Chronic nonbacterial osteomyelitis (CNO), also known as chronic recurrent multifocal osteomyelitis, is a noninfectious autoinflammatory disorder that occurs primarily in children and adolescents and is characterized by episodic musculoskeletal pain with a protracted course.Traditionally, the diagnosis of CNO is made by exclusion and commonly requires bone biopsy to rule out infection and malignancy. However, bone biopsy may be avoided when imaging and clinical characteristic features are present, such as multifocal bone lesions at typical sites, no constitutional symptoms and no signs of infection in laboratory test results. Whole-body magnetic resonance imaging (WB-MRI) can assess signs of acute and chronic inflammation and enables the detection of CNO typical patterns of lesion location and distribution, thereby helping to exclude differential diagnosis. The goal of the present study paper is to review the main clinical and imaging aspects of the disease with emphasis on the role of WB-MRI in the diagnosis, assessment of disease burden and follow-up monitoring.Radiologists need to be familiar with the imaging features to suggest the diagnosis as the early therapy may help to avoid irreversible secondary damage of skeletal system. CNO/CRMO is a chronic autoinflammatory syndrome occurring primarily in children and adolescents.Imaging plays a pivotal role in diagnosis, differential diagnosis and therapy monitoring.MRI/WB-MRI is the most sensitive imaging method to detect CNO lesions.Chronic nonbacterial osteomyelitis (CNO) is a chronic autoinflammatory syndrome occurring primarily in children and adolescents, first reported by Giedion et al. in 1972 as “subacute and chronic symmetrical osteomyelitis” . The annual incidence of CNO is estimated at 0.4 per 100,000 children , 6. One When the clinical picture is compatible and a characteristic lesion is found on initial imaging examination, whole-body magnetic resonance imaging (WB-MRI) is of fundamental importance in early diagnosis because it may assess both the symptomatic lesion that motivated the examination and possible asymptomatic lesions, confirming the multifocal character of the disease. In addition, WB-MRI provides the location and distribution of lesions demonstrating the typical pattern of symmetrical and bilateral involvement, along with disease activity data and possible complications.In the present article, we review the epidemiological, etiologic, clinical and histopathological features of CNO and the typical patterns of bone involvement in MRI, highlighting the importance of WB-MRI in earlier diagnosis, therapeutic decision-making and follow-up.The pathophysiology of the disease remains not yet fully understood. The post-infectious origin suspected initially has been ruled out since no pathogen has been found and antibiotics have no effect on the disease course . An autoIn CNO, histological examination reveals nonspecific acute, subacute or chronic sterile osteomyelitis and cellular infiltrates are highly dependent on the disease stage. Early phase is characterized by a predominance of neutrophils and osteoclastic bone resorption. During later stages of the disease, monocytes, macrophages, lymphocytes and plasma cells can be detected, along with new bone formation Fig.  8, 9]. , 9. 8, 9The distribution of CNO, specifically its tendency to involve the metaphyses and metaphyseal equivalents, is reminiscent of hematogenous osteomyelitis in children , but theSome authors have suggested that CNO and SAPHO  lie along the same clinical spectrum and some believe that CNO is the pediatric presentation of SAPHO , 12. In The main differentiating clinical feature is the location of the inflammation. CNO predominantly affects the metaphysis of long bones and SAPHO affects the diaphysis and axial skeleton with involvement of the sternoclavicular and sternocostal joints . CurrentCNO belongs to the family of autoinflammatory diseases with osseous manifestations. Some authors  considerA retrospective multicenter study with 41 children diagnosed with CNO and SAPHO syndrome found that osteomyelitis in the pelvic region is significantly associated with other features of juvenile spondylarthritis . HLA-B27The clinical spectrum and severity of CNO vary significantly, with asymptomatic/mildly symptomatic involvement of single bones at one end and chronically active recurrent multifocal osteitis at the other end, also referred to as CRMO , 17. A lClinical signs of bone inflammation include pain, tenderness or swelling. Other symptoms may be caused by paraosseous inflammation involving nerves, vessels, skin or synovia. The disease is marked by exacerbations and remissions, and symptoms may either recur in areas previously affected or involve new sites over time , 16.Patients may experience concomitant systemic symptoms, such as low-grade fever 20%), malaise, weight loss and fatigue. The laboratory findings are nonspecific, with slight increases in serum inflammatory markers , and a normal blood count 0%, malai. In a seA subset of children with CNO may exhibit inflammatory organ involvement, including psoriasis in 2–17%, palmoplantar pustulosis in 3–20% and IBD in 3–7% of patients with CNO [There is no confirmatory diagnostic test for CNO. The diagnosis of CNO is traditionally one of exclusion of other diseases, such as acute bacterial osteomyelitis, bone tumors, blood diseases, fibrous dysplasia and histiocytosis . Due to Diagnostic imaging frequently includes conventional radiography and/or regional magnetic resonance imaging (MRI) at sites of pain. Plain radiography may reveal sclerotic, lytic or mixed lesion, according to the time of disease evolution. Hyperostosis and periosteal reaction are also suggestive features, though less frequently observed . CharactOccasionally, computed tomography (CT) may be useful when MRI is unavailable, but it should be avoided in children . MRI is highly sensitive for detecting inflammatory lesions without radiation exposure, which is important, especially in young children, as MRI can reveal the site, features, and patterns of bone involvement characteristic of CNO . On MRI,Therefore, it is important for radiologists to recognize the imaging characteristics of bone lesions in CNO and promptly suggest whole-body MRI in suspected cases, which may lead to a reduction in the time between the onset of symptoms and diagnosis . In the Most recently, some authors have suggested that biopsy could be avoided when there are characteristic findings, such as suggestive clinical data and multiple bone lesions at typical sites  with normal laboratory test results and no constitutional symptoms , 8. TherThe imaging aspects of CNO include multiple bone lesions, mainly affecting the metaphyses of long bones, clavicle, vertebrae and mandible . SymmetrCNO is the most common non-neoplastic process involving the clavicle in children and adolescents, and clavicular involvement was noted in 38% of patients with CNO . These lesions typically involve the medial third of the clavicle with periosteal reaction, hyperostosis and soft tissue signal abnormality Fig. . ClaviclSpinal lesions were recently reported as a classic site and one of the most common sites for CNO , 27, butThe detection of spinal involvement is important for preventing pathological fracture, as vertebral height is not regained with treatment , 28. TheOur protocol includes morphological sequences such as "short time inversion recovery" (STIR), sensitive for identifying foci of bone marrow edema, and T1-weighted sequences, useful for differentiating true bone lesions from those of normal bone marrow conversion. In addition, it combines functional sequences, such as diffusion-weighted imaging (DWI), which have high sensitivity in detecting foci of edema of the bone marrow, increasing the conspicuity in the identification of focal bone lesions. DWI may be useful to help distinguish between benign and malignant spine fractures and the possible complications of CNO , 26. WB-MRI protocols include coronal images of the entire body and sagittal images of the entire spine acquired with fluid-sensitive sequence  without contrast, axial sequences of the pelvis and knees and sagittal images of the ankles and feet. Sagittal images of the spine are also included since spinal involvement is common and has important clinical and prognostic implications, offering the possibility of individualized treatment Fig. .Fig. 9MRWB-MRI with a scanning time of approximately 40 min is well tolerated even by children and achieves an adequate image quality in the vast majority of examinations . Whole-body MRI allows a wide coverage assessment of both the skeleton and soft tissues with high spatial resolution and is the gold standard imaging modality. It has the capacity to detect subclinical foci of bone marrow edema, demonstrating the multifocal involvement of CNO and the typical patterns of lesion locations and distribution, which helps in the diagnosis and potentially may avoid the need for biopsy Fig. . In addiThe suspicion of CNO with WB-MRI is higher when it is possible to recognize the typical patterns of bone involvement. The typical lesion in MRI is a hyperintense geographic metaphyseal lesion adjacent to the growth plates of the long bones of the lower extremities or additional lesions in the spine, pelvis, clavicle and/or sternum. In a study with 53 WB-MRIs of children and adolescents, 75% showed combinations of at least two of these typical MRI findings, which led to a higher suspicion of CNO . A retrospective study performed by Andronikou et al., with 37 children diagnosed with CNO who underwent WB-MRI, identified 317 lesions in 20 different bones, with 89% of patients having multifocal disease. They noticed three patterns: (1) a tibioappendicular multifocal pattern, which is a multifocal appendicular lesion with predominantly tibial involvement; (2) a claviculospinal pauci-focal pattern, which is a primarily clavicular group with a paucity of other lesions predominating in the spine; and (3) a tibioclavicular crossover pattern, with synchronous clavicular and tibial involvement . The mosThe diagnosis of CNO can be very challenging in some cases. Often, the diagnosis is only considered after several segmental evaluations of the symptomatic sites Fig. .Fig. 12AWB-MRI is useful to establish the disease burden of CNO by quantifying the number of lesions in the patient and the lesion extent  . In a laThe number of radiological lesions has been used as a marker of disease activity in the context of the Pediatric CNO (PedCNO), developed by Beck et al.  The PedCA large cohort study performed by Arnoldi et al. was the first to directly correlate clinical findings of CNO and WB-MRI findings by creating a radiological index for CNO (RINBO). This scoring system uses WB-MRI as a tool to evaluate the number, size, extramedullary affection and spinal involvement of CNO. The goals of RINBO are to grade the intensity of disease and to simplify the evaluation of progression, stability or remission during the disease course. Additionally, RINBO aims to help monitor treatment response and improve therapeutic decisions . No consensus or guidelines exist for the treatment of CNO, and most evidence comes from small case series or retrospective cohorts. To our knowledge, no randomized controlled trials relating to CNO treatments have been published or are currently enrolling. Figure CNO has an unpredictable course, although most cases undergo spontaneous resolution within several months to several years.CNO of long bones can result in orthopedic complications such as limb-length discrepancy, which is the most common physical deformity, fracture, thoracic kyphosis secondary to vertebral body compression and physeal bars .CNO is a diagnosis of exclusion and is often delayed. It has high variability in presentation, sites, recurrence rates and prognosis. The typical clinical presentation is a child or adolescent with a history of chronic multifocal bone pain, usually with a normal blood count and mildly elevated inflammatory markers. The characteristic lesions are metaphyseal, multiple and symmetric, involving the lower extremities, pelvis, spine, clavicle, and mandible.Currently, WB-MRI is the most sensitive imaging method to detect asymptomatic and radiographically occult multifocal lesions, demonstrating the multifocal pattern of the CNO and characteristic lesion distribution, thus helping to establish the diagnosis and reducing the need for invasive diagnostic procedures. Radiologists need to be familiar with the imaging features to suggest the diagnosis.


