Adrenal myelolipomas are benign tumors composed mainly of lipomatous elements with myeloid cells. With the development of medical imaging technology, the detection rate has gradually increased. We report a case of adrenal myelolipoma successfully excised through the laparoscope and reviewed existing literature in recent ten years to summarize the feasibility of the laparoscopic approach for this tumor.Herein, we described a case of adrenal myelolipoma resected by laparoscope in a 63-year-old male patient. He did not have any other symptoms except the incidental finding of a left adrenal mass. An abdominal CT examination revealed a mixed-density lesion containing some amount of adipose tissue. In conjunction with the patient’s willingness, we performed a laparoscopic operation to remove the lump. The definite diagnosis was confirmed as an adrenal myelolipoma according to the pathology. The patient recovered well postoperatively and without signs of recurrence at a 5-month follow-up.Adrenal myelolipoma is commonly benign, asymptomatic, and hormonal inactivity. A surgical strategy is suggested for high-complication-risk patients. The laparoscopic approach is safe and effective with an obvious advantage over open procedures. Adrenal myelolipomas (AMLs) are rare, benign, mesenchymal neoplasms, consisting of mature adipose mixed with myeloid elements, which were initially described by Gierke in 1905 . ImagingOur manuscript reporting adheres to CAse REport (CARE) guidelines .We present a case of a 63-year-old male patient with no clinical symptoms but revealed a left adrenal mass in a CT scan for a regular physical checkup.His past history included II diabetes mellitus treated with gliclazide, and he had been controlled with propranolol and amlodipine for hypertension. Upon admission, he had good general condition and stable vital signs, without palpable abdominal mass. Laboratory measurements demonstrated elevated blood Epinephrine . The serum levels of the tumor biomarker as well as thyroid hormones were normal. CT-scan showed a left adrenal mass of 5.1×5.1cm. The lesion manifested as a mixed-density shadow that contain certain amounts of adipose tissue Figure 1via a 6-cm incision on the low abdomen. A plasma drainage tube was placed to monitor the left retroperitoneal cavity drainage concerning volume, content, and color. Operating time was 270 min and blood loss was 50ml. However, free gas within the left pleural cavity was revealed in the immediate postoperative color-Doppler ultrasound examination. Pneumothorax was suspected after a CT scan of the left lung. Closed thoracic drainages were initiated following instant thoracic surgical consultation. Thoracentesis was smooth and the patient was transferred to the PACU (post-anesthesia care unit) for resuscitation. The postoperative course was uneventful and the patient was discharged after 4 days. He was satisfied with the operative outcome and complied with the follow-up recommendations. Neither dysfunction nor tumor recurrence was observed so far.During the operation, the patient was placed in the supine and parted-legs position. Using Veress needles, a 1-cm transverse incision near the right navel edge was made to establish pneumoperitoneum with a constant pressure of 13-14 mm Hg. Five trocars were used: a 5-mm trocar was inserted under the xiphoid process. A 12-mm trocar was placed below the left costal margin in the midclavicular line, and the other two 5-mm trocars were placed in the midaxillary and anterior axillary lines. The fifth trocar (12 mm) was installed a little to the left of the navel as a laparoscopic observation hole. The resection was carried out with an ultrasonic surgical aspirator , harmonic scalpel , and a bipolar clamp coagulation system . Intraoperative ultrasound sonography (IOUS) was performed for exploration and localization. The posterior peritoneum was gradually opened along the lower margin of the pancreatic body, and a 5×5cm neoplasm was observed behind the pancreatic body, demarcated clearly with the left kidney and spleen. The blood vessels around the left adrenal gland were separated and clipped, then severed with an ultrasound knife. The tumor was completely removed and the resection specimen was collected in a plastic bag and removed Grossly, a 5×5×4cm left adrenal tumor, in which, some necrosis and tumor-like changes were observed. Histopathology revealed a mixture of normal adrenal cells, adipose tissue, and three major hematopoietic components: myeloid, erythroid, and megakaryocytic lines Figure 2Adrenal lipomatous tumors are hormonally inactive and are often benign, myelolipoma is the most common type of them . InitialMost AMLs occur unilaterally , but the extra-adrenal localization, such as the presacral area, spleen, stomach, thoracic, retroperitoneal, pelvic, renal, hepatic, and osseous locations are also documented , 12. TheThe diagnosis of AMLs can be reliable by imaging techniques. A CT scan shows low-density fat (-10 to -30 Hounsfield units) mixed with higher-density marrow, which is a useful feature in identifying myelolipoma. In addition, areas of hemorrhage and calcification sometimes are found within the tumor . While MConservative management by surveillance with regular imaging follow-up is the therapy of choice for small, and asymptomatic lesions , 25. AdrAs a minimally invasive approach, laparoscopic surgery has well-known advantages over open procedures, including reduced postoperative complications, better cosmetic results, and shorter recovery time. Surgical site infection (SSI) is one of the common postoperative complications, constituting critical damage to surgery patients . While lIn addition, a small incision in the minimally invasive procedure can relieve postoperative pain and minimize scarring . Also, tAlthough limited cases were reported, retroperitoneal routes could also be utilized by the surgeon. Retroperitoneal laparoscopic adrenalectomy, which provides more direct access to the adrenal gland, approaches the lesion from the back without cutting the peritoneum . The safNotably, our patient suffered from pneumothorax immediately after the procedure. The injury to the diaphragm and pleura caused by electrocautery during the dissection of the left adrenal gland tumor was speculated to be the cause of the left-sided pneumothorax. A similar condition secondary to laparoscopic adrenalectomy has previously been observed and reported elsewhere –53. EvenIn addition, histological grading has important prognostic implications. Therefore, exact histological grading is critical for guiding the following management . In futuTo sum up, the detection of adrenal myelolipoma increased with the development of imaging modalities. However, insufficient awareness of this adrenal incidentaloma exists among clinicians. Studies for establishing a common guideline on the management of adrenal myelolipoma are needed. We suggest laparoscopy could be a safe and effective surgical approach for the treatment strategy.The original contributions presented in the study are included in the article/Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.QF and HL drafted and revised the manuscript. XC and XF collected data and revised the manuscript. QF revised the manuscript for content. JL designed the study and revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by Sichuan University from 0 to 1 project (No. 2022SCUH0017); Sichuan Science and Technology Plan Project “International cooperation in science and technology innovation/technological innovation cooperation in Hong Kong, Macao and Taiwan” (No. 2021YFH0095).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.


