection. However, failure to timely diagnose WDLPS can be dangerous and may lead to malignant transformation into DDLPS, which has a poor prognosis. Ultrasonography shows a uniform hypoechoic area in the case of hydrocele testis but a heterogeneous hyperechoic area in the case of liposarcoma. In addition, MRI shows high signal intensity on T1-weighted images in the case of a fat-fitting inguinal hernia and lipoma and a low signal intensity in the case of liposarcoma. Hence, physicians should consider this malignancy when examining patients with hernias or hydroceles of the inguinal region and should perform ultrasonography or MRI.The original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by The Institutional Review Board Kakogawa Central City Hospital Ethics Committee. The patient’s family provided their written informed consent to participate in this study.Conceptualisation: HS, and AO. Methodology: HS, and AO. Investigation: HS, YI, and AO. Data curation: HS, YI, and AO. Writing—original draft preparation: HS. Writing—review and editing: HS, YI, and AO. Supervision: AO. All authors contributed to the article and approved the submitted version.www.editage.com) for English language editing.The authors would like to thank Editage (The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In immunodeficient patients with repetitive peritoneal aggression, cystic mesothelioma should be considered as a differential diagnosis to peritoneal tuberculosis that must be ruled out in endemic countries. Physical examination of the abdomen revealed ascites of large abundance. Laboratory tests showed elevated C‐reactive protein at 242 mg/L. Peritoneal fluid analysis revealed exudate ascites poor of cells. Abdominal ultrasound showed floating membranes, and computed tomography concluded to a huge abdominal cystic mass Figure . InitialChayma Soltani: Conceptualization; investigation; writing – review and editing. Khalaf Ben Abdallah: Conceptualization; investigation; methodology; validation; writing – original draft; writing – review and editing. Yasser Bouchallouf: Conceptualization; investigation; validation; visualization.None.The authors declared that no grants were involved in supporting this work.No competing interests were disclosed.Written informed consent to publish his clinical details and images was obtained from the patient.


When performed by an experienced surgeon, robotic partial nephrectomy plus venous thrombus excision may represent as valid treatment option for imperative indications, with valuable oncological and functional outcomes. Specific surgical nuances are necessary to effectively conduct such a procedure. Partial nephrectomy (PN) may be recommended for selected patients with advanced-stage (>cT2) renal cell carcinoma (RCC) with the aim of avoiding dialysis and chronic kidney disease–related comorbidities. The spread of robotic surgery has led to expansion of PN indications to more challenging scenarios and even frontier surgeries, including advanced-stage RCC. Here we describe the management of a patient with a solitary kidney diagnosed with multiple cT3a  RCC who was treated using a conservative robotic approach. The most crucial surgical considerations for this procedure were: (1) tailored planning of the surgical approach using three-dimensional reconstruction software; (2) accurate boundary delineation for the tumors and thrombus; (3) avoiding unnecessary warm ischemia time; (4) performing an anatomical excision to follow eventual tumor bulging; and (5) en bloc removal of the main lesion and its thrombus. No perioperative complications were recorded. Histopathology revealed clear cell RCC for all four lesions with nucleolar grade 3 and negative surgical margins. At 12-mo follow-up the patient was disease-free. When performed by an experienced surgeon, PN plus venous thrombus excision for imperative cases with cT3 RCC may represent a valid treatment option with valuable oncological and functional outcomes.We describe the case of patient who had a single kidney with multiple kidney tumors and tumor extension into a blood vessel. The patient was treated with robot-assisted removal of the tumors, sparing as much kidney tissue as possible. This technique was found to be safe and effective, with no complications and good intermediate-term results. In particular, use of robotic assistance allows very precise tumor excision and was found to be protective in terms of acute kidney injury onset, postoperative complications, and failure to achieve trifecta outcomes when compared to open and laparoscopic PN Based on these considerations, the present report describes the effective management strategy for a patient with a solitary kidney diagnosed with multiple cT3a RCC lesions and treated with a conservative approach.2A 61-yr-old man was referred to our institution after incidental diagnosis of multiple renal tumors located in his left solitary kidney. The patient had already undergone open right RN for a pT1a RCC nearly two decades earlier.A computed tomography (CT) scan showed two renal masses. The main tumor was a 5-cm lesion in the anterior lower kidney pole with a tumor thrombus at the level of the inferior venous branch. The second tumor measured 3 cm in its largest diameter and was in close proximity to the main renal mass . The patA tailored preoperative assessment was performed using dedicated software  to create a 3D virtual reconstruction from DICOM images from the CT scan, which significantly enhanced perception of the tumor anatomy and kidney vascularization. Interestingly, the 3D model revealed two additional small mediorenal lesions A and shoAfter multidisciplinary discussion, robot-assisted PN with tumor thrombus excision was indicated.3A transperitoneal three-arm configuration was used. After identifying the renal pedicle, the main renal vein and artery with its collateral branches were individually dissected and isolated. The whole kidney was exposed by removing its fat covering to correctly identify the lesions and allow proper renal mobilization. The presence of two additional lesions identified on scouting with the 3D model was confirmed via intraoperative ultrasonography.Surgical management began by addressing the three minor lesions via a clampless strategy. This choice was driven by the need to save minutes of ischemia time for the main part of the procedure. We conducted enucleoresection for the two small cortical lesions outlined by the 3D reconstruction and pure enucleation for the third lesion, since it exhibited prevalent endophytic growth.In fact, while the excision strategy does not substantially affect the outcomes for cortical masses, widespread evidence has revealed that a pure enucleation approach increases the possibility of achieving trifecta outcomes Therefore, the main tumor contours were delineated using intraoperative ultrasound. A robotic linear probe can be handled independently by the surgeon, increasing the autonomy in achieving difficult angles while maintaining perpendicular contact with the kidney surface. This tool ameliorates the perception of the tumor burden, favors correct identification of the surgical plane, and allows assessment of possible interaction between the tumor and the caliceal system.After incising the renal parenchyma a few millimeters away from the lesion, the collateral arterial branches were clamped. The correct cleavage plane was then identified and followed predominantly via blunt dissection. Pointwise hemostasis was performed to maintain a bloodless surgical field. In this step, total ischemia management involved clamping the main renal artery. When feasible, this “hybrid” ischemia strategy—starting the excision with selective clamping and deferring global ischemia for the inner enucleation field—reduces devascularization damage to the healthy parenchyma while limiting bleeding during the first steps of the excision.The tumor was approached circumferentially in order to reduce possible tension. At this point, two Hem-o-Lok clips were placed at the level of the inferior venous branch and the tumor thrombus was excised en bloc with the mass. Renorraphy was performed by suturing the medulla and cortex separately using 2-0 Monosyn and 2-0 Vicryl sutures, respectively. The surgical procedure is demonstrated in the video in the Supplementary material.Overall, the operative time was 168 min and the global ischemia time was 9 min. No perioperative complications were recorded. The estimated blood loss was 450 ml and the decrease in hemoglobin was 2.7 mg/dl on postoperative day 3. The patient was discharged on postoperative day 5. Histopathology revealed clear cell RCC for all four lesions, with nucleolar grade 3 and negative surgical margins. At 12-mo follow-up the patient was disease-free with a serum creatinine level of 1.8 mg/dl.4When performed by an experienced surgeon, robotic PN plus venous thrombus excision may represent a valid treatment option for imperative indications, with valuable oncological and functional outcomes. Further prospective studies are needed to validate our preliminary experience.Author contributions: Andrea Minervini had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.Study concept and design: Minervini, Grosso.Acquisition of data: Grosso, Marìn, Di Maida, Lambertini.Analysis and interpretation of data: Grosso, Marìn.Drafting of the manuscript: Grosso.Critical revision of the manuscript for important intellectual content: Minervini, Mari.Statistical analysis: None.Obtaining funding: None.Administrative, technical, or material support: Mari, Di Maida, Gallo, Nardoni.Supervision: Minervini.Other: None.Financial disclosures: Andrea Minervini certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript , are the following: None.Funding/Support and role of the sponsor: None.