Antrochoanal polyps (ACPs) are single benign polypoid tumors that originate in the mucosa of the maxillary sinus; they may cross its ostium and extend to the floor of the nose, reaching the choana and nasopharynx.6ACPs are almost always unilateral; there are few published cases of bilateral ACPs in the international literature.A male patient aged 37 years presented with complaints of progressive nasal block for the past four years. He denied other nasal symptoms such as rhinorrhea, sternutation crises, itching, hyposmia, or pain. The nasal block improved partially when the patient used topical decongestants; he was asked to stop this medication on the first visit. The patient reported no otologic or pharyngolaryngeal symptoms, asthma, or salicilate intolerance.Nasofibroscopy revealed a polypoid tumor emerging from each maxillary sinus through widened ostia and extending to the nasopharynx.Computed tomography of the paranasal sinuses showed that the maxillary sinuses were filled with soft tissue density material that reached the nasal cavity and the choanae. The other sinuses were normally aerated .Figure 1The tumors were removed surgically - maxillary antrostomy  with a nasal endoscopy technique. The maxillary sinuses were each filled with a single cystic tumor that was implanted on the lateral wall.Histology of the two lesions described them as inflammatory polyps. The patient had no postoperative events. The tumors have not recurred six months after the procedure.Gustav Killian first described ACPs in 1906; these tumors comprise about 4% to 6% of all nasal polyps in the general population, and 28% to 33% in children.6The etiology of ACPs is unclear.The most common symptom of ACPs is unilateral or bilateral nasal block.The differential diagnosis should be made with retention mucous cysts, mucoceles, maxillary rhinosinusitis, meningoencephalocele, olfactory stesioneuroblastoma, angiofibroma, and inverted papilloma.Computed tomography and nasofibroscopy are the gold standard tests for diagnosing ACPs.Surgical treatment is mandatory.Another possible approach is nasal endoscopy. Its advocates highlight the lower recurrence and complication risks of this approach.5Bilateral ACPs are rare; the cases reported thus far have not led to a plausible explanation for this tumor. Studies defining the approach of choice for treating this disease are sparse in the literature.


Atypical teratoid/rhabdoid tumor (AT/RT) of the central nervous system is a highly malignant tumor that mainly occurs in children under the age of 3 and has only been rarely described in adults. The fact that AT/RT patients have such a terrible prognosis is even more regrettable. Herein, we reported two special cases of AT/RT, both of which were under 3 years. Symptoms at presentation included increased intracranial pressure and cerebellar symptoms such as headache, altered gait, and ataxia. As for the tumor location, one was infratentorial in the posterior fossa, and the other was the right lateral ventricle. Preoperative magnetic resonance imaging scans showed calcification and heterogeneous contrast enhancement in the lesions. The mass was excised surgically for the progression of symptoms. Postoperative pathologies of the tumors, combined with immunohistochemistry, revealed AT/RT. AT/RTs are often misdiagnosed as other types of brain tumors due to the lack of specific radiological features and other key characteristics. To improve awareness of AT/RT on the differential diagnosis of intracranial lesions among clinicians, we present this report and briefly summarize previous cases. Atypical teratoid/rhabdoid tumor (AT/RT) is a highly malignant central nervous system (CNS) neoplasm predominantly found in children under the age of 3, and is extremely rare in adults , 2. In tAccording to the 2021 WHO Classification of CNS tumors, medulloblastoma and AT/RT were classified as embryonal tumors, and all embryonal tumors  were classified as Grade 4 tumor . Using DIn addition, the treatment criteria (including stratification criteria) for patients with AT/RT are a controversial topic . The proCase 1: The patient was a 19-month-old boy with a 1-month history of claudication before admission. Neurological examination verified that the left ankle clonus and the left Babinski sign were positive. Cerebral magnetic resonance imaging (MRI) revealed a mass in the right lateral ventricle with intraventricular extension. The size of the lump was about 6 × 5 × 2 cm, which was primarily isointense on both T1- and T2-weighted MRI. Additionally, the mass appeared hyperintense on enhanced MRI, with areas of calcification and heterogeneous contrast enhancement . The patCase 2: The patient was a 27-month-old boy, whose symptoms were unstable gait for a month, accompanied by nausea and vomiting for half a month. Physical examination did not reveal positive signs. An MRI revealed the presence of a mass measured 2.3 × 1.8 × 1.7 cm in the left cerebellum. MRI showed the isointense on T1-weighted images, heterogeneous iso/hyperintense on T2-weighted images and a pronounced enhancement after using an MR contrast agent . The patAs in prior cases, the pathology of tumors showed that cells had a prominent nucleus with eccentric nucleoli and abundant cytoplasm of a somewhat “rhabdoid” morphology . HoweverAT/RT is an extremely rare and highly aggressive CNS tumor, especially in children under 3 years of age (median age 2 years) , 2, 12. Histopathologically, AT/RT is characterized by the presence of rhabdoid cells, with or without fields resembling a typical embryonal tumor, epithelial tissue, and neoplastic mesenchyme –18. The The cellular origin of AT/RT is unknown, but inactivating mutations of the hSNF5/INI1 gene in chromosomal region 22q11.2 are regarded as a critical step in its molecular pathogenesis . AT/RT iUsing DNA methylation and gene expression profiling, AT/RTs are comprised of three subgroups ATRT-TYR, ATRT-SHH, and ATRT-MYC . FurtherAt present, it is indistinct to formulate a vintage treatment for AT/RT. Therapeutic strategies of AT/RT are largely dependent on the age of the patient, the location of the tumor in the CNS, and the stage of the disease at the time of diagnosis . In geneHowever, there are some limitations in this report. First, the number of cases included in the report is relatively small. So far, there is still a lack of large sample studies, and no mature therapeutic plan has been formed. Furthermore, the figures of postoperative MRI images are missing. Finally, according to multicenter data, AT/RT is still a rare tumor with poor prognosis in children. In general, most of the patients died of local relapse, metastatic lesions through the subarachnoid space, or distant metastasis .AT/RT is a rare disease condition, and a preoperative diagnosis is difficult without an adequate knowledge of the disease. To date, despite multiple advanced diagnoses and treatments being available, the prognosis of patients with AT/RT remains grim. More AT/RT case reports should be included, which will lead to greater diagnostic accuracy as well as improvement in treatment and prognosis. Due to its aggressiveness and poor prognosis, AT/RT cannot be ruled out in the differential diagnosis of intracranial lesions. The case reports replenish the existing literature with new knowledge and hopefully will draw the attention of doctors to the rare tumor.


Chordomas are rare tumors that occur in the bones of the skull base and spine, affecting 1 in 1 000 000 people per year. Thoracic chordomas comprise just 1% of chordomas. A 36-year-old female underwent a right video-assisted thoracoscopic surgical resection for a cystic mass at the level of T2-3 which was well-circumscribed. Despite efforts to achieve an intact resection, there was tumor spillage due to friability, and it was taken off the bony vertebral body with no margin. The final pathologic diagnosis was chordoma. Thoracic chordomas are rare, slow-growing, recurring neoplasms that require proper preoperative diagnostic imaging and ideally preoperative trocar computed tomography-guided biopsy from a posterior approach if anatomic access is possible. They are prone to dissemination and sarcomatous differentiation. The surgical approaches for reported thoracic chordoma tumors vary due to their rarity and the variation in tumor location and presentation. A chordoma is a bone tumor that displays notochordal differentiation from the persistent notochordal elements of embryonic development . ChordomA 36-year-old female presented to an outside emergency department reporting chest pain, dizziness and abdominal pain for 7 hours. A computed tomography (CT) angiogram of the chest revealed a right paraspinal 4.2 × 2.8 × 3.3-cm cystic mass at the level of T2-3, which was well-circumscribed  and 2.A magnetic resonance imaging (MRI) showed that the tumor extended into the outer aspect of the right T2-T3 neural foramen and could represent a nerve sheath tumor. Sixteen months later, neurosurgical consultation repeated her MRI, which showed that the mass had grown 2 mm  and 4. TThe patient underwent a right video-assisted thoracoscopic surgical resection. The mass was found to be gelatinous, not well-encapsulated and intimately involved with the sympathetic chain at the level of the first rib. Despite efforts to achieve an intact resection, there was tumor spillage due to friability, and it was taken off the bony vertebral body with no margin. The patient was discharged with a minor Horner’s syndrome which eventually resolved. The final pathologic diagnosis was chordoma. After multidisciplinary review, the patient was referred for proton beam therapy and received intensity-modulated radiation therapy to the tumor bed and then was referred for consideration of additional proton therapy.Thoracic chordomas are rare, slow-growing and recurring neoplasms that are prone to dissemination and sarcomatous differentiation . Two pubThe surgical approaches for reported thoracic chordoma tumors vary due to their rarity and the variation in tumor location and presentation . If possThe 5-year survival after surgical resection and radiation of spine chordomas vary between 50 and 60% . The 10-Ideally, a preoperative tissue diagnosis would have been useful in this case. The preoperative findings were not specific. The preoperative presentation , while characteristic of a chordoma, may also be caused by other neurogenic lesions which are more common . For spiThoracic chordoma tumors are very rare tumors that require proper preoperative diagnostic imaging and ideally preoperative trocar CT-guided biopsy if anatomic access is possible. Non-specific symptoms and imaging characteristics, however, pose difficulties while developing differential diagnoses for cases involving thoracic chordomas because such a diagnosis is extremely rare. Ideally, chordomas should undergo margin-free en bloc resection to minimize recurrence. A combination of preoperative diagnostic results and intraoperative strategy should direct the excision of unknown thoracic tumors to be resected in the safest way possible to ensure complete resection and to prevent seeding during resection.