Nasopalatine duct cyst (NPDC) is the most common type of non-odontogenic cysts of the jaw. It has been treated with complete surgical resection using a sublabial or palatine approach. However, complete removal of the cyst can be accompanied by postoperative complications including oronasal fistula. Recently, endoscopic marsupialization for the disease has been advocated, but there are still few reports regarding the surgery. Herein, we report a case of NPDC that was treated with unilateral transnasal endoscopic marsupialization. A 43-year-old man with no relevant previous medical history was referred to our hospital for the treatment of lesion occupying the right nasal cavity. A computerized tomography scan of the sinus revealed an egg-shaped lesion with a well-defined border centered on the lower half of the nasal cavity and hard palate. Based on the site of the lesion, it was considered to be NPDC. Transnasal endoscopic marsupialization was performed to diagnose and improve nasal obstruction. Histopathological examination revealed stratified squamous epithelium without atypia, which was consistent with NPDC. Although the patient noticed paresthesia of the right upper incisor area, symptoms improved 3 months after surgery. Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article. Transnasal endoscopic marsupialization for NPDC is minimally invasive and useful; however, it is necessary to build evidence for an appropriate excision range based on the position and size of the lesion. Nasopalatine duct cysts (NPDCs) are benign non-odontogenic lesions arising from epithelial remnants of the nasopalatine duct . It is tA 43-year-old man with a several-year history of nasal obstruction and discomfort was referred to our hospital from a primary care clinic. He had no relevant comorbidities or history of facial trauma. On nasal endoscopy, a smooth-surfaced mass excluding the inferior turbinate to the outside was observed in the right common nasal meatus. A computed tomography (CT) scan of the sinus revealed an egg-shaped lesion with a well-defined border centered on the lower half of the nasal cavity and hard palate, 32 mm × 28 mm × 36 mm in size . The lesFor improving his symptoms and diagnosis, transnasal endoscopic surgery was performed under general anesthesia. Large bulges from the nasal septum to the nasal floor were observed on the right side, and only slight bulges were observed on the left . TherefoAfter surgery, nasal obstruction and discomfort disappeared. The patient noticed postoperative paresthesia of the right upper incisor area. The symptoms remitted 3 months after surgery. Paralysis of infraorbital nerve was not observed. Three months after surgery, the marsupialized cyst remained patent . WrittenThe symptoms of NPDC include swelling of the anterior palate and incisor discomfort. When it is large and is located in the upper part of the duct, nasal obstruction may occur . Pain anTypical CT findings include well-defined round, oval, or heart-shaped lesions with a diameter of 1 cm–2 cm, located on or close to the midline of the upper maxilla . The cauThere is a report of a case in which squamous cell carcinoma originated from NPDC in the anterior zone of the upper maxilla . TreatmeHere, we report a case of NPDC treated with unilateral transnasal endoscopic marsupialization. Endoscopic marsupialization may be an effective treatment option because it can reduce the risk of oronasal fistula formation. However, there are still few reports on the surgery, and a method to reliably prevent damage to the nasopalatine nerve has not been established. Careful follow-up and accumulation of a greater number of cases from multiple centers are necessary to build evidence for an appropriate excision range based on the position and size of the lesion.


Incidentalomas are asymptomatic adrenal tumors that are discovered on investigations performed for other reasons. Classically, these tumors are found on computed tomography of the abdomen. This article describes an incidentaloma that was discovered on upper gastrointestinal endoscopy performed before a bariatric operation and caused an extrinsic compression of the first and second parts of the duodenum. Further investigations showed a 15-cm non-functional adrenal tumor. The patient was treated successfully with laparoscopic adrenalectomy. The histological examination showed a benign adrenocortical adenoma with myelolipomatous changes. The article highlights the fact that incidentalomas may not only be discovered on imaging modalities but may also show up in other diagnostic methods such as endoscopy. Adrenal incidentalomas are asymptomatic tumors that are usually detected on computed tomography (CT) of the abdomen performed for other reasons . These tIncidentalomas greater than 1 cm need a diagnostic workup to exclude hormonal activity .In this case, we present an incidentaloma in a young female that was suggested on upper gastrointestinal endoscopy during preoperative preparation for a bariatric operation. To our knowledge, this is the first described incidentaloma that was detected on endoscopy.A 29-year-old woman presented to the surgical clinic seeking a medical opinion for bariatric surgery. Her past medical history was not significant and her surgical history was limited to two cesarean sections. The family history included arterial hypertension and diabetes mellitus type 2.2 . The blood pressure and the laboratory tests were within the normal limit. A further diagnostic study was initiated.The physical examination was unremarkable. The patient’s BMI was 42.2 kg/mIn the esophagogastroduodenoscopy, the gastric and duodenal mucosa showed no abnormalities, but the first and second parts of the duodenum were collapsed, apparently due to external compression from the right side. Abdominal ultrasound revealed a large subhepatic tumor with downward displacement of the right kidney. For more evaluation, computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen were performed. These showed a right adrenal mass up to 15 cm in diameter with no evidence of local infiltration, vascular invasion, or metastatic lesions  . The freIncidentalomas are classically discovered on the CT scan of the abdomen. In principle, any asymptomatic adrenal tumor that is found in investigations performed for other reasons can be designated as an incidentaloma, including the tumor found in our case. External compression can be detected on upper or lower endoscopy and may be confused with intramural lesions . Kumar eThe vast majority of incidentalomas are adrenocortical adenomas . MyeloliMost adrenal incidentalomas are between 3 and 3.5 cm in largest diameter . The larThe benefits of the minimally-invasive approach were proved in many previous works. In their study of 1683 adrenalectomy patients, Shahait et al. showed that laparoscopic adrenalectomy was associated with lower morbidity and mortality, shorter length of stay, and less blood loss compared with the open approach . In theiAdrenal incidentalomas are most commonly discovered on abdominal computed tomography, but they may be also detected by chance in other investigations such as endoscopy. All patients with incidentalomas greater than 1 cm should have a proper diagnostic workup. Small, non-functional, benign-appearing tumors do not need treatment. Surgery is recommended in tumors larger than 4 cm, with minimally invasive surgery being recommended based on the patient’s anatomy, the characteristics of the tumor, the skill of the surgeon, and the available resources. Most incidentalomas are benign, with adrenocortical adenoma being the most common variant. Associated myelolipomatous changes are one of the rare manifestations than can be found in incidental adenomas.