Currarino syndrome is an autosomal dominant hereditary disease defined as a triad of anorectal abnormality, sacral dysgenesis, and a presacral mass, primarily an anterior sacral meningocele. It is often seen in children and considered rare in adults. It is mostly found as an incidental finding. We present a 21-year-old man who presented with acute flank pain. He had a history of Hirschsprung's disease and therefore had undergone surgery in his infancy. He also had a history of prolonged constipation and had an episode of admission due to suspected obstruction. On physical examination, he had a severe costovertebral angle tenderness. urine exam revealed microscopic hematuria. Laboratory tests were otherwise unremarkable. Computed tomography scan revealed renal stones as well as a horseshoe kidney. Incidental findings included a large simple cystic structure in the presacral area suggestive of an anterior meningocele and sacral dysgenesis associated with scimitar sacral appearance. These findings suggested a diagnosis of Currarino syndrome. Urinary complications of this disease are reported in few articles. An important takeaway note for physicians is to have a high level of suspicion when encountering patients with gastrointestinal, neurologic, or urologic signs and symptoms and consider a thorough history taking and physical examination alongside proper imaging evaluation. Currarino syndrome (CS) is an autosomal dominant hereditary disease defined as a triad of anorectal abnormality, sacral dysgenesis, and a presacral mass, primarily an anterior sacral meningocele. To the best of our knowledge, less than 400 cases of this syndrome have been reported in the medical literature to this date, and most cases are diagnosed before adulthood. This syndrome is considered rare in adult patients We report a case of Currarino Triad in an adult male, which was diagnosed as an incidental radiologic finding.A 21-year-old man presented to the clinic with acute right flank pain, nausea and vomiting, and no constipation, or abdominal distention. He had a history of Hirschsprung's disease, and therefore, had undergone surgery in his infancy. He also had a history of prolonged constipation and had an episode of admission due to suspected obstruction but had been discharged without any complications. On examination, he had a blood pressure of 125/80, a heart rate of 93, a respiratory rate of 20, and a temperature of 37.8. On physical examination, he had severe costovertebral angle tenderness. Neurologic examination was normal. His history and physical examination were otherwise unremarkable. Urine exam revealed microscopic hematuria. Laboratory tests were otherwise unremarkable. With a probable diagnosis of renal colic, the patient underwent an abdominal computed tomography (CT) scan. The scan showed horseshoe kidneys and renal stones in the right kidney, confirming the diagnosis. Several incidental findings also included a large simple cystic structure in the presacral area suggestive of an anterior meningocele and sacral dysgenesis associated with scimitar sacral appearance .All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.


Osteosarcoma is a tumour that can originate in any bone and is the most frequent malignant tumour of the skeleton. It typically develops close to the metaphyseal growth plates in the limbs' long bones. The three most prevalent places are the femur, tibia, and humerus. Additional locations include the pelvis, skull, and jaw. Diaphyseal osteosarcoma involves a smaller population and is highly uncommon. Conventional kinds of osteosarcoma, such as osteoblastic, chondroblastic, and fibroblastic types, as well as telangiectatic, multifocal, parosteal, and periosteal types, are some of the variations of the disease. The primary bone tumour (cancerous) is generated by the formation of immature bone and primarily affects adolescents. We present a case of a 45-year-old menopausal female with left tibial osteosarcoma of the proximal 1/3 diaphysis infected with maggots and complaints of left knee pain and tingling. A high-grade malignant mesenchymal tumour known as osteosarcoma is distinguished by the tumour cells’ ability to generate immature bone or osteoid. Adolescence and old age are both susceptible times for this tumour to manifest, i.e., it has a bimodal distribution. Osteosarcomas account for 3% of all paediatric cancers in children -3. The iA 45-year-old menopausal woman with unremarkable medical and surgical history and no comorbidities presented to our institute with pain in her left leg and tingling. She had been seeing a local doctor for the same issue after a diagnosis of osteosarcoma of proximal 1/3 diaphysis was made eight months ago. There was no prior trauma, night-time temperature rise, weight loss, or loss of appetite. Upon inspection, the proximal end of the left tibia and knee showed slight oedema. When touched, the swelling felt tender. There was no crepitus or abnormal movement. On examination, fungating and cauliflower-shaped ulcers with everted edges were present. It was foul-smelling, friable on touch, bleeding easily, and dilated veins were present Figure  were isoIn the radiographs, the affected limb’s X-ray revealed an osteolytic lesion with periosteal reaction and tumour surrounding the proximal 1/3 of the shaft of the tibia Figure . MagnetiSheets of cancerous cells could be seen in tissue slices. These cells had hyperchromatic nuclei, scanty cytoplasm, and round to oval or spindle-shaped bodies. They also had an increased nucleus-to-cytoplasmic (N:C) ratio. Osteosarcoma was determined to be the cause of the lesion based on its malignant character, location, and results from MRI and other radiographs. Accordingly, neoadjuvant chemotherapy was started with an injection of adriamycin 40 mg from day one to day three and an injection of cisplatin 50 mg on day two and day three. Additionally, surgical debridement of necrotic tissue was performed along with the mechanical removal of larvae using turpentine oil. All of the maggots were eliminated during the subsequent five days of wound debridement. Systemic antibiotics, metronidazole, and augmentin (amoxicillin + clavulanic acid) were given.In the United States, there are 400 cases of osteosarcoma per year (4.8 cases per million people under the age of 20 years). Patients whose disease was identified between 1974 and 1994 had a five-year overall survival rate of 63% (59% for men and 70% for women). Compared to Caucasians, African Americans have a somewhat greater incidence of the disease. Males are slightly more likely to develop this disease than females. The incidence for males is 5.2 cases/million/year. Children under the age of five are less likely to develop osteosarcoma. Approximately 0.5 cases per million persons are affected annually . A limp Radiographic features alone cannot be used for diagnosis. Solely osteolytic lesions make up about 30% of all osteosarcomatous lesions, and purely osteoblastic lesions make up about 45% of cases. The recognisable Codman triangle may be seen when the periosteum is elevated ,3. AboutIn childhood and adolescence, the conventional form is most prevalent. The osteoblastic, chondroblastic, and fibroblastic kinds have been used to further categorise this type, despite the clinical indistinguishability of the subtypes. It is a grade 3 or 4 tumour. The fibroblastic variant of chondroblastic osteosarcoma features a spindle cell stroma with focal osteoid and produces cartilage. Staging tumours aims to identify different risk categories .Before the advent of chemotherapy in the 1970s, surgical resection, typically amputation, was the mainstay of osteosarcoma treatment. Despite having such strong local disease management, more than 80% of patients went on to develop recurrent illness, which usually shows up as lung metastases. Most patients had micrometastatic disease at diagnosis, inferred from the high recurrence rate. To effectively treat patients with osteosarcoma, systemic adjuvant chemotherapy is crucial. Neoadjuvant chemotherapy facilitates surgical tumour removal once the tumour has decreased, and it also gives oncologists an important risk parameter -15.The prognosis is better for patients whose tumours react favourably to neoadjuvant chemotherapy (>95% cancer cell death or necrosis) than for those whose tumours do not. Surgery is the only treatment available for osteosarcomas because radiation is ineffective in removing the tumour  . DoxorubIn this case report, we presented a case of osteosarcoma of the proximal 1/3 left tibia in the diaphyseal region, which is extremely rare, as osteosarcoma preferably grows near the metaphysis. The diagnosis was confirmed with MRI and other radiographs. The approach towards the treatment and an attempt to improve the prognosis was made by starting neoadjuvant chemotherapy. The patient came for a follow-up after the chemotherapy, but with such extent of the mass, the final treatment planned was amputation.


Suspicion for soft tissue malignancy of the hand is usually low because most tumors of the hand are small and benign. We present a case of an elderly female who presented with a rapidly enlarging, ulcerating hand mass over a few months. She was diagnosed with undifferentiated pleomorphic sarcoma (UPS), a high-grade, aggressive soft-tissue sarcoma. Computed tomography (CT) of the chest was conducted for staging purposes. It showed multiple subcentimeter pulmonary nodules, findings that were initially worrisome for metastatic disease but later proved to be newly and incidentally diagnosed granulomatous disease of the lungs. This case highlights the importance of early recognition of potential malignancy in soft-tissue tumors of the hand to facilitate proper referral and initiation of appropriate oncologic therapies. Due to early diagnosis and intervention, our patient had locally advanced disease without metastasis, a type of cancer known to have a high degree of metastatic potential. Soft tissue sarcomas of the hand are aggressive tumors with a high potential for metastatic disease. UPSs are often a diagnosis of exclusion and account for 10% of soft-tissue sarcomas in adults . UPSs ocA 60-year-old African-American female with a past medical history of hypertension presented with a large, ulcerating mass on the dorsal aspect of her left hand. The patient reported that she unintentionally slammed her finger in her car door about two months prior. She reported that the mass first appeared on her finger shortly after this accident and had been rapidly enlarging. She reported only mild pain over the fifth metacarpophalangeal joint of the left hand. She had an associated 60-pound weight loss over the past month. Her only medication included lisinopril, which she recently discontinued due to a new cough she developed. She denied any current or prior tobacco use and alcohol or illicit drug use.Vital signs on presentation revealed elevated blood pressure 171/96) and tachycardia (heart rate of 106). The rest of her vital signs were unremarkable. Complete blood count was remarkable for iron deficiency anemia and thrombocytosis . C-reactive protein level was elevated at 135 mg/L . The complete metabolic panel was unrevealing. Physical examination revealed the left hand with a large mass protruding from the fourth web space between the fourth and fifth digits  showed a large 9.6 cm heterogeneous soft tissue mass at the dorsal aspect of the fifth digit, abutting the fourth digit Figure .Magnetic resonance angiography (MRA) showed patent radial and ulnar arteries. There was evidence of vasculature feeding into the mass from the common palmar digital artery branches of the ulnar artery and deep palmar branches of the radial artery. The patient underwent an excisional biopsy of the mass with amputation of the fourth and fifth digits. There was evidence of maggots coming out of the mass during surgical resection. The mass was invading the underlying bone, and Lymphovascular invasion was also identified. Negative margins were achieved per frozen pathology. Pathology of the postsurgical specimen showed high-grade UPS. The immunohistochemical examination revealed cutaneous ulceration Figure , pleomorFurther workup to exclude metastatic disease was initiated. MRI brain with intravenous contrast showed no evidence of metastatic disease, and the whole-body bone scan also showed no metastatic disease. Staging CT of the chest, abdomen, and pelvis had evidence of multiple subcentimeter pulmonary nodules measuring up to five mm with diffuse tree-in-bud nodularity throughout the lung parenchyma Figure .CT chest findings were initially concerning for metastatic disease. Infectious causes were excluded, including negative Human immunodeficiency virus (HIV) and urine antigens for streptococcus pneumoniae and legionella. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL), which showed evidence of cobblestoning in the right and left upper lobe bronchus. Bronchoalveolar lavage (BAL) cultures, gram stain, and cytology were negative. Endobronchial biopsy revealed non-necrotizing granulomatous changes in the left upper lobe endobronchial lesion. The findings from bronchoscopy and BAL were consistent with a diagnosis of sarcoidosis. Angiotensin-1 converting enzyme (ACE) level was elevated to 111 U/L , and 1,25-vitamin D was elevated to 110 pg/mL , consistent with the diagnosis of sarcoidosis. The patient was started on daily prednisone with recommendations to follow up with pulmonology outpatient for further management. Regarding the patient’s diagnosis of UPS, she was advised to follow up outpatient for the initiation of chemotherapy. However, the patient has not yet followed up due to insurance issues.Clinical suspicion for soft-tissue malignancy of the hand is usually low because most tumors are small and benign . HoweverUPSs have no specific line of differentiation and are usually a diagnosis of exclusion . PatientDiagnostic workup for soft tissue tumors of the hand should start with conventional radiographs and MRI with and without contrast of the affected hand for local assessment and preoperative planning . CT of tOne study found that the hand’s metastatic rates for malignant soft tissue sarcomas ranged from 15% to 40% [The primary treatment of choice for soft-tissue tumors of the hand is typically limb salvage therapy . HoweverAdditionally, she had negative postoperative margins with no plans for postoperative radiation therapy. The use of adjuvant chemotherapy for patients with resectable soft-tissue sarcoma remains controversial . One stuMalignant tumors of the hand are rare, and most of our knowledge on the oncologic outcomes of these tumors is generally derived from cases of tumors of the upper extremities. Because of their rarity, these malignancies can often be mistaken as benign and have unplanned excision without the proper workup beforehand. Performing marginal excision on unsuspected malignant hand lesions may eventually lead to larger resections or amputations being necessary later in the disease course to ensure complete tumor removal with negative margins, leading to worse oncologic outcomes. This case brings awareness to a rare hand tumor known to have a degree of metastatic potential. This case highlights specific features of soft-tissue tumors of the hand that should raise suspicions of malignancy. Early diagnosis and curative excision of UPSs are essential to improve oncologic outcomes. UPSs are rapidly growing with the potential for recurrence and metastasis, making close follow-up and surveillance imperative.