The diagnosis of primary Aspergillus appendicitis can be missed or delayed because of its rarity. We report our experience of a case of Aspergillus appendicitis complicating chemotherapy of leukemia.A 48-year-old man who was diagnosed with acute myeloid leukemia developed high fever and epigastric pain two weeks after administration of his fourth consolidation chemotherapy. Right lower quadrant tenderness and rebound tenderness were noticed on physical examination, and the abdomen and pelvis computed tomography suggested acute perforated appendicitis with localized peritonitis. Emergency laparoscopy showed an inflamed appendix, which was resected. Pathology reports revealed invasive aspergillosis in the appendix. The patient recovered after high-dose antifungal therapy, although he required prolonged hospitalization.Acute appendicitis is very rarely caused by fungi infection with an overall incidence of up to 1.15 %. Differential diagnosis of fungal appendicitis without pathology report is challenging due to low incidence.Isolated Aspergillus appendicitis is a rare disease that can progress without appropriate antifungal therapy even after surgical resection of the appendix. Surgeons should pay attention to pathology reports after appendectomy to avoid missing unusual cases, especially in immunocompromised patients. •Fungal infections principally occur in the immunocompromised.•Misdiagnosis and incorrect treatment are frequent in this rare disease entity.•Early diagnosis and prompt surgery with antifungal treatment is best Vancomycin was parenterally administered as empiric therapy. Thoracic and abdominal x-rays showed no specific findings. Abdominal computerized tomography showed localized air bubbles in the peri-cecal and peri-appendiceal area with mild perilesional mesenteric infiltration  produced by Aspergillus and dispersed into the air The clinical features of Aspergillus appendicitis that distinguish this from bacterial appendicitis are not clear and will most likely resemble those of bacterial appendicitis. Symptoms of Aspergillus appendicitis are diverse, ranging from non-specific vague abdominal pain, fever, and nausea to tenderness or rebound tenderness in the right lower quadrant. Despite recent advances in radiologic technology, there is no other suitable method for diagnosis of Aspergillus appendicitis other than histopathologic study. It is difficult to diagnose aspergillosis using blood culture. For immunocompromised patients at risk of fungal infection, abdominal computed tomography, which is the investigation of choice in appendicitis, should be performed without delay if clinical manifestations of appendicitis are suspected.Since it was first performed in 1981, laparoscopic appendectomy has been the gold standard treatment for appendicitis voriconazole, posaconazole, itraconazole, and fluconazole are commonly used drugs for invasive Aspergillus. A recent study suggests that initial therapy with voriconazole leads to better responses, improved survival, and fewer severe side effects than the standard approach of initial therapy with amphotericin B in invasive Aspergillus infection In addition to surgical intervention, if histopathologic confirmation is obtained after surgery, a systemic antifungal agent must be administered to prevent disseminated fungal infection. Fungal appendicitis alone is exceedingly rare but disseminated aspergillosis with pulmonary infection can be fatal even in patients who are not immunocompromised 4In conclusion, Aspergillus appendicitis is difficult to diagnose preoperatively, and surgery is required in most cases. A laparoscopic approach could be an effective treatment. Surgeons should pay attention to histopathologic confirmation after appendectomy in order not to miss unusual cases, especially in immunocompromised patients.Not commissioned, externally peer-reviewed.Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.No approval required.There are no sponsors or special funding for writing or publication of this case report.Donghyoun Lee.1.Name of the registry: –2.Unique identifying number or registration ID: –3.Hyperlink to your specific registration (must be publicly accessible and will be checked): –.Kyoung Won Yoon and Kyung Uk Jung equally contributed to manuscript writing and editing; In-Gu Do contributed to pathologic analysis; Donghyoun Lee generally supervised whole process; all authors have read and approved the final manuscript.The authors have no conflicts of interests.


Solitary neurofibroma of the oropharynx is extremely rare. Imaging explorations may be necessary, but the diagnostic certainty is pathological. We report a case of benign tumour of the oropharynx in a 25-year-old woman who was seen for a consultation with dysphagia, a change in voice and dyspnea in the supine position. The excision was performed under general anaesthesia with orotracheal intubation via the oropharyngeal route. Pathological examination of the surgical specimen revealed neurofibroma. Although rare, solitary neurofibroma of the oropharynx should be considered in any benign tumour in the area. Neurofibroma is a benign tumour of the peripheral nerves, most often isolated but sometimes multiple, especially in neurofibromatosis. Symptoms vary depending on the location. Oropharyngeal localization is extremely rare and can manifest as simple pharyngeal discomfort, dysphagia, a covered voice or even difficulty breathing. The objective of this presentation was to report a rare case of symptomatic solitary neurofibroma of the oropharynx in a young woman and discuss its management in our context.This was a 25-year-old housewife who was seen for a consultation with dysphagia to solids developing for eight months of gradual onset. Four months after the onset of dysphagia, there had been a change in voice and dyspnea in the supine position. The ENT examination showed at the mouth opening a tumour covered with a normal-appearing mucosa from the right lateral oropharynx, which ascended to the protraction of the tongue , firm onThe surgical specimen measured 4cm x3cm x 3cm .Pathological examination of the surgical specimen revealed neurofibroma . Faced wNeurofibroma is a benign tumour that can arise from cells of the Schwann sheath, such as schwannomas, but also endoneural, perineural or fibroblast cells.Computed tomography determines the site and the limits of the tumour and reveals a tissue mass with heterogeneous contrast enhancement characteristic of neurofibromaThe management of neurofibroma is essentially surgical and helps prevent possible degeneration. Due to the close connection of the neurofibromatous lesion with normal nervous tissue, its complete surgical resection exposes neurological deficits in the case of a major nerve.Although rare, solitary neurofibroma of the oropharynx should be considered for any benign tumour in the area. Imaging explorations may be necessary, but the diagnostic certainty is pathological. Surgical management prevents the occurrence of malignant degeneration.


Post-polypectomy syndrome (PPS) is a complication that may arise after some colonoscopy procedures that require electrocoagulation, due to a transmural burn, which irritates the serous membrane. Its clinical presentation is similar to the one of intestinal perforation, but it has a favorable prognosis, and does not require surgical treatment. We report the case of a 55-year-old woman diagnosed with a polyp in the ascending colon, who was admitted for an endoscopic resection. After the procedure, she complained of nausea, emesis and abdominal pain in the right iliac fossa. She was transferred to the emergency department. An abdominal tomography showed cecal wall thickening without pneumoperitoneum. Therefore, the diagnosis of PPS was made and was managed with bowel rest, parenteral fluids and antibiotics, with full recovery. Despite of its low incidence, it is important to suspect this syndrome to avoid unnecessary surgical treatment and initiate medical management right away. In the last decade colorectal cancer (CRC), cases have increased due to better-quality screening approach. A polyp found in any screening test can progress to CRC in 70–80% of the cases; they are generally resected with colonoscopy polypectomy . LikewisPost-polypectomy syndrome (PPS) is an endoscopic complications described for the first time by Waye in 1981, as a peritoneal irritation due to a transmural burn caused by electrocoagulation during endoscopic polypectomy. Its incidence is low, presenting in ~0.03–1.2% polypectomies , 5. GiveWe report the case of a 55-year-old woman diagnosed with of a 3 cm × 4-cm polyp in the ascending colon, who was admitted for an endoscopic resection. At the beginning of the procedure the submucosa was infiltrated with adrenaline, methylene blue and saline solution, and then a heated wire loop resection was made . Six houAnalgesic management was prescribed, blood chemistry and thorax and abdomen X-ray were performed without abnormal results. An abdominal CT was performed, which showed concentric, focal thickening of the cecal walls, with a maximum thickness of 30 mm in the lateral wall, with enhancement with contrast, without evidence of pneumoperitoneum . Given tPPS refers to the development of abdominal pain, fever and signs of peritoneal irritation in the absence of documented bowel perforation, after colonoscopy procedures that required electrocoagulation , 4. The PPS can appear in 0.5–1.2% of patients taken to endoscopic polypectomy , 5, 7. STo distinguish PPS from colonic perforation can be challenging and critical since follow-up and prognosis are abysmally different. PPS has a favorable prognosis: is managed without surgery, in contrast to perforation, which has high short-term morbimortality and requires urgent surgical management . The golTreatment of PPS is conservative: bowel rest, parenteral fluids and broad-spectrum antibiotics. Patients with mild symptoms may have an early discharge on a liquid diet for 1–2 days and oral antibiotics , 11. Sevet al. They proposed a complete closure of the defect by endoscopy with assisted linear clip (LACC). It showed to have lower postoperative complications; nonetheless, large scale studies are required to have greater strength and quality of evidence [Theoretically, submucosal injection of saline solution into sessile injuries prior to electrocautery resection, like the one done in this case, may reduce the risk of PPS; however, there are not comparative studies in actual literature that support this practice . Anotherevidence .PPS is a rare complication, getting to share cases like this one can allow physicians to considered PPS as a possible complication in the context of patients who have undergone endoscopic resections with electrocoagulation. Recognizing the clinical and imaging patterns related to PPS allow physicians to carry out a proper approach. More studies needed to create preventive measures to avoid PPS.None declared.Funding for publishing open access was provided by Hospital Universitario Mayor Mederi. No funding was required for article writing and editing.