Epithelial ovarian cancer is the most prevalent gynecological malignancy leading to mortality in adults but is an infrequent finding in children and adolescents. Most gynecological tumors found in females younger than age 20 are of germ cell nature. There are very few cases of epithelial ovarian neoplasms reported in the young female population. We report a case of low-grade serous ovarian neoplasm in a 17-year-old Caucasian female. Ovarian cancer is responsible for the majority of deaths from gynecological malignancies in the United States, with a five-year survival rate of less than 45% ,2. In adThis case reviews the management of a 17-year-old Caucasian female who presented for surgical consultation due to a 13-month history of prolonged abnormal uterine bleeding and dysmenorrhea. The patient continually had uterine bleeding between her menses that reportedly appeared more voluminous than her menses at times. She also reported pelvic pain without radiation, rated at 7/10 in severity prior to and after the commencement of her menses. It was noted that this pain had increased over the week prior to her visit. Visceral symptoms such as nausea and vomiting were also noted and coincided with the increased severity of her pelvic pain. At the time of this visit, the patient had an etonogestrel 68 mg implant in place due to previous complaints of abnormal uterine bleeding. She reported minimal relief in her symptoms after implantation. She had also previously been prescribed levonorgestrel-ethinyl estradiol PO once a day, a combined oral contraceptive therapy, which was also unsuccessful in terminating her symptoms. Elagolix 150 mg PO once a day was also previously prescribed, but she was unable to tolerate it, reporting severe headache and nausea.A physical examination revealed unremarkable cardiovascular and respiratory system assessments. An abdominal examination revealed no ascites, tenderness, guarding, or rigidity. A gynecological examination revealed a normal external vagina and visualization of the cervix was made with no noted abnormalities. Past medical history was also assessed and no significant illness was noted. Her family history was significant only for hypertension on her mother's side of the family. It was, however, negative for any cancer, chronic illness, or gynecological conditions.The symptoms of abnormal uterine bleeding and dysmenorrhea were discussed with the patient, and a presumptive diagnosis of endometriosis was made. The patient expressed her desire for a definitive diagnosis and treatment, and therefore, diagnostic laparoscopy was scheduled to confirm and treat her suspected endometriosis. An ultrasound Figure  was perfLaparoscopic surgery was performed, resulting in the removal of suspected implants of endometriosis via peritoneal stripping at the posterior cul-de-sac and lysis of filmy adhesions to the ileocecal junction and appendix. During the surgery, the ovaries, fallopian tubes, uterus, and peritoneum were found to be visually normal. The specimens removed were fixed with formalin and paraffin-embedded, following which they were sent for pathological analysis to confirm their histological construct and definitively diagnose the patient.The pathological analysis demonstrated serous glandular proliferation within an inflamed and hemorrhagic reactive-appearing fibrous stroma. Some glands were associated with cuffs of CD10+ endometrial-type stroma, suggestive of endometriosis. However, the majority of glands lacked an associated stromal cuff and showed numerous psammomatous calcifications and architectural complexity with focal papillary configuration. No increased mitotic activity, necrosis, or high-grade nuclear features were seen. These unusual findings led to the sample being referred to the University of Michigan for expert consultation. This analysis resulted in findings consistent with a diagnosis of papillary serous neoplasm implant.In light of this finding, and the unremarkable anatomical findings noted during the laparoscopic procedure, it was decided to seek further extra-departmental consultation from the Cleveland Clinic, Ohio. This analysis returned findings consistent with a low-grade serous neoplasm. These pathological findings led to the establishment of a differential diagnosis of a non-invasive implant of a serous borderline tumor of ovarian origin, a primary peritoneal serous borderline tumor, and less likely, papillary endosalpingiosis mimicking a serous neoplasm.This diagnosis was discussed with the patient and a referral to an oncologist was made for continuity of treatment following this new finding. The patient was then seen after the procedure, where her menorrhagia and dysmenorrhea were evaluated for improvement. Genetic testing was also performed due to the rarity of this diagnosis within her age group as well as her unremarkable family history. This testing revealed negative results for BRCA1, BRCA2, or any other notable mutations. A discussion regarding mature oocyte cryopreservation was also conducted. On this visit, the patient noted a reduction in her pain level, describing it as 2/10 in severity. She still experienced mild bleeding between periods. Upon discussion, a progestin intrauterine device was implanted and her etonogestrel implant was removed. The patient proceeded with treatment under the supervision of her oncologist.Globally, ovarian cancer accounts for over 200,000 deaths annually, making it the eighth most common cause of cancer-related death in women. Among the types of ovarian cancer that exist, epithelial-related neoplasms account for over 90%, with the serous subtype being the most common. Furthermore, non-specific symptoms lead to misidentification of this diagnosis and possible attribution of these symptoms to other disease processes. Increasing age correlates with an increased incidence of disease, and therefore, postmenopausal women are most affected ,4.The pathogenesis of epithelial ovarian cancer is still a highly debated topic. The most widely accepted theory describes cellular DNA damage, due to repeated physical trauma of surface epithelial cells during ovulation, as the catalyst for developing ovarian tumors. This theory aligns with the epidemiological data for ovarian cancer as well as the known risk factors of early menarche and late-onset menopause. In 2004, a theory brought forward by Kurman and Shih grouped ovarian cancers into two categories according to their histological, clinical, and genetic makeup. This "two-pathway theory" describes type 1 ovarian tumors as being associated with K-RAS and BRAF mutations, as well as being characteristically more benign and growing more slowly. Contrastingly, type 2 ovarian tumors were described as being more aggressive and genetically unstable. They were said to be associated with BRCA1/2 and TP53 mutations [Our case is remarkable as it features a 17-year-old female who was definitively diagnosed with a low-grade serous neoplasm. Among this population, germ cell tumors are far more common and the occurrence of an epithelial ovarian neoplasm is a very rare phenomenon, with the incidence estimated at 2.6 cases per 100,000 girls per year ,6. FamilAbnormal uterine bleeding and dysmenorrhea in a female under the age of 20 should lead to prompt evaluation with an ovarian neoplasm included as a possible differential diagnosis. However, in this population, other diagnoses such as endometriosis have a similar presentation and are far more likely. Due to the risk associated with an invasive procedure, the use of pharmacological treatments such as oral contraceptive pills offers a viable alternative for the resolution of symptoms, especially when the physical exam is normal, imaging is unremarkable, and alarming symptoms are absent, as seen in this patient. A definitive diagnosis still relies on laparoscopic surgery, and in the event of treatment failure, this is the preferred next step in management. If an ovarian tumor is suspected, preoperative tumor markers such as CA125 may assist with the diagnosis but have been proven to be unreliable and non-specific. Screening methods, including imagining and physical examination, have not led to any reduction in cancer incidence .Most of these tumors, especially when low grade, may be treated with a conservative approach that maintains fertility, which is especially favorable in this young population . A dual Our patient is currently undergoing chemotherapeutic treatment and efforts are being made to preserve her fertility. Importantly, the documentation of such a clinical phenomenon is worthwhile reporting as it broadens clinicians' management of similar presentations to include the possibility of such an occurrence.We presented an uncommon case of an epithelial ovarian neoplasm in a teenage patient. This is a rarity and often excluded from possible differential diagnoses within this population due to its unlikeliness and the non-specificity of the common presenting symptoms. Furthermore, in younger populations, such as this patient, the preservation of fertility is paramount and diagnostic accuracy is vital. With early diagnosis and intervention being a pillar of this gynecological condition, highlighting the possible incidence of such a case is significant. This case highlights the need to perform thorough clinical, radiological, pathological, and laboratory examinations on all gynecological patients irrespective of age.