Melanoma is a malignancy that develops from pigment-producing cells known as melanocytes. Although it is considered one of the most fatal tumors in the world, its early diagnosis is associated with a better prognosis and overall survival. A 49-year-old man was admitted to the dermatology department with a 15 cm lesion on the left arm. It was growing on a congenital nevus to reach an enormous size. Surgical excision was not possible and the treatment was controversial as the patient showed unpredicted resistance to immunotherapy. Further evaluations revealed false-negative BRAF mutation, which completely changed the course of treatment. Cutaneous melanoma is a rare malignancy, accounting only for 1% of skin cancer cases, and having it arising on a pre-existing congenital nevus is even much rarer. Although there is no decisive definition of giant melanoma, some authors define it as a lesion of more than 10 cm in diameter. Through the literature, only a few cases of giant melanoma on the arm have been reported. Through our paper, we are revealing the importance of early diagnosis and treatment of melanoma and confirming the significant role of regular follow-up for patients with a congenital melanocytic nevus. Moreover, we are showing the importance of having alternative methods for detecting BRAF mutations to avoid false-negative results and have better outcomes. Malignant melanoma represents only about 1% of all skin cancers and <1% grows on a congenital nevus . In our A 49-year-old male was presented to our clinic with a wide ulcerated skin lesion on the upper area of the left arm. It started 6 months earlier on a congenital nevus, which remained unchanged since birth. There were no skin tumors in his family history. Laboratory tests were within the normal range. Physical examination showed a reddish-brown to black-colored, vegetative and erupted with irregular borders lesion. It measured 15 cm × 12 cm × 2 cm in the left deltoid area .de novo [There were many differential diagnoses. Nodular melanoma appears as an amelanotic symmetrical and well-circumscribed papule or nodule with a uniform color, although it can be melanotic and ulcerated occasionally . Lentigode novo .A cutaneous biopsy was performed and sent to the pathology department. Microscopic examination of the biopsy revealed proliferation of variably size nodules of malignant cells in the dermis . InfiltrBy performing the radiological investigation, positron emission tomography-computed tomography scan revealed hypermetabolic lesions with local and distant metastases to the lymph nodes, liver and bone , while m2 D1 → D5. A good response started after two courses but the patient had rapid progression after initiating the third course, which encouraged us to change the protocol to paclitaxel 100 mg/m2 D1, D8, D15 and carboplatin 150 mg/m2 D1, D8, D15, but there was no response. At that stage, the patient suffered from disabled left arm due to severe pain and edema. Immunotherapy with nivolumab 280 mg/m2 was initiated, but unfortunately, there was no response observed after three courses. Surgical consultation claimed that surgical intervention is inapplicable due to locally advanced disease. Another wedge biopsy was taken for further histopathology evaluation. The result was identical to the first biopsy. The tumor was invading to anatomic level (at least V-Clark) and a measured depth (at least 3.5 cm-Breslow). The second BRAF mutation analysis, in contrast to the first one, came positive for BRAF V600E mutation. Targeted therapy with vemurafenib 960 mg was initiated. A significant response was noted within 2 weeks, including the appearance (BRAF mutation analysis was performed and the result was negative for BRAF V600E. Therefore, targeted therapy with anti-BRAF drugs was excluded and the patient underwent chemotherapy with dacarbazine 250 mg/mpearance , edema, Cutaneous melanoma is a rare malignancy, accounting only for 1% of skin cancer cases, and having it arising on a pre-existing congenital nevus is even much rarer . ThroughCutaneous melanoma is a very aggressive type of skin cancer that can arise from a pre-existing congenital nevus. Our case reveals the significant role of regular follow-up on any pigmented skin lesions, especially melanocytic nevus. Furthermore, it indicates the importance of having alternative methods for detecting BRAF mutations to avoid false-negative results and therefore have better outcomes.The authors have no conflicts of interest to declare.None.Not applicable.Written informed consent was obtained from the patient for the publication of this case report. A copy is available for review by the Editor-in-Chief of this journal.No approval was required for this submission.