In this report, we describe a case of concomitant basilic vein aneurysm and palmar hemangioma with peri- and inter-tendinous growth around the fourth and fifth flexor digitorum superficialis and flexor digitorum profundus tendons.It seems reasonable for physicians and radiologists to keep in mind the possibility of venous aneurysms in the presence of soft tissue hemangiomas; as they can present as palpable mass and be mistaken for other pathologies. Familiarity with clinical and imaging findings of this entity could be helpful to prevent misdiagnosis. Venous aneurysm (VA) - defined as focal saccular or fusiform dilatation of a vein- is an uncommon clinical entity; and is classified based on etiology as primary or secondary. Secondary venous aneurysms are caused by trauma, infection, venous valve insufficiency or in association with hemodialysis fistulas. Primary venous aneurysms are attributed to a congenital defect in walls of a vein. This type of venous aneurysms are very rare; especially in superficial veins, and can be a source of diagnostic challenge Basilic vein aneurysm has been reported in very few cases A 35-year-old woman presented to general surgery clinic with complaint of slowly-growing mass on her distal forearm, which has grown over the previous year. She also had noticed a painless, stable-size palpable mass on the palm of her hand since over four years ago. Patient had no history of trauma or any cannulation at any time.On physical examination, a tubular mass-like structure was visible in the medial aspect of distal forearm. There was also a palpable, soft, fluctuant and nontender mass in the hypothenar region at the site of lump palpation. The masses were not pulsatile or tender.On grayscale and color Doppler ultrasonographic examination, an aneurysmally dilated basilic vein was noted in the medial aspect of the distal forearm; with a 22 mm diameter and slow turbulent flow . There wMagnetic resonance imaging (MRI) study revealed a well-circumscribed mass with low signal intensity on T1-weighted images and high signal intensity on fluid-sensitive sequences in the hypothenar region with peri- and inter-tendinous growth around the fourth and fifth flexor digitorum superficialis and flexor digitorum profundus tendons. Small internal hyposignal foci within the mass were noted, indicating calcifications. The imaging findings were in favor of palmar hemangioma with phleboliths. The basilic vein was aneurysmally dilated; draining multiple vessels which were derived from the hemangioma , Fig. 4.Patient underwent venous aneurysm resection and reestablishment of basilic vein continuity, along with resection of palmar mass. Histopathologic examination confirmed the nature of the palmar mass as capillary hemangioma. In 6 months follow-up, the patient did not develop any complications, such as recurrence or movement restriction.Superficial VA is a rare and unsurveyed entity. Very limited number of cases with basilic vein aneurysms has been reported in the literature Among the wide range of differential diagnosis for a soft tissue mass in the upper extremity, masses of vascular origin are usually overlooked by clinicians. This may lead to inappropriate biopsies and subsequent complications. Our clinical observation emphasizes the need for through imaging evaluation before performing any aggressive procedure over a palpable upper extremity soft tissue mass. Doppler ultrasonography is an inexpensive and accessible method used for initial evaluation of any mass with suspected vascular etiology. In cases of diagnostic challenge, computed tomography (CT scans) and MRI can also be used. MRI and MR venography have been introduced as the preferred imaging modalities for evaluation of vascular tumors and lesions of the hand This clinical observation highlights the fact that vascular lesions should be considered in the differential diagnosis of any asymptomatic extremity lesion, and thorough imaging evaluation is needed before any aggressive procedure. Also, the co-occurrence of venous aneurysm and vascular tumors  should be kept in mind; so it seems reasonable to lower the threshold for utilization of Doppler ultrasound and MRI in evaluation of lesions with suspected vascular origin.


Small bowel and ileocecal diseases remain a diagnostic and therapeutic challenge, despite the introduction of various modalities for deep enteroscopy. Novel Motorized Spiral Enteroscopy is an innovative technology that uses an overtube with a raised spiral at the distal end to pleat the small intestine. It consumes less time and meets both the diagnostic and therapeutic needs of small bowel diseases. The objective of this article is to highlight the possibility of using NMSE as an alternative technique when a target lesion is inaccessible during conventional colonoscopy or cecal intubation cannot be achieved. We report the case of a 61-year-old man who presented with pain in the right lower abdominal segment, diarrhea, and rapid weight loss for more than 3 months. An initial ultrasound showed a suspicious liver metastasis. Computerized tomography scans showed an extensive ileocecal tumor mass with liver metastasis. The colonoscopy was unsuccessful and incomplete due to dolichocolon and intestinal tortuosity. Later, endoscopy was performed using a Novel Motorized Spiral Enteroscope in a retrograde approach, passing the scope through the anus and colon up to the ileocecal segment, where a tumor biopsy was performed and adenocarcinoma was pathohistologically confirmed. The role of endoscopy in the diagnosis and treatment of gastrointestinal disorders has become irreplaceable in the past decades. Even though new endoscopic modalities have been developed, distant parts of the gastrointestinal system, especially the small bowel, remain inaccessible by endoscopic methods in some cases. In 2001, video capsule endoscopy was presented as an innovative technology that enabled examination of the entire small bowel but with a significant drawback regarding the impossibility of performing therapeutic interventions ,4,5. SpiNovel Motorized Spiral Enteroscopy (NMSE) is a new technology with an incorporated motor adjacent to the endoscope. The spiral enteroscope control unit regulates the direction and speed of rotation of the spiral segment  8,9]. I,9. I8,9]In 2016, Neuhaus et al.  reportedSince this is a newly introduced diagnostic procedure that is used only in a small number of facilities, the available literature on this topic is very limited. In addition to the small intestine, the use of this device via the retrograde route can be of great importance in the diagnosis of ileocecal diseases when the target lesions are difficult to access with conventional colonoscopy. According to the literature, 1.6–16.7% of all colonoscopies are found to be unsuccessful due to failure to achieve cecal intubation ,13,14. TA 61-year-old man presented to the hospital with a history of pain in the right groin area, a change in his bowel habits with frequent mushy stools, and unintentional weight loss. These symptoms started about 3 months prior to admission. He was a professional driver with a history of type 2 diabetes mellitus and arterial hypertension who did not consume alcohol or tobacco. No family history of cancer or other inherited medical conditions were reported. Physical examination revealed mild pain to palpations in the right upper and lower quadrants of the abdomen. There were no other abnormal findings during the examination.The initial evaluation included laboratory tests, which revealed elevated tumor markers CEA 3410 μg/L (upper reference limit 3.4 μg/L) and CA 19-9 292 U/mL (upper reference limit 25 U/mL), whereas AFP was normal (1.23 kU/L); upper reference limit 5.8 kU/L). The other laboratory findings were normal.The initial abdominal ultrasound verified changes in the liver parenchyma suspected of metastatic lesions. The abdomen and pelvis CT scans showed multiple focal nodal areas of the liver parenchyma highly suspicious for liver metastases. In the area of the caecum, there was an infiltrative thickening of the wall of the terminal ileum area with associated luminal narrowing, reactive changes of perivisceral adipose tissue, and reactive lymphadenopathy . The proColonoscopy was incomplete since it was performed only up to hepatic flexure. Further progression to CT-verified cecal infiltration was unsuccessful due to an abnormally long, large intestine (dolichocolon) and malignant rotation of the intestine. NMSE was performed in a retrograde approach in order to reach the ileocecal infiltration. A spiral enteroscope was used to examine the colon because of the abnormal tortuosity of the intestine due to a tumor of the ileocecal segment as well as dolichocolon. A series of light movements of the spiral enteroscope enabled passing through the lumen of the large bowel and reaching a region with circular infiltration that almost completely obstructed the lumen .Six biopsies were taken and adenocarcinoma was pathohistologically confirmed . The patThe small bowel and ileocecal segment diseases accompanied by pathological intestinal tortuosity have always been a significant drawback for endoscopists. In the last two decades, with the introduction of DBE in 2001 and SBE in 2006, enteroscopic examination has significantly improved ,20,21. VThe available literature mainly deals with the usage of this procedure for the diagnosis and treatment of small bowel diseases since it has been primarily developed for that purpose. However, some authors have reported the benefits of using this technique in cases when conventional colonoscopy is unsuccessful.In a recent study, the authors reported about 36 patients who had previously undergone incomplete diagnostic and/or therapeutic colonoscopies due to dolichocolon . The cecBeyna et al.  evaluateIn other studies, this procedure was mainly performed using anterograde and/or retrograde approaches in patients with gastrointestinal bleeding and unrevealing proximal and distal endoscopy and in cases when small bowel disease was suspected ,26. PrasSince NMSE is a new technology, data are lacking on its efficacy and safety in comparison with other endoscopic modalities. According to the literature, cecal intubation was achieved in 88–95% using DBE ,30,31, 1In addition, recent research has shown that spiral enteroscopy could be an effective solution for ERCP in patients with altered gastrointestinal anatomy  and it could significantly shorten the time required to perform the procedure .So far, rare adverse events associated with NMSE have been reported, including acute pancreatitis, perforations, and erosive lesions of the esophageal mucosa . No adveIn this report, we aimed to highlight the possibility of performing NMSE in patients after unsuccessful conventional diagnostic or therapeutic colonoscopy, especially in patients with dolichocolon and suspected ileocecal disease. As already understood, failure to achieve cecal intubation during the examination of the colon increases the risk of missing a lesion, especially neoplasms in the inaccessible parts of the bowel. Therefore, the visualization of the entire colon is necessary and when it cannot be achieved during conventional colonoscopy, NMSE should be performed as a safe and effective alternative technique. It could be considered an alternative technique in patients who have undergone incomplete colonoscopy due to different causes, mainly in patients with a long, tortuous colon, presence of angulation or fixation of bowel loops, as well as adhesions due to previous surgeries. In these cases, NMSE is effective because it enables the straightening of the loops by pleating the bowel. This mechanism allows for the deeper advancement of the endoscope through the colon and provides a more stable position for the device while performing polypectomies and biopsies compared to a conventional colonoscope. This technique should not be applied in cases where strictures of the bowel are present and cause severe narrowing of the intestinal lumen. In these cases, if increased resistance is detected, spiral rotation is stopped automatically to avoid perforation. In addition, the larger caliber of the spiral overtube and the rigidity of the attachment segment can increase the risk of perforation.Additional studies with a larger number of patients are needed to examine the safety and efficacy of NMSE and to compare this new technology with conventional colonoscopy and balloon-associated enteroscopy.The NMSE is a procedure that enables both diagnostic and therapeutic interventions for small bowel diseases. However, this case report highlights the possibility of using this innovative tool as an alternative technique when the target lesion is difficult to access during conventional colonoscopy. Its advantages include a simplified technique performed by a single operator, a shorter time of examination, and the ability to perform both diagnostic and therapeutic interventions.