Trichofolliculoma is a rare tumor that arises from immature hair follicular tissue. In this report, we present the case of a 51-year-old man with a trichofolliculoma in the left external auditory canal. Uniquely, there was no prior trauma in this patient, despite previous trauma being hypothesized in the etiology of this tumor. The lesion was excised using microsurgical instruments and the tumor was closely adherent to the cartilage of the external auditory canal. Histopathology following excisional biopsy confirmed the diagnosis. Trichofolliculoma (TF) is a rare pilar tumor which lacks maturation of the hair follicle and represents an intermediate stage of differentiation between simple hyperplasia of the hair follicle (hair follicle nevus) and trichoepithelioma . In adulAuricular involvement is extremely rare, and to the best of our knowledge only three cases of ear canal TFs have been reported in the English literature . HistopaA 51-year-old male with unremarkable medical history presented to the Otolaryngology Clinic referred by his primary care physician with a small nodule on the left external auditory canal. The lesion was present for ~1 year, and the patient did not recall any history of local trauma or infections. He did not have hearing concerns. Microscopic otoscopy was performed in the office. The lesion appeared as a small, well-circumscribed nodule measuring ~5 mm in maximum diameter. It was skin-covered, dome shaped and had regular borders . It feltThe procedure was performed with periauricular nerve block with lidocaine 1%/1:100 000 parts epinephrine under the surgical microscope. The lesion was removed in its entirety with the use of microsurgical instruments and a ‘beaver’ blade scalpel. It was found closely adherent to the cartilage of the external auditory canal. The incision on the ear canal skin was approximated with one single 5–0 plain gut absorbable suture. Histopathology revealed the diagnosis of TF following hematoxylin and eosin (H&E) staining .TF is considered a rare, adnexal hamartomatous tumor originating from the hair follicles. It typically presents as a dome shaped, skin-colored nodule with a central pore showing protrusion of immature hair in the head and neck region in adults. The etiology of TF is unknown, although previous local trauma is considered to have a role . HistoloThe histopathological differential diagnosis of TFs includes hair follicle nevus, trichoepithelioma and accessory tragus . These eTF is typically asymptomatic but surgical excision is indicated for biopsy purposes. Similar to previous cases, we conducted surgical excisional biopsy for this tumor. Despite its benign nature, there has been a report in the literature for a facial TF, with perineural invasion which may be indicative of more aggressive behavior . In thesAlthough rare in the external auditory canal, TF should be included in the differential diagnosis of external auditory canal lesions. Its diagnosis is histopathological after excisional biopsy. Long-term follow-up will be required to rule out local recurrence.


Primary Retroperitoneal mucinous cystadenoma (PRMC) is an extremely rare benign tumor, predominantly occurring in women, with unclear pathogenesis.A 31-year-old woman, with no medical or surgical history, presented with left flank pain.An abdominal computed tomography (CT) scan revealed an 11cm retroperitoneal cyst. Due to its large size, percutaneous CT-guided drainage followed by a laparotomy surgical resection, were performed. Post-operative course was uneventful. Histological and immunohistochemical findings were consistent with PRMC. The patient was disease-free after a 6-month follow-up.Mucinous cystadenoma is a very odd finding in the retroperitoneum. Multiple differential diagnoses are to be considered beforehand, as most of cystic lesions in this anatomical region are malignant and require a different surgical approach. Radical resection, by laparotomy or laparoscopy, is the treatment of choice. •Primary retroperitoneal mucinous cystadenoma is a rare benign cystic tumor.•Preoperative radiological diagnosis of benignity is fundamental.•Histologically composed of tall columnar cells and low cuboidal cells, on a collagenous stroma.•Surgical resection is the recommended treatment. They account to 0.2% of all tumors . Clinico2A 31-year-old woman was admitted to the emergency department with acute lumbar pain. She had no medical or surgical history, and had not any known drug allergies. Her family history revealed hypertension, but no other significant medical or surgical diseases. The patient declared that the pain started a week before, denying her of sleep and hindering physical activity, but lately intensified and was associated with an episode of vomiting. Physical examination revealed tenderness in the left flank. Biological tests  were normal. A Computed tomography (CT) scan was performed and found a cystic lesion measuring 112x72x71 mm, with a thin wall and a homogenous liquid content . At firsThe surgical specimen was sent for pathological examination. On gross examination, the cyst had a thin wall (2mm thickness), was unilocular, without content, and measuring 70 × 68 mm. Histologically, The cystic lining was alternating between two types of cells: Tall columnar cells and flat low cuboidal cells, resembling mesothelial cells. The tall columnar cells had a clear cytoplasm charged with mucin with basal nuclei and were stained by Alcian blue. Flat low cuboidal cells had a scant cytoplasm with ovoid nuclei. There was no nuclear atypia, stratification, papillary growth or stromal invasion of epithelium. The stroma was moderately cellular and collagenous. Flat low cuboidal cells expressed, in immunohistochemistry (IHC), calretinin and N-terminus WT1 (nuclear staining) .Fig. 2HiClinical and radiological assessments performed in the outpatient unit reveled no recurrence after a 6-month follow up.3PRMC was first described by Hanfield-Jones in 1924 in his study on retroperitoneal cysts . Most ofClinically, patients with PRMC usually describe abdominal or pelvic pain, abdominal distention or discomfort, and in some instances, complain of a painless abdominal mass . IncidenFrom a clinicopathological approach, PRMC could be classified intro three subtypes: mucinous cystadenoma (≈36%), mucinous cystic tumor of borderline malignancy (≈13%), and mucinous cystadenocarcinoma (≈51%) . Mixed s9.Histological examination of PRMC shows that the lining of the cyst alternates between two types of cells, tall columnar cells (TCC) and flat low cuboidal cells (LCC). LCC are usually positive for mesothelial markers such calretinin, cytokeratin CK 5/6, CA 125, and D2-40 and are usually negative for mucinous cell makers, while TCC are positive for these markers. TCC are also positive for CK 7 Elevated serum tumor markers, such as CA 125, CA 19-9 and CEA could be helpful in the diagnosis or follow-up, but they exceptionally elevated in PRMC and are not specific .As for pre-operative imaging, ultrasound can aid in the initial evaluation of abdominal masses and can determine morphologic features suggestive of a malignant behavior of the tumor . However, CT scan and magnetic resonance imaging (MRI) are fundamental to determine the location, the extension and the content of the cyst. They can also show its impact on adjacent organs and detect possible signs of malignancy, such as ascites, peritoneal implants and lymphadenopathy. Analogous to our case, PRMC is usually unilocular with water-like fluid, thin-walled (<3 mm) and does not display papillary projections or mural nodules .Due to the rarity of PRMC, other differential diagnoses should be considered when dealing with retroperitoneal cystic lesions. This includes benign tumors, such as cystic lymphangioma, cystic teratoma, cystic mesothelioma, tailgut cysts, epidermoid cysts and bronchogenic cysts; and other tumors with malignant behavior and cystic presentation, like neurilemmoma, paraganglioma and perianal mucinous carcinoma . InteresSince the benign or malignant nature of cystic retroperitoneal lesions can only be confirmed by pathology, a careful and complete surgical removal of the tumor is necessary; and most importantly, without rupture of the cyst, as to prevent possible tumor dissemination, following content spillage. Although the surgical approach, undertaken in our case, was successful, CT-guided percutanous drainage is not without risks, mainly fistula formation, bleeding and sepsis . In the 4Primary retroperitoneal mucinous cystadenoma (PRMC) is a rare benign epithelial tumor that should be taken into account when confronted to retroperitoneal cystic lesions. A preoperative diagnosis, by CT and MRI, is essential, seeing that most of retroperitoneal tumors are malignant and that surgical management is different; which in the case of PRMC is more conservative and tends to be minimally invasive. The final diagnosis relies upon histological examination.None, The authors have received no funding from any agency in the public, private, or not-for-profit sectors.Not commissioned, externally peer-reviewed.N/A.None, The authors have received no funding from any agency in the public, private, or not-for-profit sectors.SF: Writing-original, draft preparation, resources, review and editing.SBH: Writing-review and editing, pathologic images, resources.SB: Review and editing, radiologic images, resources.AZ: Conceptualization, reviewing and editing, resources, supervision.NL, RH, AB and CC: Reviewing and editing, resources.All authors contributed to the development of the manuscript. All authors approved the final manuscript.N/A.Dr Safouane Frini.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The authors declare that there are no conflicts of interest in this work.