Oncocytic cell neoplasms are usually found in the thyroid or salivary glands and the kidneys. Adrenal oncocytoma (AO) is an extremely rare localization. It is often non-functional and the suspicion of malignancy is considered when the size of an adrenal incidentaloma is greater than 4 cm. These adrenal oncocytomas, however, are large, round, and encapsulated with a benign presentation and evolution.We report on a 40-year-old male patient. Upon suspicion of a SARS-CoV-2 infection, the general physician instructed a chest CT scan, which, fortuitously, revealed a suspicious left adrenal lesion measuring 62x45mm. A biochemical investigation was negative for either pheochromocytoma or Cushing's syndrome, allowing the recommended surgery to be performed. The anatomopathological analysis showed an uncommon benign adrenal lesion, an adrenal oncocytoma. Adrenal oncocytoma is an extremely rare tumor. It was originally reported by Kakimoto et al.  in 1986.Oncocytoma is an epithelial neoplasm consisting of cells with an eosinophilic cytoplasm and rich in mitochondria. They can occur in different organs, including the kidneys, the pituitary, the thyroid, the salivary, and the parathyroid glands . Rare caThe diagnosis of adrenal oncocytomas is commonly incidental since they are often nonfunctional; however, biochemical testing is suggested to rule out the functional form. Imaging is not a valuable diagnostic method for oncocytomas because they may have characteristics that are seen commonly in other tumors, like adrenal carcinoma .As oncocytomas are likely benign tumors, the diagnosis has important implications for monitoring. However, there is limited data on monitoring strategies .Herein, we present the case of a 40-year-old male patient whose chest CT scan showed a suspicious adrenal lesion. The patient underwent surgery after pheochromocytoma and Cushing’s syndromes were ruled out. The lesion finally turned out to be an oncocytoma, a rare benign lesion.We report the case of a 40-year-old male patient with no significant medical history. In 2021, the patient complained to his family physician of a flu-like syndrome; a chest CT scan was performed to rule out a SARS-CoV-2 infection, which revealed a suspicious adrenal lesion. The patient was referred to our department for adrenal incidentaloma, where we performed a hormonal analysis to check for the potential of a functional mass and a repeat chest CT scan. The latter showed a left adrenal lesion measuring 62 x 45 mm, solid-necrotic with a spontaneous density of 40UH, 84% absolute washout, and 37% relative washout Figure -1B.Considering that the patient had neither hypertension nor hypokalemia, we wanted to rule out pheochromocytoma and Cushing's syndrome. The results of this study are as follows: a negative urinary fractionated metanephrines test, 1 mg dexamethasone overnight of 0.6ug/dl µg/dl. In the presence of atypical features of the adrenal lesion on the chest CT scan, an MRI was performed and detected a large mass in the external portion of the left adrenal gland. The mass was well limited with regular contours, encapsulated with intermediate T2 signal with areas of high T2 signal, restrictive in diffusion, without signal drop in out-of-phase (OOP) sequences, and with progressive heterogeneous enhancement following a type III enhancement curve, outlining areas of necrosis Figures . It measThe patient underwent a left adrenalectomy via laparotomy and had an uneventful recovery.The histological analysis revealed large polygonal cells with abundant granular and eosinophilic cytoplasm and a vesicular nucleus without cytonuclear atypia. The immuno-histological analysis showed an intense and diffuse marking of anti-synaptophysin and anti-MelanA antibodies, anti-chromogranin antibodies, and cytokeratin, which were all negative. The proliferation index evaluated by Ki67 is less than 5% (2%). Besides, the PS100 antibody showed the presence of scattered star cells. Hence, the diagnosis of adrenocortical oncocytoma was made.A month after the surgery, the patient was completely asymptomatic, with no evidence of surgical wound infection or incisional hernia. He is now under follow-up.The oncocytic cells have been described initially in 1931 by Hamperl as cells with a granular and eosinophilic cytoplasm . AlthougAdrenal oncocytoma is extremely rare; nearly 200 cases have been published since Kakimoto et al. reported the first case . They afAccording to current recommendations, an adrenal incidentaloma greater than 4 cm and over 10 HU is presumptively malignant. Despite this fact, an adrenal oncocytoma is usually benign. Approximately, 25% of AOs reported in the literature are malignant, but in some recent series, a percentage greater than 60-70% have been found . Also, AImaging techniques  have limited sensitivity for adrenal oncocytoma because it is hardly distinguishable from a malignant tumor. Basically, AOs are in general large (8.5 cm on average), low in lipids, with increased attenuation on the CT from 20 to 40 HU, and have malignant features such as heterogeneous contrast enhancement or fibrous encapsulation.Macroscopically, the AO is a well-circumscribed enclosed lesion, in which areas of bleeding and/or necrosis can be detected. The defining histological characteristic of these tumors is a proliferating oncocytic cell, with an increased size and an eosinophilic granular cytoplasm, due to the accumulation of mitochondria. They are usually positive for vimentin, calretinin, alpha-calretinin, alpha-inhibin, and melanin-A and negative for S100 and chromogranin .In terms of prognosis, while the Weiss criteria  are usedConcerning the treatment of these tumors, their association with hormonal hypersecretion and their suspicion of malignancy make surgery the first option. Adrenalectomy is usually performed by laparotomy for large tumors or by laparoscopy for smaller ones if imaging shows a well-encapsulated tumor with no invasion.There are few recommendations for follow-up. No recurrent benign or indeterminate oncocytomas have been reported. Patients with malignant oncocytomas, however, have a five-year survival rate of 50-60% after surgery. Out of the nine cases of malignant oncocytoma, five were reported disease-free in six months, whereas four experienced a recurrence .It is recommended that regular monitoring should be maintained for at least five years ,7.Adrenal oncocytoma is a rare tumor. Surgical removal remains the primary method of treatment and it can be considered in most cases as a benign tumor. This case report is a valuable contribution to understanding adrenal oncocytoma due to the lack of information based on cases reports. However, large clinical studies are much needed to confirm the results as well as in order to evaluate the prognosis and establish follow-up strategies.


Pseudomonas aeruginosa is the most common organism that causes GNS. It is an opportunistic human pathogen that preferentially colonizes moist environments, and thus, it usually affects patients with a history of prolonged exposure to moist environments. Here, we describe a case of GNS in an epidemic prevention volunteer that was caused by wearing personal protective equipment for prolonged durations. The case was reported during the outbreak caused by the SARS-CoV-2 Omicron variant in Shanghai. After receiving information about his condition and proper treatment, the patient was cured.Green nail syndrome (GNS) is an infectious disorder characterized by greenish discoloration of the nail plate.  Pseudomonas aeruginosa is the most common causative pathogen (Green nail syndrome (GNS), also known as chloronychia, is an infectious disorder characterized by greenish discoloration of the nail plate . Pseudompathogen . GNS maypathogen .It is well-known today that various skin disorders are induced by the use of personal protective equipment (PPE) such as facemasks and gloves . Here, wA 34-year-old otherwise healthy male presented with asymptomatic, greenish discoloration of the nail plate that had set in over a period of 4 weeks. The discoloration began at the distal margin extending to the middle of the nail plate. The patient did not report any history of trauma or onychosis. Before the lesions appeared, he was an epidemic prevention volunteer who wore PPE  for at lP. aeruginosa. Subsequently, drug sensitivity tests were performed, which revealed sensitivity to fluoroquinolones including ciprofloxacin and levofloxacin.Physical examination revealed greenish black discoloration from the middle to distal parts of the first and third toenails of the left foot . A whiteGNS was diagnosed based on these findings, and the patient was instructed to stop wearing PPE, to wash his feet daily, and to keep his feet dry. Based on previous literature , 6 and dP. aeruginosa  and the Shanghai Municipal Commission of Health and Family Planning (Grant Number 20194Y0337).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Hemangioma is a well-known neoplasia in veterinary and human medicine. Several subtypes have been described and are distinguished based on their histologic appearance. The classification schemes of hemangiomas in human and veterinary medicine are different, and various purpose-based schemes can be found in the literature.A six-week-old puppy was presented that suffered from a neoplasia that extended to the musculature of the hind limb. After surgical excision, the mass was submitted for pathohistological examination. The mass was composed of endothelial cells forming vascular slits admixed with a fibrous stroma and spindle cells. Immunohistological examination was positive for factor VIII-related antigen and smooth muscle actin, supporting the diagnosis of hemangioma.The final diagnosis of granulation tissue-type hemangioma was given due to the histological appearance of the neoplasia. Granulation tissue-type hemangioma is a rare subtype of hemangioma. In this case an uncommonly young dog was affected. Vascular tumors are common neoplasms in dogs. Approximately half of all canine vascular tumors occur in the skin, and most of them are benign neoplasms or tumor-like lesions  . Hemangi2]). The tissue was infiltrated with small numbers of lymphocytes, macrophages, and plasma cells. Neutrophilic granulocytes were found in some vascular structures formed by the tumor (not shown). There was mild regeneration of the skeletal musculature. The endothelial cells were positive for factor VIII-related antigen  and vascular malformations  is fluid, and the subclassification of these tumors is often vague and not clearly defined. The current International Society for the Study of Vascular Anomalies (ISSVA) classification of benign vascular tumors in humans distinguishes infantile hemangioma, congenital hemangioma, tufted angioma, spindle-cell hemangioma, epithelioid hemangioma, and pyogenic granuloma, in addition to some other subtypes that differ in appearance, incidence and prognosis . Infanti