This case report describes the clinical utility of computed tomography (CT) in preoperative evaluation of otitis media in three calves, each exhibiting unilateral head tilt and ear droop. Of the three animals examined by CT, right-sided and left-sided involvements of this disease could be diagnosed in two animals and one animal, respectively, as represented by the accumulations of hyperattenuating contents within the extended tympanic bulla. These cases were treated with a ventral bulla osteotomy, which was conducted between the sternothyroid muscle and the omohyoid muscle via an incision made caudally to the area of the thyroid cartilage. The postoperative outcome was satisfactory in one case. However, the remaining two cases showed unsatisfactory outcomes; one calf died on the 10th postoperative day, as it was already seriously ill. The other animal died suddenly during surgery, potentially due to stimulation of the vagus nerve. The use of CT could allow effective visualization of unilateral lesions, proving helpful for the recommendation of surgical intervention. Based on the unfavorable results in two cases, we note that to prevent surgical complications, the clinical applicability of CT such as the creation of severity criteria and development of imaging-assist procedure should be advanced. Otitis media is one of the most common infectious diseases in younger calves ,2,3. TheContinuous, long-term administration of antibiotics and anti-inflammatory drugs is the first choice of treatment for bovine otitis media ,6,7,8,9.In previous cases, affected calves have been treated with bulla osteotomy using lateral and ventral approaches ,16,17,18Some previous reports have discussed ventral bulla osteotomy (VBO) as a minor surgical option in bovine otitis media, including detailed methodological explanations ,7. RegarA slip-ring CT scanner  was used in this study. A common therapeutic protocol for all three cases, including preoperative CT examination, and subsequent treatment with VBOs, was carried out while under general anesthesia. Anesthesia was composed of applying 2–3% isoflurane  via an endotracheal tube, inserted after sedation with an intravenous injection of xylazine hydrochloride . Scanning was performed with the animal positioned in the dorsal recumbency on the examination table, with X-ray conditions of 100 kVp and 100 mA. In all three calves, CT was used to gather the tympanic bulla measurements of both ears. Each left and right tympanic bulla was measured for its dorsoventral height and mediolateral width on the transverse section, and the craniocaudal length on the sagittal section of the skull CT . AdditioA 4-month-old male Holstein calf with a body weight of approximately 100 kg had presented with a head tilt toward the right and right ear droop, which had been evident for the past month. The case presented normal physical performance in terms of appetite, drinking, and activity. Clinical signs did not respond to continuous administration of a penicillin and streptomycin combination solution . On admission, the severity of the neurological findings was scored as 2, according to Bertone’s criteria .On admission, CT confirmed an accumulation of hyperattenuating contents into the entire cavity of the right tympanic bulla. On the transverse section, the wall structures were entirely hypoattenuating, and thick and rounded in shape due to being extended medially and ventrally a. On thePasteurella multocida was isolated in the irrigation fluid obtained from the tympanic cavity during surgery. A prednisolone solution  and an oxytetracycline hydrochloride solution  were administrated intraoperatively. Postoperative care was performed by a seven-day administration of an oxytetracycline hydrochloride solution . The animal showed a quick improvement of clinical signs, such as the disappeared torticollis, and could develop normally.The animal was positioned in dorsal recumbency with the neck extended via a cushion beneath it. A 15 cm incision was made longitudinally in the right paramedian cervical skin caudally to the medial level of the angle of the mandible a. ThrougA 1-month-old male Japanese Black calf with a body weight of 35 kg suddenly presented a head tilt toward the right, right ear droop, and bilateral horizontal nystagmus. Severe depression was also evident, together with declined physical performance. The calf’s difficulty in standing was suspected to be associated with vestibular ataxia. On admission, because of the quick development of the clinical signs, the severity of the neurological findings was scored 7 . On the Mycoplasma bovis and Streptococcus suis were isolated. For three postoperative days, the drainage tube was used for irrigation flushing with warm saline solution and was removed on the 3rd postoperative day. Medication consisted of an intraoperative administration of a prednisolone solution  and an oxytetracycline hydrochloride solution , followed by the postoperative administration of an oxytetracycline hydrochloride solution . However, the clinical signs did not entirely improve in the animal, finally resulting in death on the 10th postoperative day.The surgery was performed using the same procedure as in Case 1. A 10 cm longitudinal incision was made in the tight paramedian cervical skin. The rounded ventral surface of the tympanic bulla was identified soon after the exposure of the ventral surface of the skull, using two Gelpi retractors on the extended surgical opening a. The veA 2-month-old male Japanese Black calf with a body weight of 45 kg had developed a head tilt toward the left and left ear droop roughly 10 days previously. Neither depression nor abnormal physical performance were evident. A therapeutic response could not be obtained from a single injection of tilmicosin phosphate solution  followed by the administration of an oxytetracycline hydrochloride solution . On admission, the severity of the neurological findings was scored 2 . The preA 10 cm longitudinal incision in the left paramedian cervical skin confirmed that the sternothyroid and omohyoid muscles were running superficially in the surgical opening. Subsequently, two Gelpi retractors were carefully used to make a wider surgical opening, with one hooked tip of the blade applied to the medial area including the left external carotid artery and the left vagus nerve together with the sternothyroid muscle, and the other hooked tip applied to the lateral area of the surgical opening. At approximately 40 min after surgery, electrocardiography (ECG) revealed that tachycardia (>150 per min) and cardiac arrest started to be repeated periodically at intervals of 2–3 min when using an ECG recorder by an A-B lead for intraoperative monitoring . In one Radiography is a routinely used imaging modality, providing distinctive findings of bovine otitis media, as represented by osseous changes in the affected tympanic bulla. These include thickened walls or osteolysis and increased soft tissue opacity, which is clearly distinguishable from the radiolucent lumen of the normally air-filled tympanic bulla ,5,17,20.Bovine cases of otitis media commonly involve bilateral lesions within the tympanic bulla, even if presenting unilateral clinical signs; the prevalence of bilateral affection in animals with otitis media accounted for 60–70% ,3,5. In Radiography has previously been applied slightly obliquely to the skull of the anesthetized, recumbent animal, while keeping a metal landmark placed on its surface ventrally than the ear, before treatment with LBO . Based oIn bovines, chronic development of otitis media is a frequent cause of invasion of the peripheral structures . ExtensiIn Case 3, the present VBO procedure induced abnormal cardiac rhythms, characterized as an alternation between tachycardia and cardiac arrest, resulting in intraoperative death. Despite never being reported in bovine practice, this phenomenon may be explained by a previous human case study . The vagTo enhance the therapeutic effects obtained from VBO, it is recommended that a drain tube be placed into the tympanic cavity via the perforation made at the ventral wall of the tympanic bulla, to allow postoperative irrigation in bovine cases . HoweverIn addition to preoperative and/or postoperative uses of CT in diagnosing, therapeutic planning, and evaluating the degree of surgical achievements, the intraoperative utilization of CT may represent an advanced technique to prevent intraoperative contingency and postoperative complications. Instead of the macroscopic operation via the surgical view obtained from the use of self-retaining retractors, the procedure of VBOs assisted by CT may contribute to a reduction in surgical time, >1 h in three present cases, because it is effective to perforate the tympanic bulla via a shortened skin incision. The imaging can provide therapeutic evidence to detect whether LBO or VBO is applicable for each case based on preoperative evaluations, such as the concurrent situation of otitis media/interna and otitis externa, degree of extension in the surrounding structures, and the osseous changes in the tympanic bulla, such as the degrees of expansion, thickening, and osteolysis. Based on the utility of CT in the three cases above, the severity of such osseous changes can be evaluated quantitatively by comparison with the normal ranges obtained from age-matched animals. Further utilization of CT for bovine otitis media is required to establish the age-based reference values of tympanic bulla sizes.


Schwannomas are tumors of the Schwann cells found in the myelin sheath. They cause 5% of all benign soft-tissue cancers, occur equally in males and females, and occur later in life. Since they remain asymptomatic, diagnosing and treating them becomes challenging; current guidelines recommend imaging followed by excision. Here, we present a case of a 19-year-old male who presents in an outpatient setting with a history of painless swelling of the fifth digit for the past four years. Past medical history and physicals are unremarkable. Microscopic findings from fine-needle aspiration cytology (FNAC) confirmed the schwannoma diagnosis, showing loosely arranged spindle cells with elongated nuclei with pointed ends dispersed within the myxoid stroma. Peripheral nerve sheath tumors (PNSTs) are the most common nerve tumors of the hand and upper extremities. These tumors can be classified as benign peripheral nerve sheath tumors (BPNSTs) and malignant peripheral nerve sheath tumors (MPNSTs) -3. PlexiWe present a case of a 19-year-old male who came to the surgery outpatient department (OPD) of a public tertiary care hospital with painless swelling of his little right-hand finger for the past four years. Past medical history is insignificant for any trauma, inflammatory, or genetic disorder. On physical examination, subcutaneous swelling mainly involves the ventral side of the proximal and middle phalanges of the right hand's fifth digit, as shown in Figure An X-ray showed a mass located at the little right-hand finger, as shown in Figure Surgical tumor excision under local anesthesia was recommended. Informed written consent was obtained from the patient for surgery. Excision was performed without extensive dissection of tissues of the fingers, especially nerve fascicles were preserved during the operation. A nodule of 18 mm × 12 mm × 8 mm pinkish hard mass separated as shown in Figure The surgery went uneventful. Postoperative examination reveals intact movements and sensations in the right hand. In addition, the patient was prescribed antibiotics, analgesics, and multivitamins. His condition improved and he was kept under follow-up.Harkin et al. discovered plexiform schwannoma in 1978. Among all schwannomas, plexiform schwannomas account for up to 5% of all schwannomas. Plexiform schwannomas are a rare benign proliferation of Schwann cells that presents as a multinodular growth pattern (plexiform) . PlexifoThe risk factors for solitary plexiform schwannoma are not entirely understood. However, the etiology of multiple tumors is multifactorial and more frequently associated with neurofibromatosis type II, schwannomatosis, Gorlin-Koutlas syndrome, and patients with a positive family history or history of trauma . PlexifoSurgical excision is the recommended therapeutical intervention for managing cases with schwannomas in which enucleation of the tumor from the nerve sheath is done carefully without damaging the nerve and adjacent structure. In our case, we performed microsurgical dissection carefully with a surgical loupe. Ultimately, no nerve was compromised; moreover, the patient's postoperative sensory and motor function was intact in the affected digit. The patient showed improvement in response to surgery.Plexiform schwannomas of the extremities are rare tumors associated with a good prognosis due to the development of successful microsurgical dissection techniques. However, resection is unsatisfactory if the tumor is significant with the involvement of multiple sensory or motor nerve fibers. The diagnosis of plexiform schwannoma is based on imaging modalities and histopathological examination, as seen in our patient. Our patient responded well to the treatment. Further research needs to be done for better surgical therapy and pharmacotherapy for disease management and improved outcomes.