Cholelithiasis can present from a milder form of biliary colic to a more severe and complicated one like empyema gallbladder and a lesser-known variant of gangrenous gallbladder called marbleization of the gallbladder. The clinical signs and symptoms are similar to acute cholecystitis. Diabetes mellitus could have a role in the process of marbleization. Diagnosing marbleization of the gall bladder is not easy preoperatively. Computerized tomography is a better diagnostic modality when compared to laboratory investigations. Urgent cholecystectomy is the only option, and there is no role of conservative treatment. We report a case of a 36-year-old man with newly diagnosed Diabetes Mellitus diagnosed initially as acute cholecystitis and managed conservatively. He did not respond to treatment and hence underwent cholecystectomy and intraoperatively was found to have marbleization of the gall bladder. Cholelithiasis and its related complications are commonly seen in the surgical wards. The various complications that Cholelithiasis can cause are acute cholecystitis, ascending cholangitis, biliary pancreatitis, etc.A 36-year-old man with newly diagnosed Diabetes Mellitus presented with acute right hypochondriac pain associated with colicky abdominal pain for one week. He started to vomit on the day of admission. The patient was admitted to General Hospital and was treated as acute cholecystitis for four days before he came to our Centre. He did not have a fever or jaundiceOn examination, his vital signs were normal. He was not anaemic or jaundiced, and oxygen saturation was 99%. His upper abdomen was guarded with marked tenderness over the right hypochondriac region and murphy sign positive. His Erythrocyte Sedimentation Rate: 127 mm/hr., WBC: 14.1×10^9 /L, Blood Glucose:15.1 mmol/l, Alkaline phosphatase: 218 IU/LCT abdomen showed distended gallbladder with hyperdense layering seen at the dependent part with pericholecystic fluid collection and there was a breach of gallbladder wall at the posterior aspect. The adjacent duodenum (D2) was compressed with gallbladder fluid. No intrahepatic or extrahepatic duct dilatation was noted.Laparoscopic cholecystectomy was done the next day. Intraoperatively there was omental and peritoneal adhesion which were released. A shiny dark green marble-like structure was identified as a gall bladder . The galGall Bladder was removed without any complication. The patient was well post-operatively and kept on antibiotics for five days. He was discharged uneventfully.The incidence of GC ranges from 2%to 30% in all patients with acute cholecystitis.3If left untreated, acute cholecystitis may progress to emphysematous gall bladder, gangrenous gall bladder, or perforated gall bladder. It is important to diagnose complicated acute cholecystitis, mainly GC, correctly and early as it is associated with increased morbidity and mortality.6Marbleization of tissues is commonly encountered in forensic medicine where putrefaction occurs. After death, the organisms enter the blood vessels and use blood as the culture media, causing tissue disintegration and bacterial decomposition giving rise to a greenish external appearance to the tissues called marbleization.Diagnosing MGB can be difficult due to the subtle symptoms masked by existing comorbidities. Imaging modality can assist in diagnosing MGB rather than laboratory tests and Computerized Tomography (CT) has a better and accurate result. Important findings on CT are lack of mural enhancement with gallbladder distension, thickening of the wall, and pericholecystic fluid collection.Our patient presented with minimal symptoms and was afebrile which could be due to the concealed perforation of the gall bladder as it was contained due to the omental covering. He was newly diagnosed with Type 2 Diabetes Mellitus. Diabetes mellitus can cause an immunocompromised state. The symptoms were also minimal due to the effect of DM on the immune system. Prior to admission to our Centre, he had been treated partially with antibiotics. This has reduced the severity of the gangrenous gall bladder. The ideal treatment for GC has been proposed to be open or laparoscopic cholecystectomy by many authors.MGB is an intraoperative finding difficult to diagnose preoperatively as clinical laboratory and imaging modalities are nonconclusive. Early laparoscopic or open cholecystectomy with careful dissection of the GB and good peritoneal lavage can improve the patient's outcome.


Metanephric adenoma is an extremely rare renal neoplasm, especially in pediatrics. Chemotherapy combined with surgery in metanephric adenoma has not been reported.We describe a case of metanephric adenoma in a child less than 2 years old, which were treated by chemotherapy combined with surgery.Nephron sparing surgery was performed after regular chemotherapy, and the pathological result was metanephric adenoma.Pediatric metanephric adenoma is extremely rare; the clinical manifestations and imaging examinations lack specificity. Nephron sparing surgery is recommended as the preferred treatment for metanephric adenoma. Long-term follow-up and more in-depth molecular genetic research are still needed to determine the benign or malignant of metanephric adenoma and whether chemotherapy drugs have an effect on it. Metanephric adenoma (MA) is an extremely rare epithelial tumor of the kidney, which accounts for about 0.2% of all renal epithelium-derived tumors. This neoplasm mostly occurs in patients aged 50–60 years old, with a female-to-male ratio of 2:1  first diRetrospective analysis was performed on the case data of a child with MA admitted to the Department of Urology, Hainan Women and Children’s Medical Center, on 13 September 2021. The child aged 1 year and 11 months was accidentally examined by urologic color Doppler ultrasonography in a local hospital, and found to have a hypoechoic mass in the left kidney. He was then admitted to our hospital for further treatment. Physical examination showed no abnormality. Color ultrasound showed that a substantial mass with a size of 54 × 43 × 44 mm could be detected in the middle and lower pole of the left kidney, which was surrounded by a capsule. The mass was protruding out of the capsule with clear boundary, and mainly parenchymal echo; a small number of no echo areas also could be seen in it. The nodular growth of the mass was observed without obvious strong echogenic. CT suggested a solid space-occupying lesion in the middle and lower segment of the left kidney, about 36.70 × 42.10 × 50.60 mm in size, and nephroblastoma (stage I) was considered . MRI revThis study was approved by the Review Board of the Hainan Women and Children’s Medical Center, Haikou, China. Written informed consent was obtained from the legal guardian of the child.According to CCCG-WT-2016 , the chiThe left trans-costal incision was made after completing preoperative preparation. The tumor was located in the middle and inferior pole of the left kidney and protruded on the renal surface; the capsule was intact, the boundary with the renal parenchyma was clear, and it was not connected with the renal binding system. There were no enlarged lymph nodes in the retroperitoneum, renal hilum, and abdominal aorta. The tumor nutrient artery came from the left renal artery. Partial left nephrectomy plus left perirenal lymph node dissection was performed, and the renal artery was blocked 19 min during the operation. The tumor was completely removed as well as part of the normal renal tissue 1 cm from the edge. The operation ended smoothly.Postoperative pathology: The tumor was oval in shape, about 58 × 35 × 34 mm in size, with a small amount of kidney tissue locally attached on the surface. The cut surface was gray and white with focal gray red, solid and medium in quality. There were several palpable nodules in perirenal fat sacs and lymph nodes, with a size of 3 × 2 × 2 mm to 10 × 6 × 2 mm. Microscopic observation: the tumor tissue was a lamellar, small tubular, and focal glomerulus-like structure. The tumor cells were uniform in size, with hyperchromatic nuclei and rare mitotic signs. No necrosis was observed . ImmunohBrisigotti et al.  researchMetanephric adenoma occurs at all ages and has been reported from 15 months to 83 years old. Its clinical manifestations are not