Sinonasal teratocarcinosarcoma (SNTCS) is a highly malignant and rare tumour characterised by a complex admixture of teratomatous and carcinosarcomatous components. In the head and neck area, it almost exclusively occurs in the sinonasal cavities; however, rare instances of nasopharyngeal and oral cavity involvement have been reported, with fewer than 100 cases reported in the literature.The contributed case involves the correlative CT, MRI and histopathology of a sinonasal teratocarcinosarcoma with intracranial involvement. A series of 86 cases of SNTCS reviewed by Misra et al. reported 20.9% of cases demonstrating intracranial, cribriform plate and anterior cranial fossa involvement.8Owing to its heterogeneous histological appearance, adequate sampling and recognition of all the components of this type of tumour are needed for its correct diagnosis. Inadequate sampling may lead to erroneous diagnoses of olfactory neuroblastoma, squamous cell carcinoma, undifferentiated carcinoma, adenocarcinoma, malignant salivary gland–type tumours and adenosquamous carcinoma.This article describes the CT and MRI findings as well as the histopathology of a rare case of a SNTCS, with the epicentre in the left nasal cavity involving the left maxillary sinus, with intracranial extension. To the authors’ knowledge, this is the first case described in South Africa.A 44-year-old man presented with a 3-month history of a rapidly growing left-sided nasal mass. He complained of recurrent epistaxis, blocked nose and generalised headaches, concentrated mostly on the left side of his face; however, there were no visual or olfactory disturbances. His medical history included hypertension and previous pulmonary tuberculosis. Nasal endoscopic examination revealed a distended left nostril with a protruding, friable, haemorrhagic, exophytic, foul-smelling mass. The rest of the clinical examination was unremarkable.Brush cytology of the lesion showed atypical malignant epithelial cells morphologically suggestive of a carcinomatous lesion. Based on the cytological features and radiological imaging, a provisional diagnosis of a Schneiderian papilloma with malignant transformation, sinonasal neuroendocrine carcinoma (SNEC), sinonasal undifferentiated carcinoma (SNUC), sinonasal adenocarcinoma or a malignant salivary gland neoplasm was considered.Following demonstration of an intracranial component on MRI, a decision was made to treat surgically with a combined rhinology and neurosurgery approach. The intracranial tumour was removed first, followed by a transnasal endoscopic procedure. Histology revealed a SNTCS. Postoperatively, the patient developed a brain abscess with associated seizures and convulsions. The brain abscess was drained, but the patient subsequently demised as a result of rapid disease progression.A CT scan revealed a soft tissue mass with its epicentre in the left nasal cavity, measuring approximately 89 mm × 30 mm × 46 mm in diameter . Anteriorly, the mass projected through the nostril and posteriorly extended to the posterior choana. Superiorly, the mass extended to the cribriform plate with bony demineralisation. Bulging and demineralisation of the medial wall of the left orbit was present, but no intra-orbital involvement was evident .The MRI showed a T2 hyperintense, T1 isointense and post–contrast enhancing mass in the left nasal cavity. The nasal septum was deviated to the right, with obstruction of the maxillary sinus. Superiorly, the mass extended into the left anterior cranial fossa and frontal lobe with mild mass effect but no peritumoural oedema  and 3. TAt DWI B-1000/mm, the mass showed increased signal. There were areas of susceptibility artefact anteriorly and at the posterior skull base . The axiThe surgically resected specimen showed a necrotic, friable haemorrhagic tissue mass. Microscopic examination revealed fragments of inflamed sinonasal mucosa with foci of atypical glandular structures, composed of pleomorphic cuboidal to columnar epithelium, demonstrating irregular hyperchromatic nuclei and abundant cytoplasm . AdjacenImmunohistochemical staining revealed a high proliferation index in the atypical glands and primitive round cells. The adenocarcinoma component showed immunoreactivity with cytokeratin AE1 and AE3 (not shown). The primitive neuroepithelium was positive with S100, CD56 and neuron-specific enolase (NSE)  and g, a2 The histogenesis of SNTCS is debatable. The presence of neural tissue in these neoplasms raises the possibility that the origin may be in some way related to the olfactory membrane, or alternatively to the sinonasal membrane, as it also develops from the olfactory membranes. Other theories propose germ cell origin or pluripotential progenitor cell with multidirectional differentiation.10 In contradiction to malignant gonadal teratomas, which are frequently found in patients at a younger age, SNTCS does not contain histological evidence of embryonal carcinoma, choriocarcinoma or germinomas (seminomas), making germ cell origin for SNTCS unlikely.11Sinonasal teratocarcinosarcoma is a rare and aggressive tumour showing combined histological features of a carcinosarcoma and a teratoma.10 In a series reported by Smith et al., a total of 9 out of 10 tumours occurred in the nasal cavity with extension to the maxillary sinus, the ethmoid sinus and sphenoid sinus.12 A review of the literature revealed 15 cases of SNTCS with intracranial extension between 1998 and 2020.15 The first case of a primary thyroid teratocarcinosarcoma in a 17-year-old male patient was reported by Abayie et al., implying that teratocarcinosarcomas can occur in primary tissues other than the sinonasal tract.16These tumours are more common in adults in the fourth to fifth decade and occur mostly in male patients, with only five cases reported in children.17 Nguyen reported that F-18 fluorodeoxyglucose (FDG) uptake by normal brain parenchyma may be a pitfall of not detecting intracranial invasion on F18-FDG-positron emission tomography (PET)/CT. An advantage of FDG-PET/CT, however, is that regional and distant metastases can be detected.17Sinonasal tumours usually lack specific CT and MRI features, and the imaging is similar to common malignant sinus tumours such as olfactory neuroblastomas, small cell carcinomas, immature teratomas, carcinosarcomas and adenocarcinomas. CT findings of a mass widening the olfactory recess and extending to the cribriform plate should alert to the possibility of intracranial extension, and MRI is indicated.The infrequency, complex phenotypic composition and radiological similarities with other malignant sinonasal tumours often lead to misdiagnoses and management difficulties. These tumours may therefore be mistaken for olfactory neuroblastoma because of their neuroectodermal histological component and transgression of the cribriform plate on radiology. Histological features that may aid in the recognition of these tumours are the presence of immature neural tissue and foetal clear-cell epithelial structures admixed with various malignant and mesenchymal elements. A panel of immunohistochemical antibodies – monoclonal and polyclonal – can be utilised to assist in the diagnosis of SNTCS. The glandular and/or epithelial structures show positive immuno-expression with epithelial membrane antigen (EMA) and keratins (CK); the mesenchymal components express various antibodies, for example, vimentin, desmin and alpha smooth muscle actin (α-SMA), the latter two indicating smooth muscle differentiation. Neurofilament (NF), glial fibrillary acid protein (GFAP), neuron-specific enolase (NSE) and S100 protein show the presence of primitive neural elements. CD99 expression is noted in the foetal clear-cell epithelial component while Beta human chorionic gonadotropin (β-HCG) and alpha foetoprotein (AFP) are typically negative, highlighting the absence of germ cell elements.19 Aggressive tumour spread, intracranial extension and high recurrence rate may negatively impact the survival rate.15 Despite aggressive surgical resection and adjuvant radiation therapy, the prognosis is still poor, as half of the patients with SNTCS succumb to their disease within three years of diagnosis.15In summary, SNTCS is an aggressive tumour, exhibiting a highly invasive behaviour and a propensity for recurrence and dissemination. Both CT and MRI can detect the tumour and determine the local extent; MRI is, however, more sensitive for detection of intracranial extension. Total excision of the tumour and aggressive sampling for histopathological examination is necessary to avoid an erroneous diagnosis. Treatment usually involves multimodal surgical resection, with or without adjuvant treatments comprising radiation and chemotherapy.


Pneumomediastinum is free air within the mediastinal cavity which can spread along tissue planes leading to the accumulation of large amounts of subcutaneous emphysema. Patient is a 21-year-old male with a history of autism spectrum disorder and rhabdomyolysis who presented with diffuse “popping under the skin” and was found to have crepitus extending from his neck to his bilateral ankles. He exercises frequently and performs chin-up pullovers and will often hold his breath during this movements. He uses an inversion table but denies any valsalva maneuvers or straining while inverted. Radiological imaging demonstrated pneumomediastinum, pneumoperitoneum, and diffuse subcutaneous emphysema extending into the pelvis. Diagnosis requires a combination of history, physical exam findings, and imaging findings. Patients with spontaneous pneumomediastinum typically experience self-limited disease, and efforts should be made to minimize low yield invasive testing. Most patients can be treated on an outpatient basis after monitoring and education about potential complications. Pneumomediastinum is defined as free air within the mediastinal cavity . PrimaryPatient is a 21-year-old male with a history of autism spectrum disorder and rhabdomyolysis who presented with diffuse “popping under the skin.” On evaluation, he was found to have crepitus extending from his neck to his bilateral ankles. He exercises frequently and performs chin-up pullovers with self-inversion and will often hold his breath during this movements. He also uses an inversion table, which is a device that suspends an individual in an inverted position by their ankles against gravity. He denies any valsalva maneuvers or straining while inverted. He denies any recent illnesses, straining with bowel movements, illicit drug use, asthma, pulmonary disease, scuba diving, falls, trauma, recent surgical interventions, recent endoscopies, or history of connective tissue or autoimmune disease. Labs were negative for any acute findings. COVID testing was negative. Urine drug screen was negative. Chest X-ray showed pneumomediastinum with extensive air throughout the chest wall and neck bilaterally. CT head was negative for any acute intracranial abnormalities but did demonstrate subcutaneous emphysema. CT neck showed extensive air throughout the soft tissues of the chest wall and neck, pneumomediastinum with air dissecting cephalad in the prevertebral space, and with air in the epidural space. CT chest showed pneumomediastinum and extensive subcutaneous and soft tissue emphysema throughout the chest and back without signs of a pneumothorax. CT abdomen and pelvis showed extensive soft tissue subcutaneous emphysema below the inguinal ligament into the scrotum, mild pneumoperitoneum, and mild extradural air in the lumbosacral spine. The extensive subcutaneous emphysema can be visualized in The patient suffered a spontaneous episode of pneumomediastinum secondary to repeat valsalva maneuvers in the setting of intense physical exercise while inverted. He developed diffuse subcutaneous emphysema and pneumoperitoneum secondary to inversion maneuvers which allowed air dissection along the spine, the pelvis, and into the bilateral lower extremities. This was easily diagnosed with radiological imaging, and the patient was managed conservatively.Typically, subcutaneous emphysema does not traverse into the lower extremities beyond the inguinal ligaments. There is one case reported in the literature of a patient developing diffuse subcutaneous emphysema extending into the bilateral lower extremities. This occurred in a patient who was found hanging from his ankles below a bridge for an unknown amount of time . This waDiagnosis requires a combination of physical exam findings and imaging though in this case, the history of inversion maneuvers played a paramount role in diagnosis. Spontaneous pneumomediastinum is a diagnosis of exclusion. Common findings include cough, dyspnea, chest pain, dysphagia, crepitus, neck pain, and Hamman's sign . Chest XTreatment focuses on supportive care as spontaneous pneumomediastinum is usually self-limiting. Patients must be monitored for complications such as massive subcutaneous emphysema causing compression of internal structures, pneumothorax, or pneumopericardium . These c