During the interview she reported she had been feling a discomfort in the region for a month. During intraoral examination we noticed a normal-looking mucosa, with normal color, without any visible change. However, during palpation we felt an endophytic nodular, soft lesion, measuring approximately 1cm. The diagnostic hypothesis was lypoma. We did an excisional biopsy. During microscopy with HE dye, we noticed that the specimen had ductiform structures in its parenchima, made up of internal cells with eosinophylic and cubic cytoplasm and na external layer made up of clear cells . In the ,,,,MEC is a rare malignant tumor of the salivary gland,,The MEC diagnosis is based on the light microscopy and was confirmed by immunohistochemistry,,,As far as treatment goes, most of authors agree on surgical excision with proper safety margins, probservation and, in some cases, adjuvant radiotherapy when there is difficulty in outlining the surgical margins It is mandatory to be aware of cases, such as the one presented here, so as not to underestimate tongue lesions and include neoplasia among differential diagnosis so that the surgical approach can be as accurate as possible. In cases of recurrence, te patient must be educated on the fact that it is a rare lesion which needs long follow up.


Unilateral biportal endoscopic (UBE) technique can easily decompress the bony spinal canal and accommodate all open surgical instruments under endoscopic guidance. However, indications and reports of this technique have been limited to degenerative and infectious diseases.We used the UBE technique for the decompression and removal of extradural mass lesions in five patients. Under endoscopic guidance, a unilateral approach was used, and decompression and flavectomy were performed. After decompression, removal of the tumor was performed using various forceps. We evaluated the technical process of the procedure, the patient's pre- and postoperative symptoms, and operative radiology and pathologic results.Postoperative pain and disability improved clinically for all patients. Four patients were confirmed as having an epidural cyst and one patient was diagnosed with hemangioma. During follow-up, no recurrence was observed.We successfully removed five extradural mass lesions using a biportal endoscopic posterior approach without complications. The biportal endoscopic approach may have advantages, such as minimizing trauma to the normal structures, magnified endoscopic view, and early recovery after the surgery. Biportal endoscopy may be used as an alternative surgical treatment for symptomatic intraspinal extradural benign lesions. Extradural spinal masses stem from soft or bony tissues and can cause clinical symptoms related to axial destruction of the bony structure, as well as myelopathy and radiculopathy caused by spinal cord and nerve compression. Traditionally, open surgery was performed for an extradural mass. This method should split the paravertebral muscles, resect both laminae, and be followed by a pedicle screw fixation. This definitely increased patients' psychological and economic burdens. Later, uniportal endoscopy was reported to treat epidural arachnoid cysts , schwannUnilateral biportal endoscopy (UBE) is an emerging technique among various minimally invasive spinal surgery options with free handling of the instruments under a magnified clear view. For spinal degenerative –6, traumIn this study, we describe five cases that clarify how to use UBE to completely remove extradural mass lesions with obvious improvement of symptoms .The patients underwent surgery under general anesthesia in the prone position. The number of incisions was made according to the extent of lesion involvement. Under image intensification, paramedian skin incisions were created along the medial pedicle line for ipsilateral spinal canal and foraminal decompression. After serial dilation, an endoscopic portal and a work portal were created. After soft-tissue dissection using a radiofrequency (RF) probe, the entire ipsilateral lamina, facet joint, and interlaminar window were exposed. First, a cranial laminotomy was performed along the inferior border of the upper lamina and the medial part of the inferior articular process using a 3.5-mm-diameter endoscopic diamond drill. Drilling was extended cranially until the proximal free margin of the ligamentum flavum was exposed. Therefore, the laminotomy was extended until the adhesive tissue faded, and the free epidural space was confirmed. After broad drilling of the spinous process base, contralateral sublaminar bony drilling was performed by crossing the midline to expose the medial end of the extradural mass. Subsequently, caudal laminotomy was performed by drilling the medial superior articular process and the superior part of the lower lamina until the distal free end of the ligamentum flavum and free epidural space was exposed. The ligamentum flavum was detached from the epidural adhesion tissues and bony margins using dissectors and punches. After removing the ligamentum flavum, the mass was exposed. The dissecting plane between the dura and mass was meticulously created using a nerve hook. Careful dissection was continued along the dissection plane until the mass was entirely detached from the dura. Finally, the extradural mass was removed en bloc. The skin wounds were closed by inserting a drainage catheter through the working portal.A 47-year-old man presented with a 3-month history of insidious-onset and progressively aggravated motor weakness in his lower extremities. In addition, he had a chest band feeling during the most recent month. A neurological examination revealed no obvious sensory abnormalities, and the motor power of his lower extremities decreased to grade 4 (out of 5). He showed a clumsy and staggered gait after 5 min of walking. Preoperative magnetic resonance imaging (MRI) showed a large intraspinal extradural mass, extending from the left foraminal area at the T2–3 level, across the midline to the contralateral . The masA 74-year-old woman complained of low back pain that radiated to the anterolateral thigh and motor weakness in both her legs for 3 months. No obvious changes were observed in her bowel and bladder functions. The strength of the bilateral quadriceps muscle was 4 out of 5; all muscle strength below the knees was intact. A sensory examination showed a slight decrease to pinprick over the anterior thigh below the groin corresponding to the second and third lumbar dermatomes.Preoperative T2-weighted MRI showed a large intraspinal extradural cystic mass, extending from the right foraminal area, across the midline to the contralateral at the T12–L2 level. Peripheral rim enhancement of the cystic mass was observed on T1-weighted contrast-enhanced MRI . The masPostoperatively, neurological deficits, including sensory, motor weakness, and back pain, improved in all patients. The hospital stay of all patients was in the range of 7–10 days. There was no recurrence of symptoms in either patient during the 6–12 months of follow-up. A pathological examination of surgical specimens revealed cysts in four patients and a hemangioma in one patient. No fixation was performed in either patient. Postoperative MRI showed a sufficiently decompressed spinal canal and foramen after the complete removal of the extradural mass. Postoperative CT images revealed a hemi-laminotomy of the lamina while preserving the spinous process and the facet joint.Intraspinal extradural benign mass lesions, such as hemangioma and epidural cyst, are not uncommon. In the past, the most commonly used treatment is surgical removal by laminectomy via open surgery. Large lesions extending over two or more vertebral segments require extensive laminectomy and subsequent fixation usually performed in order to avoid anterior subluxation or kyphosis of the spine. In addition, open surgery has the disadvantages of being a long operation and having a long hospitalization time, large surgical trauma, more intraoperative bleeding, and slow recovery. In order to reduce the injury to the vertebral lamina and posterior muscles, less invasive procedures should be pursued for benign masses involving the spinal canal. Percutaneous uniportal endoscopy, which is used for disectomy, was reported to treat extradural arachnoid cysts, schwannomas, hematomas, and even metastatic tumor, through a transforaminal or interlaminar approach , 10, 11.Unilateral biportal endoscopy, which separates the observation and operation channels, has the advantages of being a flexible operation, having clear surgical vision, and being easy for bilateral decompression. The literature on the biportal technique is mostly limited to treatments for degenerative disease, including spinal stenosis decompression, herniated disc removal, and interbody fusion for instability . Since 2To treat intraspinal extradural mass lesions with the UBE technique, there are several areas of concern. First, what kind of extradural mass can be treated with UBE? In our case series, all masses were mainly located at the dorsal part of the spinal cord, and the mass should not extend to both extraforaminal areas. UBE is also a candidate for anterolateral masses located at the lumbar spine; however, for anterolateral masses in the cervical or thoracic spine, UBE is not the first choice, because dragging the spinal cord or nerve root is dangerous. The pathology of our mass is benign. So far, extradural masses treated with UBE have been mostly benign; a primary malignant tumor was not illustrated , 15. ThiAlthough the UBE technique for intraspinal extradural benign masses has achieved good results in our cases and has impressive advantages, this technique should be considered in select patients. Large masses with obvious neurological deficits should be considered for open surgery. If facet joints are broken or segmental instability is found on preoperative radiographic images, stabilization is recommended to avoid kyphosis.