specific; most patients are only occasionally found during physical examination . In 1995Metanephric adenoma lacks specificity in imaging. Ultrasound usually presents as a well-defined round solid mass with few vessels and may be hyperechoic, isechoic, or hypoechoic . CT plaiWith the increase of MA case reports, the research of immunohistochemistry, molecular biology, and genetics has been gradually deepened. MA can occur in any part of the kidney, usually unilateral, with or without capsule, and some may be accompanied by cystic changes, hemorrhage, or necrosis. Histologically, MA can appear as spherical masses and bud-like structures. These two special forms are unique organizational structures of MA and have diagnostic value. Immunohistochemical staining of CK7 negative, AMACR negative, WT1 positive and CD57 positive were considered as the characteristics of MA; Kinney  found thIn pediatric cases, MA and nephroblastoma are difficult to identify, and fine needle biopsy is still controversial , 22, 23.In this case, stage I nephroblastoma was considered in preoperative examination, and nephron sparing surgery was planned . PreoperMetanephric adenoma is mostly reported as individual cases at present, and the incidence rate of pediatrics is lower. There is a lack of medical evidence in a large number of cases. We considered that the clinical manifestations and imaging examinations of children with MA lack specificity, and partial nephrectomy with nephron sparing is the preferred treatment for children with MA. Long-term follow-up data and in-depth molecular genetic studies are still needed to determine the benign and malignant effects of MA and whether chemotherapy drugs have an impact on it.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Written informed consent was obtained from the minor(s)’ legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.SH wrote the manuscript. ZW and WB enrolled the information of the child. SC collected the imaging and pathological information. ZZ and YL supported the project. All authors reviewed 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.


Dyke-Davidoff-Masson syndrome (DDMS) is a rare neurological disorder found in children as well as adults. It is characterized by hemi cerebral atrophy. To date, very few cases of this disorder have been reported. Radiological imaging including magnetic resonance imaging (MRI) and computed tomography (CT) are accurate tools for the diagnosis of DDMS. We present a case of a 13-year-old female child who came with complaints of multiple episodes of generalized tonic-clonic seizures. In our case, clinical history and imaging with CT and MRI were accurate enough to diagnose DDMS. Dyke-Davidoff-Masson syndrome (DDMS) is an uncommon neurological disorder and is characterized by hemicerebral atrophy that typically results from brain injury during fetal or early childhood. It is most often accompanied by contralateral hemiparesis and ipsilateral compensatory osseous hypertrophy . We descA 13-year-old female child presented with multiple episodes of generalized tonic-clonic seizures. The patient was a known case of seizure disorder and was on medication for the same. For the past six months, an increase in the number of seizure events was noted. At the age of nine months, the patient suffered an episode of high-grade fever followed by an episode of seizure and weakness in the right upper and lower limbs. The right lower limb weakness improved over the next six months; however, the right upper limb weakness still persisted. The patient was a full-term normal vaginal delivery, with no prior neonatal intensive care unit (NICU) admissions. All the growth milestones were achieved until nine months of age. On neurological examination, the patient was fully alert and was oriented to time, place, and person. Hypotonia was noted in the right upper limb. The patient had right-sided hemiparesis . All the deep tendon reflexes were absent. The right plantar reflex was absent and the left plantar reflex was flexor. The rest of the systemic examination of the patient was within normal limits.The patient has been advised a computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain. On CT and MRI evaluation, atrophic changes with volume loss and gliosis were noted involving the left frontal and parietal lobes as seen in Figure This was associated with ex-vacuo dilatation of the body and frontal horn of the left lateral ventricle with the ipsilateral displacement of the falx and other midline structures as seen in Figure DDMS was described for the first time in 1933 by Dyke, Davidoff, and Masson on skull radiographs and pneumo-encephalograms . AnotherClinically, DDMS is described as a syndrome of hemiplegia, seizures, facial asymmetry, and intellectual disability. Seizures can be either focal or generalized . While tImaging findingsOn ultrasonography, hemiatrophy and “shifted falx” signs have been reported as early as 29 weeks of gestation. On a plain radiograph, unilateral calvarial thickening with the ipsilateral expansion of paranasal sinuses and mastoid air cells is noted. Most commonly the frontal sinuses are involved since they were pneumatized last and expand up to adolescence. Elevated ipsilateral greater sphenoid wing, petrous ridge, tegmen, fovea ethmoidalis, and planum sphenoidale may also be appreciated on a plain radiograph. On a CT scan of the brain, atrophic changes with volume loss involving the ipsilateral cerebral hemisphere are noted. Enlarged sulci and cerebrospinal fluid (CSF) spaces involving the ipsilateral hemisphere with enlarged lateral ventricle and ipsilateral displacement of the falx are noted. As the patient grows older, these imaging results become more prominent. Compensatory calvarial hypertrophy is often observed in cases of brain injury that occurred during the intrauterine period or prior to the age of three years. In some cases, mild contralateral compensatory hemispheric hypertrophy is seen. On MRI, in addition to the CT findings, the etiology of any atrophy may be more clearly evaluated. Areas of hyperintensity on T2 weighted imaging and fluid-attenuated inversion recovery (FLAIR) along with encephalomalacia and gliosis due to vascular or infectious insult may be seen. Wallerian degeneration of the ipsilateral cerebral peduncle and thalamic atrophy may also be noted .Differential diagnosisSturge-Weber SyndromeAlthough the skull, sinuses, mastoid, and ipsilateral cerebral atrophy may resemble DDMS, other features such as facial port-wine stain, pial angioma, dystrophic cortical calcification, and ipsilateral choroid plexus enlargement help differentiate it from DDMS .Rasmussen EncephalitisIn this case, hemiatrophy mainly involves the frontotemporal, insular, and parietal regions. There may be crossed cerebellar atrophy or diaschisis. Due to this, it is a close differential diagnosis of Rasmussen encephalitis. However, no calvarial features are seen in Rasmussen encephalitis since it occurs in childhood around six to eight years and 10% of them occur in adolescents or adults .HemimegaloencephalyIn this case, there is a hamartomatous overgrowth of the cerebral hemisphere with the ipsilateral enlarged lateral ventricle, thereby causing apparent atrophy of the contralateral hemisphere .Parry Romberg SyndromeIn this case, there is typical progressive hemifacial atrophy. Other features include cerebral hemiatrophy, microhemorrhages, calcification, white matter abnormalities, cortical dysgenesis, meningeal thickening, and enhancement .TreatmentSymptomatic treatment is given in the form of antiepileptic drugs for seizures. However, in case of intractable seizures, hemispherectomy is advised. Long-term supportive management in the form of physical, language, and occupational therapy may be required.DDMS is a progressive neurological disorder with infantile as well as adult variety. Very few cases of DDMS have been described in the literature till now. A generalized tonic-clonic seizure is the most common presenting symptom of this disorder with other symptoms of brain insult which may progress over time. Therefore, timely diagnosis is essential to initiate the appropriate management. The use of radiological imaging, particularly MRI, enables prompt and accurate diagnosis allowing appropriate management of DDMS.