The incidence of pleural disease is increasing, and interventions are crucial in this subspecialist area of respiratory medicine. One of the cornerstones of pleural effusion investigation and management is medical, which is also known as local anaesthetic thoracoscopy. This allows fluid drainage, biopsy for diagnosis and preventative measures for further fluid potential build-up. This article summarises the evidence around this procedure through a narrative review of the available evidence. Complement du Dictionnaire de l’Academic Française using the term as early as 1842 [British Medical Journal published a report whereby Sir Francis Richard Cruise, an Irish endoscopist, used regular direct endoscopic inspection of the pleura to monitor a patient’s protracted recovery from pleural infection. Together with Samuel Gordon, an Irish internist at the time, Cruise used a modified endoscope that had been created by A J Desormeaux. Furthermore, Carlo Forlanini, in Pavia, Italy, used a similar method in 1882 to create an artificial pneumothorax and induce lung collapse, a treatment that was thought to be beneficial in pulmonary tuberculosis [Thoracoscopy, meaning examination of the thoracic cavity, has been a technique used since the 19th century. Hans-Christian Jacobaeus is widely credited with first performing and publishing his technique of using a cystoscope to insufflate air into the thoracic cavity and diagnose tuberculous pleural adhesions in 1910 [rculosis . At the In recent years, local anaesthetic thoracoscopy (LAT), otherwise known as medical thoracoscopy or pleuroscopy, has become widely used by respiratory physicians as a tool in undiagnosed exudative pleural effusions ,5. In thLAT can thus be performed in the treatment of malignant pleural effusion, pneumothorax and pleural infection. An in-depth discussion of the latter two conditions is beyond the scope of this article, and the article will concentrate on LAT in malignant pleural disease, but we will discuss the other conditions briefly where appropriate. There have been some excellent articles detailing the increasing epidemiology of malignant pleural disease ,10, and LAT is performed predominantly to determine if a malignant process is present in the pleural space. Various case series would suggest that it has a 92.6% diagnostic sensitivity in malignant pleural disease ,5. MaligLAT has been employed for the treatment of pneumothorax, pleural infection, lung biopsy and sympathectomies . These hThe indication for surgery in those with pneumothorax is predominantly to prevent recurrence, and the whole array of procedures that can be performed are beyond the scope of this article. These are usually completed via video-assisted thoracoscopy or an open thoracotomy approach . HoweverCareful patient selection is required prior to LAT: a detailed history regarding the disease process including previous occupational exposure  and previous malignant disease is important. A baseline functional assessment is useful to assess suitability to proceed with the procedure as well as potential treatment, and therefore, a World Health Organisation Performance Status of 2 or above is recommended ,28. The The commonest form of sedation is a combination of midazolam and fentanyl, as recommended by the BTS 2010 guidance . Other mw/v, 1 in 200,000 is used. In Leicester NHS Trust, xylocaine  is used as standard. A small incision will be then performed with a scalpel, and a Boutin needle (with blunt and sharp ends) will be used to pierce the parietal pleura. Approximately 10–20 spontaneous breaths by the patient are then sufficient to induce a pneumothorax so that the lung ‘peels away’ from the parietal pleura. Then, using small forceps, a tract is then created from the skin to the pleura and a 7-millimetre (mm) trocar is passed through the tract. Fluid can be removed through the trocar using standard suction tubing  to allow for inspection of the pleura and lung with either zero- and fifty-degree scopes, and then biopsy of any lesions deemed appropriate. Talc poudrage can then be performed, and a large bore drain or an indwelling pleural catheter inserted.Medical thoracoscopy can either be performed in a surgical theatre or an interventional suite, and there are no specific requirements for the hospital, except that the medical  and nursing staff are trained at the procedure and can deal with any complications that might arise or refer to a local or regional cardiothoracic unit if urgent surgical intervention is required , the patient will lie in the lateral decubitus position, with the side of the pleural effusion to be investigated facing upwards. A point of care USS will be completed pre-procedure to choose a puncture site, and local anaesthetic will be infiltrated at that site. The authors of this article are from two separate centres. In Northumbria Healthcare, between ten and twenty millilitres (depending on patient weight and if an erector spinae block has been performed) of bupivacaine and adrenaline (epinephrine) injection BP 0.5% 2) were obtained with rigid forceps than semi-rigid ones (11.7 mm2) [The rigid thoracoscope via a single port is most commonly used by respiratory physicians ; however1.7 mm2) . Both ty1.7 mm2) ,38,39,401.7 mm2) ,36,37,381.7 mm2) . Table SLAT is considered a very safe procedure and is described as such by the British Thoracic Society guidelines . PotentiOf note, biopsy during LAT has a similar efficacy to video-assisted thoracoscopic surgery (VATS) biopsy in the diagnosis of malignancy, with the latter being performed predominantly under general anaesthesia by thoracic surgeons, although local anaesthetic approaches have been described ,44. LAT As described above, the diagnostic yield of LAT is very high, but for that small percentage of patients in whom a malignant diagnosis is suspected  and whose biopsy is interpreted as benign , further procedures  are often required ,43,44,45False negative results are often thought to be due to ‘difficult’ LAT, where the amount of fluid might be minimal, the lung might not ‘go down’ at pneumothorax induction resulting in limited views, or where there might be significant loculations or adhesions again limiting access to the parietal pleura or where ‘deep’ (incorporating adipose and muscle tissue) biopsies of the parietal lining were not performed or feasible .It is important to note the distinction between a true false negative biopsy and pathological findings that would suggest non-specific pleuritis (NSP) which describes chronic pleural inflammation which does not have a specific benign or malignant cause. Up to 30% of cases of exudative pleural effusions can have NSP as a final diagnosis. However, close clinical and radiological follow-up is required for a period of 24 months due to the risk of malignant transformation .There are thus a number of suggested practices to improve diagnostic yield, as the macroscopic appearance of the pleura is neither sensitive nor specific .Firstly, rapid onsite evaluation (ROSE) of the specimens by histopathologists in real time at the time of LAT is an option, notwithstanding the limitations in assessing some cancers such as mesothelioma where differentiation between benign fibrinous material, atypical mesothelial cells and tumour with ROSE might prove impossible. ROSE has not been tested in large multi-centre trials, but monocentric observational data would suggest that combining radiological imaging and ROSE findings would increase diagnostic yield . HoweverA new, exciting development recently presented at the 2020 and 2021 European Respiratory Society Congress is confocal laser endomicroscopy . This isPleurodesis is commonly performed if malignancy is strongly suspected ,5,6. ThiThere has been a palpable shift, evidenced by case series , towardsThere is also the possibility of conducting another procedure concurrently  if the ROSE preparation suggests a non-malignant process in a patient with high index of suspicion for malignancy . This isFor those presenting with an unexplained pleural effusion, with a high pre-test probability of malignancy, LAT is a safe procedure with high diagnostic sensitivity. Guidance governing its practice is outdated, but updated documents from the British Thoracic Society and European Thoracic Society are expected in late 2022. We hope that the above narrative review informs the general physician about a cornerstone procedure in pleural disease and that for established respiratory physicians, it serves as an expert opinion-based summary of the literature.The feasibility and safety of day case LAT with IPC insertion;The widespread application of new techniques such as ROSE preparation and confocal laser endomicroscopy;The feasibility of LAT in early stage pleural infection  compared with surgical techniques.We highlight areas for future research, which are:Medical thoracoscopy is a diagnostic and therapeutic procedure for unexplained pleural effusion with a very high diagnostic yield.In those patients with a high pre-test probability for cancers such as mesothelioma, a direct to biopsy approach via medical thoracoscopy should be the preferred approach.Medical thoracoscopy has an acceptable safety profile, the main concerns being pleural infection (empyema) and prolonged air leaks.