Atypical teratoid rhabdoid tumor is a rare lesion that occurs mainly in children can be supratentorial or infratentorial and it accounts for 1-2% of pediatric brain tumors and over 10% of central nervous system (CNS) tumors in infants, with a male preponderance up to 3 years of age, more than 50% of these occur in the cerebellum. In this report we describe four new cases of sellar AT/RTs underwent endoscopic endonasal approach and different adjuvant therapies. Our aim is to report the clinical, radiological and pathological features of these rare lesions, focusing on the possibility to perform an early diagnosis and appropriate therapeutic strategy. Atypical teratoid rhabdoid tumor (ATRT) was first reported in 1981 by Biggs and colleagues as a new biologically aggressive central nervous system tumor presented in a three-month-old boy with unique clinical and morphological features , and wasIt is a rare lesion that occurs mainly in children can be supratentorial or infratentorial and it accounts for 1-2% of pediatric brain tumors and over 10% of central nervous system (CNS) tumors in infants, with a male preponderance up to 3 years of age, more than 50% of these occur in the cerebellum.Despite aggressive treatments, ATRTs present poor prognosis, with a median survival less than 1 year. Currently, few reports described a survival of more than 2 years with the combination of radiation therapy and high-dose alkylator-based chemotherapy or by a multi-agent approach. Adult cases are rare and mostly supratentorial, and sellar localization is rare: there are 50 cases described in literature.In this report we describe four new cases of sellar ATRTs underwent endoscopic endonasal approach and different adjuvant therapies. Our aim is to report the clinical, radiological, and pathological features of these rare lesions, focusing on the possibility to perform an early diagnosis and appropriate therapeutic strategy.A 32-year-old female not known to have any medical illnesses, mother of two children presented to our division, in January 2017, with a history of severe headache associated with double vision, vomiting, polyuria and polydipsia. The headache was progressive over 2 months, then became severe and associated with vomiting and double vision 10 days prior to presentation. Her neurological examination showed no neurological deficits apart from right sixth nerve palsy with pale optic disc and bitemporal hemianopia. The rest of examination was unremarkable. Hormone profiles showed a blood prolactin level slightly increased . Preoperative magnetic resonance imaging (MRI) identified a large sellar mass with supra and para sellar extension  of the A 40 years-old female was admitted to our Clinic, in July 2017, for intense retro-orbital headache, vomiting, double vision and eyelid ptosis in left eye. She underwent a brain and sellar MRI with and without contrast that showed an intra and left para-sellar lesion with heterogeneous contrast enhancement, left carotid artery encasement, and imprinting suprasellar cistern  alternating with 3 cycles of IE  was used for chemotherapy. The treatment was well tolerated without significant acute toxicities and symptomatic relief was observed at the end of irradiation. The last control MRI demonstrated a volume reduction of the mass lesion. The patient is still alive and receives a regular follow-up at 18 months after surgery.Sections for morphology and immunohistochemistry were prepared from formalin-fixed paraffin-embebbed (FFPE) tissue specimens. Microscopic examination of hematoxylin and eosin-stained slides as well as immunohistochemistry were conducted for cases 1 to 4. Immunohistochemistry was performed with different antibodies, according to the main morphology-based differential diagnoses for each case. Sequent antibodies were applied: glial fibrillary acid protein , vimentin , smooth muscle actin , S100 , epithelial membrane antigen , pancytokeratin , leukocyte common antigen , CD99 , CD1a , synaptophysin , CD34 , Ki67  INI1 .Two out of three cases (case 2 and 3) were predominantly composed of diffuse proliferation of small to medium-sized cells with vesicular nuclei, prominent nucleoli and pale, clear, or vacuolated cytoplasm (https://www.dkfz.de/de/index.html). Generated methylation data were compared with the Heidelberg brain tumor classifier to assign a subgroup score for the tumor compared with 91 different brain tumor entities . For DNA isolation from FFPE tissue, 10 × 10 μm sections were cut and DNA isolated using the Qiagen FFPE kit (according to manufacturer’s instructions). About 500 ng DNA was used for bisulfite conversion by the EZ DNA Methylation Kit (Zymo Research). Finally, the Infinium Methylation EPIC BeadChip Kit (Illumina) was used to quantify the methylation status of 850,000 CpG sites, on an iScan device (Illumina). Raw IDAT files were analyzed by bioinformatic tool previously published  for ATRT methylation class . The third case showed a similarity for the ATRT methylation class with a calibrated score =0,4. Subclass analysis showed that all 3 samples cluster into a specific epigenomic subclass: ATRT-MYC. This subclass includes ATRT with a supratentorial localization. All cases are associated with INI protein loss and activation of the MYC oncogene. These data confirm that methylome analysis is a useful tool to support the diagnosis of ATRT.ATRT has been defined a “tumor of infancy” for its earliest onset and highest perinatal incidence 80.5%). In pediatric age ATRT can developed at supratentorial or infratentorial localization and it constitutes 1-2% of pediatric brain tumors and over 10% of central nervous system (CNS) tumors in infants, with a male preponderance up to 3 years of age, more than 50% of these occur in the cerebellum , 5. The %. In pedTypical genetic alteration is the somatic mutation of SMARCB1 (formerly INI-1) or SMARCA4 (formerly BRG-1), retained immunohistochemical hallmarks of this tumor and demonstrated being an essential component of the ATP-dependent chromatin remodeling SWI/SNF complex, interacting with various pathways  important for lineage specification, maintenance of stem cell pluripotency, and gene regulation .Furthermore, this genetical condition is associated with the rhabdoid tumor predisposition syndrome (RTPS) characterized by a markedly increased risk of developing rhabdoid tumors commonly in the central nervous system more than 50% occur in the cerebellum, occurring predominantly in infants and children younger than age three years. Individuals with RTPS typically present synchronous tumors with aggressive clinical behavior before age 12; RTPS type 2 is associated with SMARCA4 germline mutation and with a worse prognosis . Then a We reported four novel cases of sellar ATRT in adult patients, and our series describe the classic phenotype of patients with this rare pathological entity: an adult female subject with acute symptoms of anterior and posterior pituitary insufficiency and ophthalmoplegia. As a matter of facts, sellar ATRT is almost exclusively diagnosticated in adult females and this suggest that this tumor is a clinicopathologically and genetically distinct variant of ATRT for its molecular and histopathologic features , 14.On the base of a literature review, we found 50 cases of ATRTs reported before , 15–20; The period of survival observed was included between 1 and 120 months and the most used therapeutic strategy was multimodal therapy based on trans-sphenoidal surgery, radio, and chemotherapy.The transsphenoidal approach is the unique surgical technique utilized in the resection of these tumors and in all reported cases the lesion is characterized for fibrous consistency and absence of cleavage planes from the surrounding structures, so that, there are no total resection reported cases. Endoscopic endonasal technique is a valid instrument for neurovascular decompression and as this surgery provides adequate opportunity of obtaining tissue sample, crucial for continuing the integrated adjuvant therapies protocols .Concerning adjuvant radiotherapy, the principal strategies were represented by fractionated radiation therapy and radiosurgery (gamma-knife). The protocols for adult ATRT recently developed are similar to the treatment protocols used for childhood ATRT: ICE protocol, anthracyclines, and cisplatin are most used chemotherapeutical agents Table 2.On microscopic examination ATRTs are known to be extremely heterogeneous tumors. In spite of their designation, the lesions are usually not composed largely of cells with rhabdoid features, but rather a jumble of medium to large cells with clear-appearing cytoplasm. At times, ATRTs can be predominantly “small cell” tumors, giving rise to a challenging differential diagnosis with other embryonal tumors, as well as with other “small round-blue-cell” neoplasms. Some authors , 40 idenRecently, three molecular subgroups of pediatrics ATRTs have been described: ATRT-TYR, ATRT-SHH, and ATRT-MYC based on cluster analysis of DNA methylation profiles. Recent studies , 41, 42 TYR and MITF. In the subgroup ATRT-MYC tumors are mostly supratentorial, older age at diagnosis (4-5 years), and the genes MYC, HOTAIR, and HOX are overexpressed. The subgroup ATRT-SHH tumor location may be infratentorial or supratentorial, diagnosis is between ages two and five years, and sonic hedgehog pathway genes are overexpressed (MYC oncogene) , and overexpression of the genes xpressed , 42, 43.xpressed . Finallyncogene) . In sellncogene) , a groupIn adult patients, ATRT has a predilection for midline structures, particularly the pineal and pituitary glands, recognized as a source of neural stem cells in adults . Sellar Concerning neuroradiological features of sellar ATRT we found intra, supra and para-sellar lesions with heterogenous contrast enhancement without distinctive radiological signs respect to a pituitary adenoma, whereas the postoperative MRI after two weeks showed a massive tumor progression and neurovascular midline surrounding structures infiltration compatibles with high grade lesions.exitus three months after surgery during chemotherapy and radiotherapy, one patient died before adjuvant treatment after a month, and one patient is still alive today with a protocol VCD/IE and proton therapy after 18 months after surgery. Conforming literature data, these patients are female and with poor prognosis.In our series there are two patients arrived to Common genetic feature in our series is the loss of SMARCB1 , a core member of the SWI/SNF chromatin remodeling complex. It’s possible of detecting this genetic alteration also in others midline tumors such as poorly differentiated chordomas, and this genetic alteration changes the prognosis and make it unexpectedly unfavorable compared to classical chordomas with SMARCB1 retained .Regarding these molecular alterations, the future therapeutical perspectives are oriented to molecular pathways modulation and several trials are ongoing. The first phase I/II trials employing agents targeting molecular is started for Aurora Kinase A Inhibitors, Hedgehog/GLI inhibitors, and EZH2 inhibitor , 49.This tumor represents a model disease for malignancies not purely based on genomic mutational events but also on epigenetic alterations so that others targeted trials are required for detecting other biological treatment combined with epigenetic inhibitors, immune therapy as well as conventional chemotherapy with RT to refine therapeutic approaches to ATRTs RT .Sellar ATRTs are rare lesions for histopathology and localization with poor prognosis.Endoscopic endonasal approach is an instrument for early diagnosis and treatment of these lesions due to absence of clinical distinctive features.Multimodality treatment approach is most commonly used in the management of this pathology so that prognosis improvement is possible by the identification of effective adjuvant therapies to control relapse and progression.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.This study was approved by the Institutional Review Board of the School of Medicine of Università degli Studi di Napoli “Federico II”, which waived the necessity for informed consent due to the retrospective nature of the study. Written informed consent was obtained from the patients prior than any invasive clinico-diagnostic and surgical procedure; indeed, it was obtained for the eventual publication—for scientific purpose—of any patient records/information anonymously. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.TS and CB: conception and design. CB, RD, and RF: acquisition of data. MB, LMC, EJ, LC, and TI: supervision and validation. CB, RD, RF, and TS: writing original draft and review and editing. All authors have read and agreed to the published version of the manuscript.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.