Although the vast majority of pediatric neck masses are benign, pediatric malignancies commonly present in the supraclavicular region. We present the case of a 4-year-old male who presented with a mass in the trapezius muscle with accompanying lymphadenopathy. An extensive work-up was performed to exclude malignancy, and the patient was ultimately diagnosed with a benign monocytic mass, which surgically excised. He has been doing well since surgery with no evidence of recurrence. A review of the literature revealed this case to be the first of its kind to be reported. Although 80–90% of pediatric neck masses are benign, they are common and can be an ominous presentation of malignancy , 2. Of tIn this case, we present a 4-year-old male with supraclavicular fullness and an intramuscular, superficial neck mass that was treated with surgical excision. After an extensive pathologic review revealed infiltrating monocytes and histiocytes, the mass was deemed to be benign and the work-up was completed.A 4-year, 7-month-old male presented to our otolaryngology department with supraclavicular fullness and an enlarging, firm, right-sided 2 × 3-cm neck mass. At the initial visit, his vital signs were remarkable for an isolated fever of 101.6°F. A pertinent review of systems was negative per the patient’s parents. Possible environmental exposures included mice and bats as the patient lived on a farm. Past medical history was unremarkable. Physical examination demonstrated a mass located on the superior dorsal side of the right shoulder with a few mildly enlarged, mobile and cervical lymph nodes. An ultrasound of the mass was negative for abscess. The patient was started on ampicillin and sulbactam due to concern for infection; however, a pharyngeal swab and chest radiograph were negative. A magnetic resonance imaging (MRI) demonstrated the mass within the mid-belly of the right trapezius muscle and revealed significant inflammation and cellulitis of the subcutaneous tissue, as well as a small fluid collection in the supraclavicular space consistent with necrosis . A compuAn excisional biopsy was performed 4 days after the initial biopsy, revealing skeletal muscle with a histiocytic/monocytic infiltrate with marked necrosis, and a lymph node demonstrating sinus histiocytosis . MicroscAnaplastic large cell lymphoma was deemed an unlikely as CD30/ALK cells were absent. In addition, despite the infiltration of monocytes, negative CD34, CD117 and low mitotic activity (low Ki-67 index) decreased suspicion for monocytic sarcoma. A CT scan was also performed for further evaluation, which demonstrated a potential paratracheal mediastinal lymph node with questionable clinical relevance. Flow cytometry of this lymph node was negative for myeloid neoplasm and lymphoma . FurtherTwo weeks later, the patient reported no further symptoms at follow-up. However, due to the inconclusive pathology report, a bone marrow biopsy was scheduled to rule out a potential lymphoma. Twenty days following the clinic visit, the patient underwent another MRI as well as the bone marrow aspiration. This MRI demonstrated significant improvement in the size of the mass and no lymphadenopathy. The bone marrow biopsy demonstrated mild hypocellularity and nonmalignant characteristics . Flow cyNeck masses are common in pediatric otolaryngology and can be secondary to numerous etiologies. Although 80–90% of pediatric neck masses are benign, it is of the utmost importance to promptly rule out malignancy. Features indicative of a potential malignancy include firm and immobile lymph nodes with a supraclavicular location . In thisIn general, posterior cervical space masses are typically lymphatic abnormalities consisting of cystic spaces and endothelial cells , 4. In tThe literature, however, is absent in regard to cases of benign, intramuscular masses presenting in children. This patient was extensively evaluated for a malignant process and neither excisional biopsy nor bone marrow biopsy led to a neoplastic etiology. There has been no recurrence since the excision. Although the etiology remains unclear, the patient’s environmental risk factors secondary to living on a farm make an insect, rodent or bat bite a potential source. In fact, the patient’s parents had specifically noted bats in the house previously. However, the patient did not present with any obvious skin lesions indicative of a bite, and the literature has not revealed any cases supporting this hypothesis.This is a case report of an initially aggressive supraclavicular neck mass in the trapezius muscle with monocytic/histiocytic pathology, which has not been previously described. This patient underwent extensive evaluation to rule out malignancy. Although the mass was ultimately deemed benign, we feel that this case demonstrates an example of a thorough work-up of an atypical pediatric neck mass.None declared.


IntroductionDiverticula of the appendix is a rare entity, may be complicated by inflammation/infection, and clinically mimics acute appendicitis. The reported associated risk factors include male gender, Hirschprung’s disease, cystic fibrosis and adult age, where some reports claim that they are also associated with an increased risk of appendiceal malignancy. Imaging has a place in pre-operative diagnosis, however, most of the cases were diagnosed during a pathological examination after surgery. They are associated with a higher rate of perforation . In this review, we present a case series of five patients diagnosed with diverticulitis and one with diverticulosis of the appendix that were managed at a single centre. Our aim is to explore the common clinical, radiological, and intra-operative findings associated with this disease as well as the outcome of management.Materials and methodsA total number of six cases of diverticular disease of the appendix diagnosed and managed at Basildon University hospital in the period between 2016 and 2020 were studied. The demographic details and clinical data including presenting symptoms, laboratory results, radiological characteristics, intraoperative findings and histopathological features were analysed.ResultsThe study group included four males and two females, with an age range of 20-84 years. The most common presenting clinical symptoms were right iliac fossa abdominal pain, nausea, anorexia, and diarrhoea. Half of the cases showed a thickened appendix in the pre-operative CT scan. An inflamed or perforated appendix was seen in five cases as well as inflammation of the diverticula.ConclusionAppendiceal diverticulitis is an uncommon pathology that imitates acute appendicitis, and appendicectomy is the standard treatment. Prophylactic appendicectomy is recommended for non-inflamed diverticula - this is due to the potential risk of inflammation, perforation, and the risk of developing an appendiceal neoplasm. Diverticulosis of the appendix is an uncommon pathology, first described by Kelynack in 1893 . SymptomWe present six cases of diverticular disease of the appendix diagnosed and managed in our unit, those cases were diagnosed in the period between 2016 and 2020. The clinical records for those cases were retrieved and demographic data, such as age and gender, was collected. Also, the clinical information related to the presenting features, such as abdominal pain, nausea, anorexia, and diarrhoea, was analyzed. The diagnostic work-up included inflammatory markers assessment and imaging studies. The intra-operative findings were also been reviewed in every case.Case 19/L. Computed tomography (CT) reported a thickened appendix (diameter of 1.3 cm) with extensive perifocal fat stranding , nausea, and diarrhoea. On clinical examination, there was tenderness in the RIF with guarding. Initial blood investigations showed a C-reactive protein (CRP) of 288 mg/L and a white cell count (WBC) of 14x10 Figures .Case 