Squamous papillomas are benign neoplasms. The occurrence of middle ear squamous papilloma is rare. It is usually associated with nasosinusal pathology. The authors report a case of middle ear squamous papilloma and discuss its diagnostic aspects. Squamous papilloma is a benign neoplasm derived from ectodermal tissue. These lesions occur normally on the skin of the face, trunk, arms and external auditory canal, which may affect the oral cavity, nose, pharynx and larynx mucosa, but rarely the middle earMiddle ear papilloma pathogenesis is uncertain, and it may be associated with human papilloma virus (HPV), but there is no correlation between it and genital diseaseE.O.J, male, 72 years old, with history of right ear intermittent otorrhea, associated with ipsilateral hearing loss for 3 years. He did not report otalgia, otorrhagia, local trauma, vertigo or tinnitus. At otomycroscopy we identified lesion of polypoid multilobulated aspect with light pink transparent color comprising the whole right external auditory canal, coming from the middle ear. Left ear examination showed no affections. Temporal bone computer tomography scan (CT scan) evidenced complete obliteration of external and middle ears on the right with hyperattenuating material and evidence of ossicle chain erosion and obstruction of oval and round windows on the same side. The left ear did not present any affections .Figure 1After biopsy in the laboratory, under local anesthesia, it was possible to delimit the presence of wide central perforation of the tympanic membrane, and we could visualize residual lesions close to the malleus anterior process and posterior-superior region of tympanic membrane. The auditory tube orifice was free from the disease. There was resolution of otorrhea. Nasofibrolaryngoscopy did not show any abnormalities.Histopathology examination with sections stained with hematoxylin-eosin evidenced connective dense axis with pluri-stratified paved keratinized epithelium without cell atypia, with final diagnosis of squamous papilloma. HPV serology was negative .Figure 2Audiological assessment revealed presence of severe mixed hearing loss on the right with speech detection threshold at 90dB and moderate to severe sensorineural loss on the left and speech recognition index within the normal range.We performed CT scans that revealed the presence of material with attenuation of soft parts partially filling the right epitympanic cavity, as well as obliteration of the ipsilateral oval window niche with hypoattenuated and sclerotic mastoids .Figure 3The patient was submitted to radical mastoidectomy on the right and we observed that the mastoid was eburnean, with normal sized mastoid antrum, recovered with thick mucosa. Exposed to attic with removal of inflammatory tissue. The incus was normal and there was absence of the tip of malleus anterior process. We removed the border and tympanic annulus, as well as the whole thickened, edematous and friable mucosa of the promontorium and auditory tube. Postoperatively, there were no adverse events.Middle ear squamous papilloma is extremely rareMiddle ear papilloma normally manifests with otorrhea and/or hearing loss, and there may be sensation of foreign bodyAn association that has been well documented is between middle ear papilloma and nasosinusal papilloma, especially in inverted subtype papilloma, making it necessary to investigate the nasal cavity, paranasal sinuses and nasopharynxThe treatment of middle ear papilloma is mainly surgical. It is necessary to perform complete resection of the lesion to prevent disease recurrence. Despite the appropriate treatment, in about 20% of the cases, there is lesion recurrence, and then it is necessary to perform new surgical interventions to be able to eradicate itMiddle ear squamous papilloma is a rare event. Despite the benign aspect of the lesion, the possibility of recurrence after surgical treatment makes it sometimes difficult to control this pathology. More studies are required to define its etiology.


Budd–Chiari syndrome (BCS) is rarely caused by trauma. We reported a case of transient and secondary BCS post polytrauma that resulting from massive perihepatic and abdominal fluid and compressed liver, causing stenosis of the inferior vena cava and hepatic veins. This was a special BCS case related to but not directly caused by trauma. With conservative management and active surgical procedures, the patient recovered well. Budd–Chiari syndrome (BCS) comprises a heterogeneous group of conditions characterized by partial or complete hepatic venous outflow obstruction involving one or more hepatic veins (HVs), the inferior vena cava (IVC), or the right atrium. The most common causes include a hypercoagulable or prothrombotic state, extension of the thrombus, a direct mass effect caused by liver lesions including liver tumors and abscesses, and congenital development abnormality of IVC . BCS is rarely caused by trauma that influences mortality because of massive bleeding and the difficulty associated with its repair. Common treatments for BCS include anticoagulation therapy, transjugular intrahepatic portosystemic shunting, surgical shunting, and liver transplantation. The risks and benefits of living donor liver transplantation have also been the focus of recent attention , 2. In tA 35-year-old man with polytrauma was transferred to our Burns & Trauma ICU on September 1, 2021. He was accidentally smashed in the left thigh by a trunk while sawing the tree and was then picked by other dropped trunks to a height of 3 m and hurt severely with pain. In the Emergency Department, computed tomography (CT) showed liver rupture, perihepatic hemorrhage, exudation around the pancreatic head, abdominal and pelvic effusion, fracture of the left femoral backbone, and fracture of the left tibia . After cThe following day, the patient still had intermittent abdominal distension, abdominal pain, and fever with slightly elevated inflammatory indicators  as well as jaundice. To find the cause of bile fistula, a laparotomy was performed on October 7. Rupture of the distal choledochusal near the pancreatic duct, extensive intestinal adhesion, and encapsulated effusions were found in the surgery. Choledochal “T” tube drainage + enteroclysis + peritoneal effusion removal was performed. Abdominal distension, abdominal pain and fever, and inflammatory indicators significantly improved, and ascites disappeared postsurgery. Abdominal enhanced CT on November 8 showed that IVC and hepatic veins returned to be normal .via surgery that the true cause was a biliary fistula.BCS is defined as “the obstruction of hepatic venous outflow that can be located from the small hepatic venules up to the entrance of IVC into the right atrium, if a right heart failure or constrictive pericarditis has been excluded” . Since tEmergent surgical management of BCS including primary repair, patch repair, or reconstruction with various grafts is used to manage BCS caused by trauma, but the optimal strategy for surgery remains controversial. There are many causes of BCS, which need to be identified by the clinician in the context of the medical history and examination. In the past, a patient with liver disease had BCS due to a giant hydatid cyst, which was effectively relieved by catheterization with a drainage catheter in the cystic cavity . In thesOverall, this patient had massive perihepatic and abdominal encapsulated effusion due to liver rupture and bile fistula. Then, effusion extrusion of the liver caused severe stenosis of IVC/HVs, resulting in clinical transient secondary BCS. In turn, secondary BCS aggravated ascites and clinical symptoms. After removing the inclusion effusion and reducing liver extrusion via surgery, the symptoms and signs improved and disappeared. We fully recorded the development and management of this transient secondary BCS case. At the same time, we also realize that this is a nonclassic trauma-related BCS case, and ascites clearance and repair of bile fistula are keys for the management of transient secondary BCS.


Unicornuate uteri are a type of Mullerian duct anomaly and the majority present with rudimentary horns. Rudimentary horn pregnancies are extremely rare and have a high risk of rupture. A high index of suspicion is needed to diagnose them early and unfortunately, the majority of cases are undetected until the patient presents with a ruptured uterus. Early diagnosis and management will reduce morbidities and mortality for patients.We present a case of a 29 year old who had a routine ultrasound scan in the first trimester that raised an index of suspicion for a rudimentary horn pregnancy. An MRI scan was performed and supplemented the ultrasound findings. The patient underwent laparoscopic management, and the non-communicating rudimentary horn, the foetus, and the attached tube were excised. The patient had a smooth recovery and had no complications. Due to the rarity of rudimentary horn pregnancies, a high index of suspicion is needed for a diagnosis. Timely detection and intervention are crucial to prevent complications. Ultrasound scans and MRIs can aid in the diagnosis. Traditional management involved laparotomy, but with surgical advancements, laparoscopic surgery can be utilized as a less invasive alternative. A non-communicating rudimentary horn pregnancy (RHP) is an extremely rare event with a reported incidence of 1 in 76,000 - 150,000 pregnancies . The keyWe report this rare case of non-communicating rudimentary horn pregnancy in a young lady who was diagnosed early and proper surgical strategy was applied. The present case depicts the high importance of early diagnosis since it allows safer treatment compared to an intervention on an acutely ill patient.A 29-year-old woman, Gravida 1 Para 0, not known to have any past medical or surgical history, came in for a routine antenatal check-up during her 10th gestational week. Up to this point, she had no complaints, and all her vitals were normal, however, upon ultrasound examination, an empty uterus with a thickened endometrium was seen and a viable 10-week foetus was visualized in an extra-uterine space surrounded by thick-walled myometrium  are rare conditions, with a reported incidence of 0.1- 3% in the general population; 2-8% amongst infertile women, and 5-30% amongst women with a history of miscarriage ,7. FurthEarly detection of rudimentary horn pregnancy is crucial, as the risk of uterine rupture is estimated to be 80-90% by the second trimester, which could result in high morbidity and mortality . A high Traditionally, according to reported cases, RHP was treated using laparotomy to excise the rudimentary horn and the ipsilateral fallopian tube, however, with the advancement of surgical innovations and surgical expertise, the laparoscopic technique has become more favorable due to earlier patient recovery . LaparosRHP is a rare entity, requires a high index of suspicion, and can lead to uterine rupture if left untreated. As a result, it is important to be familiar with the proposed ultrasound criterion in the literature that can lead to earlier detection of RHPs. In addition, an MRI can improve accuracy. Due to the earlier diagnosis, we were able to successfully use laparoscopic surgical repair as a treatment modality instead of the traditional laparotomy.