An 80-year-old male presented with an obstructive lower urinary tract and intermittent low back pain lasting approximately 6 months. Digital rectal examination (DRE) revealed asymmetric prostate enlargement. Laboratory examination revealed elevated PSA, CRP, and sedimentation. Multiparametric magnetic resonance imaging (mp-MRI) and lumbar MRI were performed due to suspicion of prostate cancer and bone metastasis. On T2-weighted images (T2-WI), a low-signal intensity lesion with unclear borders was observed in the left anterolateral peripheral zone A. The deIsolated tuberculous prostatitis and concomitant Pott's abscess are extremely rare entity


In times of peace and except for terrorist attacks, fatalities by explosions are rare. Fireworks have deadly potential, especially self-made or illegally acquired devices. The use of professional pyrotechnics by untrained persons poses a life-threatening hazard. We present a case of devastating blunt force and blast injuries to the head and chest of a young man. After ignition of a display shell  without the use of a launching pipe, the device hit the man’s face, nearly simultaneously followed by the explosion of the burst charge. The autopsy revealed injuries to the face and forehead as well as extensive tissue structure damage and a massive contusion with a bloody edema of the lungs. Autopsy results are supplemented with CT imaging and 3D reconstruction of the fractured mid face, as well as histological and toxicological examinations. This case of a misused display shell demonstrates both its devastating destructive potential and the corresponding and rarely observed injury pattern. A 20-year-old man died in a field near the city of Jena  from the impact and explosion of a display shell, and in Berlin, such a device caused injuries in 12 persons (https://www.faz.net/aktuell/gesellschaft/ungluecke/silvester-tote-und-verletzte-bei-feuerwerk-explosionen-17710689.html). In this report, we will present the case of the 20-year-old man from Thuringia.In times of peace and except for terrorist-attacks, fatalities by explosions are rare [Lit]. Besides some case reports in the forensic literature, German and Austrian newspapers reported on some cases from the New Year’s Eve 2021/22. In this regard, two people were killed by the so-called display shells. A self-made device in Hennef near the city of Bonn  killed a 37-year-old man  and suitable only for trained professional pyrotechnicians with usage permits. They are known for spectacular effects like sparkling fireballs in high altitudes and consist of two units  [https://www.heute.at/s/todesfalle-kugelbombe-vier-tote-in-10-jahren-100181938). In addition, the pathomechanical basis of the injury pattern is presented and should serve as a reference for similar cases.This case impressively shows that improper use of such devices can cause fatal injuries. A literature review places this case in context to similar deaths in the recent past , as well as on the upper chest Fig.  with botThe region comprising the left corner of the mouth and the left cheek appeared as the primary impact site Fig. . This imThe left hand sustained burn injuries of up to third degree. Neither external nor internal inspection of the skull cavity or the CT imaging revealed any fractures of the skull. Cerebral cortex contusions on the left basal side corresponded to the mid facial trauma as signs of pressure influence. The brain showed an edema and weighed 1642 g. The trachea contained ample hemorrhagic secretions. Both lungs showed relatively high weights  and a severe hemorrhagic lung edema , and the USA [https://www.heute.at/s/todesfalle-kugelbombe-vier-tote-in-10-jahren-100181938). In addition, intentionally misused display shells may cause injuries in bystanders as in Berlin in 2022 (https://www.berliner-kurier.de/berlin/blutiges-silvester-kugelbomben-attacke-in-friedrichshagen-12-verletzte-li.203576). Besides serious injuries, the explosive power of detonation can also lead to significant property damages [Fatalities in the context of nonprofessional fireworks are rare. However, an internet and literature research revealed some comparable fatalities due to display shell accidents reported in the last years, for example in Germany, Austria (https://www.beuth.de/de/norm/din-en-15947-5/235033731). In the present case, the forensic autopsy including computed tomography, toxicology and histology showed a combination of blast lungs and head injury as the cause of death. The uncommon injury pattern is due to misuse of an illegally acquired display shell, which is provided in Germany for professionals only, and has approximately 12 times the amount of explosives compared to freely available fireworks.The reports prove the high risk emanating from these pyrotechnic devices with a severity of injuries otherwise only seen in military contexts. “Civilian blast-associated injuries are not common, but they can be severe, and in many  respects they seem similar to those described in published case series of military blast victims” . Our casTable According to Karger , blast lhttps://www.presseportal.de/pm/156523/5009947#) by a German manufacturer, 1800 participants were asked about injuries caused by fireworks in the last 10 years, and 72%  have indicated that they have suffered injuries to one hand, 14.6% involving the ears, 11.4% the eyes, and 12% the face (without eye injuries).The severity of injuries concerning the lungs and the head with extensive lacerations of the facial soft tissue indicate high pressure and blunt force by direct impact. According to literature, legal fireworks can cause injuries of the head , 7, parthttps://www.kleinezeitung.at/lebensart/gesundheit/5344904/Aerzte-warnen_Alkohol-und-Feuerwerk_So-gefaehrlich-ist-diese-Kombi) typically report on firework accidents in the context of alcohol consumption. On the other hand, a Danish study [The literature and public media (Covid regulations prohibiting public firework in Germany in 2021/2022 resulted in a nationwide decrease of 40% in hospitalizations due to injuries caused by fireworks . In cont


The primary splenic lymphoma is extremely uncommon with an incidence rate of <1% of all the lymphomas under the strict criteria for diagnosis expounded by Das Gupta et al. Clinical presentations of nonspecific symptoms are weight loss, weakness, fever, and left upper quadrant pain or discomfort due to enlarged spleen. Abdominal ultrasound and CT are the most widely used imaging modality for the assessment of lymphoma. The imaged features of splenic lymphoma are nonspecific; typical lymphoma presents as a diffusely enlarged spleen. The abdominal CT scan in our case showed a large cystic splenic mass measuring 14 cm without enhancement after contrast medium. Lymphoma is often described as an aggressive tumor because its rapid doubling time can quickly increase the size of a tumor. In our case, the tumor grew to more than 100 times its original size in 4 months. So, we present this unusual rapid growth of primary splenic lymphoma. A 36-year-old man working as a nurse in our hospital presented with left upper quadrant (LUQ) pain, which had persisted for 1 week. He denied any past systemic disease, but the patient had undergone an abdominal ultrasound during a routine examination 4 months earlier, which had revealed a 3 cm hypoechoic splenic nodule . At thatPhysical examination revealed a large palpable mass with local tenderness over the LUQ. The patient’s white blood cell count was 17,000/μL, with segment neutrophil 83% and lymphocyte 10%, and platelet: 475,000/mL. An abdominal computed tomographic (CT) scan revealed a large cystic splenic mass measuring 14 cm without enhancement after contrast medium . The masThe splenectomy operation removed a large solid splenic tumor. The histology exhibited a diffuse proliferation of a monotonous population of large neoplastic lymphoid cells and extensive necrosis . ImmunohLymphoma is the most common malignancy of the spleen, but primary lymphoma of the spleen is very rare with an incidence rate of <1% under the strict criteria for diagnosis expounded by Das Gupta et al. According to their criteria, diagnosis of primary splenic lymphoma should only be made when the disease is confined to the spleen but may also involve the hilar lymph nodes with no recurrence of the disease after splenectomy ,3. In ouClinical presentations of nonspecific symptoms are weight loss, weakness, fever, and left upper quadrant pain or discomfort due to an enlarged spleen. CT is the most widely used imaging modality for the assessment of lymphoma. The imaged features of splenic lymphoma are nonspecific; typical lymphoma presents as a diffusely enlarged spleen. Focal lesions appear as low-density areas in the imaging with little or no enhancement following injection of intravenous contrast medium. Ahmann classified lymphomatous involvement of the spleen into the following four categories: (1) homogeneous enlargement without masses, (2) miliary masses, (3) 2–10 cm masses, and 4) a large solitary mass  a large ,6,7. SigLymphoma is often described as an aggressive tumor because its rapid doubling time can quickly increase the size of a tumor ,8,9,10.


Hemangiomas are nonmalignant vascular lesions commonly seen in both the skin and mucosa that rarely occur in skeletal muscles. According to the type of vessel, a hemangioma can be differentiated into capillary, cavernous, or mixed types. The following report describes a case of temporalis muscle hemangioma in a 45-year-old female who presented with painful swelling in the left outer orbital wall, which had been growing in size over the past 12 months. CT scan and MRI revealed a well-demarcated lesion in the temporalis muscle measuring 10 mm × 13 mm × 15 mm. Surgical resection of the lesion was performed, allowing a definitive diagnosis of cavernous hemangioma to be made histologically. As radiological images are mainly inadequate for definitively diagnosing these lesions, surgical intervention is usually required. The recurrence rate differs among the three subtypes; thus, clinical follow-up and radiological imaging as needed are recommended. Hemangiomas are benign vascular lesions that are classified based on the size of the involved vessels into cavernous (large vessel), capillary , and mixed hemangiomas ,2. ApproA 45-year-old female was admitted to the Neurosurgery Department in King Abdulaziz Medical City, Riyadh, Saudi Arabia. She had a history of painful left orbital swelling on the outer wall that had been progressively increasing in size for a year. She denied any history of trauma, surgery, or visual symptoms. The physical and neurological examinations were unremarkable, with the exception of a smooth and immobile swelling in the outer wall of the left orbit that measured approximately 1.5 cm in diameter and was tender on palpation. No overlying redness or warmth of the skin or any signs or symptoms of inflammation were observed. Additionally, no pulsation or bruit over the lesion was noted. Magnetic resonance imaging (MRI) was performed, revealing a slightly lobulated deep subcutaneous lesion measuring 10 mm × 13 mm × 15 mm in the lateral side of the temporalis muscle at the same level of the left orbit. T1-weighted imaging (T1-WI) exhibited a low signal intensity Figure , 3.The lesion on contrast-enhanced MRI Figures , 5 appeaThe patient was taken to the operating room for surgery under general anesthesia. A curvilinear incision was made approximately 1 cm in front of the tragus, and the temporalis muscle and the fascia were dissected by using monopolar electrocautery until a dark-red, soft tissue mass (1.0 cm × 1.0 cm × 0.5 cm) was encountered. Total resection of the lesion with a margin of normal muscle was performed. Histological examination showed a collection of back-to-back cavernous-sized vascular channels. Given the presence of chronic inflammation and epithelioid histiocytes, CD34 and D2-40 immunohistochemistry was performed. The vascular channels were found to be immunopositive for CD34 and immunonegative for D2-40 Figure .The postoperative events were uncomplicated, and the patient was discharged home in good condition on the second day. Six months of follow-up did not reveal any local recurrence.Hemangioma is a type of vascular abnormality. Intramuscular hemangioma is a rare benign lesion, as it represents less than 1% of all hemangiomas, 14% of which are found in the head and neck region. The most commonly affected muscles are the masseter 36%) and trapezius (24%) % and tra. Allen aThe etiology behind these lesions is not known; however, recurrent trauma or hormonal changes can cause the lesion to grow as a result of the proliferation of embryonic vascular tissue . ClinicaIntramuscular hemangioma is diagnosed preoperatively in only < 8% of cases because of its low incidence and lack of specific symptoms ,14; hencIn the international literature, only 33 cases of temporalis muscle hemangioma have been reported to date Table . All repHemangiomas are nonmalignant vascular lesions that are uncommonly found in the temporalis muscle. Based on histological findings, they are classified into three subtypes. As radiological images are mainly inadequate for a definitive diagnosis of these lesions, surgical intervention with resection is the treatment of choice in most cases. The recurrence rate of intramuscular hemangioma differs among the three subtypes. Clinical and radiological follow-up and radiological images as needed are recommended.