Esophageal carcinosarcoma (ECS) is a rare malignant tumor that often presents as an intraluminal polypoid lesion in the esophageal lumen. The pathogenesis of esophageal carcinosarcoma is not clear and its etiology is still being discussed.We report the case of a 68-year-old male who had dysphagia for approximately three months. Contrast-enhanced computed tomography showed an irregular enhancing mass in the lower esophagus. Endoscopy showed a gray-white mass with a smooth surface that almost filled the esophageal lumen at a location 28 cm from the incisor tooth. Considering the location of the tumor, we opted for Ivor-Lewis esophagectomy with intrathoracic anastomosis through a 5-port laparoscope and uniport video-assisted thoracic surgery (VATS). Pathological analysis showed that the mass comprised carcinoma in situ and pleomorphic sarcoma, without lymphatic metastasis. The postoperative pathological stage was T1bN0M0, stage I . The latest follow-up of the patient was 14 months after the surgery, and no signs of recurrence or metastasis were found.This case demonstrates a rare esophageal malignancy with a peculiar histological composition. Successful VATS esophagectomy with intrathoracic anastomosis was conducted without recurrence or metastasis at the 14-month follow-up. Esophageal carcinosarcoma (ECS) is regarded as a rare malignant tumor that is biphasic in nature, and is composed of both carcinomatous and sarcomatous elements . VariousA 68-year-old male patient presented to the thoracic surgery department complaining of dysphagia for approximately three months. The patient had begun to experience choking sensations when swallowing solid items three months previously. He could only consume semisolid items when he presented to our hospital and sometimes experienced vomiting or reflux after eating. His history of past illnesses included hypertension for more than ten years and diabetes for more than six years. The patient had been taking nifedipine (20 mg bid) to control his blood pressure and glipizide (5 mg tid) to control his plasma glucose level. He denied odynophagia, retrosternal chest pain and weight loss. No specific family history was mentioned by the patient.An X-ray barium meal test revealed an irregular, approximately circular filling defect, with a diameter of 8 cm, in the mid-inferior part of the esophagus, accompanied by stenosis and stiffness of the esophageal cavity Fig. A. EndoscBased on the location of the tumor, the patient was treated with Ivor-Lewis esophagectomy with intrathoracic anastomosis. The abdominal stage was performed with a 5-port technique, and the thoracic stage was performed with the uniport video-assisted thoracic surgery (VATS). The peritoneum covering the pancreas was dissected above the common hepatic artery, and the upper abdominal lymph nodes were exposed and dissected. The left gastric vessels were exposed and transected. The lymph nodes along the left gastric artery were also dissected. The gastrocolic ligament was transected along the greater curvature of the stomach. The left gastroepiploic and short gastric vessels were exposed and transected. The gastric fundus was sequentially mobilized. Then a 5-cm wide gastric tube was created with a linear endoscopic stapler. The right crus of the diaphragm was transected to allow access to the posterior mediastinum. The retropericardial segment of the esophagus was then mobilized with the surrounding tissue and lymph nodes. For the thoracic stage, the patient was placed in the left lateral decubitus position, and an incision was made at the sixth intercostal space on the right side. The esophagus was mobilized by dissection of the soft tissue, including the lung, pericardium, aorta and pleura. Lymphadenectomy of the mediastinum was carried out at the same time. The esophagus was resected with scissors 3 cm above the tumor. Then, the gastric conduit was pulled into the pleural cavity through the hiatus, and an incision was made in the proximal end of the stomach tube to place the handle of the end-to-end anastomosis stapler. The anvil was delivered to the incisal edge of the esophagus as the anastomosis point through a nasogastric tube by the anesthesiologist. Finally, the stapler was connected to the anvil, and the anastomosis was completed. The anastomosis was covered by fatty tissue, and drainage tubes were placed into the pleural cavity and the mediastinum.The tumor was a large, hard polypoid tumor with a broad pedicle and ulcerations on its smooth surface Fig. , and it The first case of esophageal carcinosarcoma was reported by Hansemann in 1904 . The incECS shares similar clinical manifestations with ESCC. Both malignancies have dysphagia as the most frequent symptom and are sometimes accompanied by chest pain, odynophagia, hematemesis and weight loss , 14. A sThe therapeutic management of primary ECS is decided by the location, pathological type, TNM stage and pathological stage of the neoplasm. Endoscopic treatment might be used to manage on ECSs with smaller sizes that are limited to the mucosal/submucosal layer without lymph node or distal metastasis, as well as those in patients with poor health, as these individuals may have a high risk of perioperative complications or contraindications to major surgery , 18. ComRegarding the prognosis of ECS compared to ESCC, there is still a controversy. Some scholars believe that ECS has a better prognosis than ESCC. Wang analyzed the clinical outcomes of 33 patients and found that the median OS time for all patients with esophageal carcinosarcoma was 43.5 months and that the 1-year, 3-year, and 5-year OS rates were 74%, 57%, and 48%, respectively, better than those of patients with ESCC in their center . The reaIn summary, we reported a case of ECS in which the polypoid tumor comprised squamous cell carcinoma in situ and undifferentiated pleomorphic sarcoma. The patient underwent Ivor-Lewis subtotal esophagectomy with intrathoracic anastomosis, without recurrence or metastasis at the 14-month follow-up. Our report suggests that ECS should be considered with regard to the diagnosis of esophageal tumors. Surgical treatment should be conducted in patients diagnosed with ECS, and VATS esophagectomy could be an alternative to open surgery with fewer complications.


Primary spinal epidural non-Hodgkin's lymphoma (PSENHL) is a tumor of central nervous system origin. It is one of the rarest tumors seen in the fourth to fifth decades of life. The majority of PSENHLs are diffuse large B-cell lymphomas and are most commonly caused because of chronic inflammatory process, chronic infection, or autoimmune disease. Here, we are presenting a case of a 51-year-old male who was found to have a diffuse large B-cell lymphoma, specifically germinal center B-cell type that is considered a rare presentation. Primary spinal epidural non-Hodgkin's lymphoma (PSENHL) is one of the rare central nervous system (CNS) tumors. Among all the central nervous system tumors, only 0.1%-6.5% arise from the epidural location. The majority of PSENHLs are diffuse large B-cell lymphomas and are usually seen in individuals 40-50 years of age. PSENHL affects the midthoracic spine (69%), lumbar spine 27%), and cervical spine (4%) [7%, and cA 51-year-old gentleman presented with a complaint of worsening back pain radiating to the right lower quadrant of the abdomen for the last four months. His past medical history was significant for tobacco use, hypertension, and a traumatic back injury 16 years prior that was treated with intra-articular steroid injections. The pain was dull, 7/10 in intensity, worsened with movement, and was minimally relieved with analgesics. Despite the injections, the back pain continued.On examination, the patient was vitally stable, and the physical exam was within normal limits except for mild tenderness to palpation in the right lower quadrant of the abdomen. The neurologic examination and anal sphincter tone were normal. The laboratory work-up was significant for leukocytosis, but an X-ray of the spine was within normal limits. Magnetic resonance imaging (MRI) of the spine revealed enhancement of the T10 vertebral body with a 0.5 cm about 0.2 in) abnormal signal focus suggestive of an abscess, spondylitis, or neoplastic process  scan shows no evidence of disease anywhere other than the spine, then three cycles of chemotherapy followed by radiation would be done. However, if there is evidence of disease elsewhere, then more cycles of systemic chemotherapy would be indicated. Since there was spine involvement, it was recommended to follow with consolidation radiation therapy after the completion of chemotherapy. The PET scan showed the fluorodeoxyglucose (FDG) uptake in the T10 and T11 vertebral bodies, adjacent right paraspinal and intercostal soft tissues, as well as an increased uptake in mediastinal lymph nodes, concerning malignancy. Bone marrow was also performed, and the aspirate and biopsy showed no evidence of tumor involvement. The patient also underwent a lumbar puncture with cerebrospinal fluid (CSF) analysis, and cytology was negative for malignancy. He was then started on chemotherapy, and is now status negative following four cycles of R-CHOP (rituximab-cyclophosphamide-hydroxydaunorubicin-Oncovin-prednisone regimen) and two cycles of intrathecal methotrexate. The repeat MRI of the thoracic spine with and without contrast did not show any recurrent epidural mass, and there was even an interval decrease in the paraspinal tumor size. He also denied any complaint of tiredness, weight loss, shortness of breath, bowel and bladder dysfunction, or weakness in his lower extremities. In this case, the patient had significant improvement in his back pain after decompressive surgery and postoperative radiation therapy. He is currently being treated with chemotherapy and is tolerating it well. He does not have any neurological deficits or symptoms of bowel/bladder dysfunction.Primary spinal epidural non-Hodgkin’s lymphoma is one of the rarest CNS tumors. The diffuse large B-cell lymphoma involving the spinal epidural space could be further classified into germinal center B-cell type, which is CD10+ or CD10-, BCL-6+, MUM1- and non-germinal center B-cell type that can be CD10-/BCL-6- or CD10-/BCL-6+/MUM1- type . It mostLymphomas are malignant lymphoid tumors that usually develop in the lymphoid tissues and can spread to other organs. Less commonly they can arise from extra-nodal locations like the skin, tongue, lung, stomach, small bowel, and thyroid . Extra-nThe exact etiology of PSENHLs is unclear, but it is assumed that autoimmune diseases, chronic inflammatory processes, and chronic infections may play a role . The lymAll patients presenting with the complaint of chronic back pain should be evaluated thoroughly as it is difficult to diagnose underlying pathologies based on a clinical examination alone. The exclusion of a primary lymphoma requires a proper laboratory work-up for inflammatory markers, radiological imaging with myelography, computed tomography, as well as MRI . LaboratDue to the rarity of the tumor, guidelines for the management of PSENHLs are not certain. Emergency decompressive surgery, with or without resection, in the acute phase followed by radiotherapy and chemotherapy is considered as the mainstay of treatment of PSENHLs. Any patient with acute paresis and/or loss of bladder/bowel control requires emergency decompression of the spinal cord . The surEarlier diagnosis and treatment are associated with improved functional outcomes . It has PSENHLs can be missed in patients who present with symptoms such as worsening back pain. Given the fact that PSENHLs are so rare, the diagnosis becomes more challenging. In any patient who has progressively worsening back pain with any neurological signs and symptoms, a high index of clinical suspicion is needed to consider this rare condition. Timely diagnosis and treatment are vital to improve the functionality, outcomes, and quality of life.