29/L. Ultrasonography revealed a thickened and oedematous, non-compressible blind-ended bowel loop in the RIF measuring 8 mm in diameter  associated with peri-appendiceal inflammatory changes within the RIF, consistent with acute appendicitis  suggesting inflammation , though none of the patients had leucopenia. The CRP was raised in all five symptomatic cases, however, significantly raised only in one case (288 mg/dl), moderately raised in three cases (>10-100mg/dl), and slightly raised in one case (<10 mg/dl). Three cases had pre-operative CT scans that revealed a thickened appendix with peri-appendiceal inflammatory changes in two cases , and the presence of diverticulosis alone in the sixth. There was no evidence of parasites, dysplasia, or malignancy in the examined specimens Table . There are two different types of appendiceal diverticula: congenital (incidence - 0.014%) and acquired (incidence - 1.9%). Acquired-type diverticula occur secondary to increased pressure within the appendiceal lumen, leading to an outpouching of the mucosa through the muscularis propria at low-pressure points along the mesenteric and antimesenteric borders . Causes Luc Deschenes et al. in 1971 described five morphological types . The firRisk factors associated with the development of this pathology include age more than 30 years and a history of cystic fibrosis or Hirschsprung’s disease . The disYamana et al. in 2012 reported a lower white blood cell count and a high C-reactive protein level in patients with appendiceal diverticulitis compared to those with acute appendicitis . This suDetecting the presence of appendiceal diverticulitis preoperatively is important in arriving at an accurate diagnosis. However, in most cases, the diagnosis is typically made during the histological examination of the appendix. Features of acute appendiceal diverticulitis on CT have been described in just a few publications. The presence of an inflamed diverticulum on CT is typically seen as a round, small cystic out-pouching with wall enhancement due to increased contrast uptake within the diverticular wall . Lee et Sonographic features of acute appendiceal diverticulitis include the presence of hypoechoic inflamed diverticula surrounded by echogenic fatty tissue. In typical, acute appendicitis, mucosal and submucosal inflammation can be visualised as an echogenic ring with an internal echo-free space filled with fluid. This differs from appendiceal diverticulitis wherein all the appendiceal wall layers are inflamed and visualised as thickened and echogenic with an internal area of echogenicity, which implies the presence of air .Acute appendiceal diverticulitis may progress to several complications, which include perforation, intra-abdominal abscess, pelvic pseudocyst, and vesicocaecal fistula. Appendiceal diverticulosis may also lead to intra-abdominal haemorrhage and intussusception . There iAppendicectomy is the procedure of choice for acute appendiceal diverticulitis, and prophylactic elective appendicectomy is the recommendation for patients with diverticulum. This is due to the risk of progression to diverticulitis, perforation or malignancy. Clinicians should always remain cognisant of the differentials of acute appendicitis and keep appendiceal diverticulitis in mind when treating patients with right-sided, lower quadrant abdominal pain.In this series, the clinical features of acute appendiceal diverticulitis were similar to those of acute appendicitis, and this was not diagnosed pre-operatively in those that had CT imaging. In looking at the literature, we find that it is possible to differentiate the two entities on CT and increased awareness is required on the part of radiologists. Despite the risk of neoplasm with this pathology, none of our patients had any long-term complications.Appendiceal diverticulitis is an uncommon pathology that imitates acute appendicitis and is usually treated by appendicectomy. Prophylactic appendicectomy should also be performed for non-inflamed diverticula. This is due to the risk of possible inflammation in the future, risk of perforation, and risk of developing an appendiceal neoplasm.


Hemorrhage in vestibular schwannoma (VS) is a rare but potentially devastating complication, owing to the proximity to the brainstem and small space in the posterior fossa.it is a challenge to manage such patients, coming in emergency in comatose state and whether early intervention can reverse the consequence or not.A 42-year-old male presented in emergency room (ER) with sudden onset of severe headache followed by loss of consciousness, with GCS- 3 (E1V1M1) and mid-dilated fixed pupil. Computer tomography (CT scan) head revealed a large hematoma in the right cerebellopontine angle (CP) with hydrocephalus, requiring urgent CSF diversion  in the ER. Subsequently microsurgical excision of the tumor was done after few days, once patient has shown improvement in GCS. Histopathology confirmed it as hemorrhagic VS. Post-operatively, he had right HB (House- Brackemann) grade IV facial weakness which could not be appreciated in preoperative phase. He gradually recovered well and was able to walk without support at the time of discharge.At 4 months follow up, facial weakness slightly improved to HB grade III, and patient was doing his daily activity without difficulty. Follow-up magnetic resonance imaging (MRI) imaging showed a small residue near internal acoustic meatus (IAM).Hemorrhage in VS is associated with increased morbidity and mortality; and few times, urgent intervention can save life despite of comatose state of the patient. •Vestibular schwannoma with bleed is a rare phenomenon.•These tumors becomes very challenging to manage because of significant increase in size causing brainstem compression and herniation.•Urgent Cerebrospinal fluid (CSF) diversion in patients with Glasgow coma scale (GCS) score-3 can also revive the patient if attempted early. The incAcute neurological deterioration due to gross intratumoral hemorrhage is exceedingly rare and occurs in less than 1% of cases . Till no2A 42-year-old previously healthy man presented in the emergency room (ER), with a history of sudden onset severe headache, vomiting, followed by loss of consciousness with no history of previous similar episodes. On neurological examination, GCS was E1V1M1 and pupil bilateral mid-dilated, fixed. After immediate resuscitation including the intubation, Computed tomography (CT) brain was done. The imaging revealed a large hematoma with lesion in the right CP angle region, compressing the brain stem along with hydrocephalus A. UrgentUnder general anesthesia, in park bench position, patient underwent right retromastoid suboccipital craniotomy and excision of the lesion under cranial nerve neuro-monitoring. After craniotomy and dural opening, cerebellum was tense and bulging. On opening of the tumor capsule, hemorrhagic fluid under pressure came out. The lesion was soft to firm in consistency with multiple blood clots inside the lesion with good plain of cleavage. Near-total (>95%) excision was done and small part of the tumor capsule, densely adherent to the facial nerve near IAM was left behind. The lower cranial and facial nerves were identified and preserved. At the end of the surgery, the cerebellum was lax and pulsatile. The procedure was uneventful and patient was shifted to NICU for the elective ventilation. On the first postoperative day, he became conscious and obeying command but ventilator support was required for airway support. EVD was removed after 48 hours of surgery. He underwent tracheostomy on postoperative day (POD) 4, which was gradually closed on POD 15 after the partial recovery of lower cranial nerve palsy. During the postoperative phase, lateral tarsorrhaphy was also done in view of inadequate eye closure [House-Brackmann (HB grade IV)]. Histopathological examination was consistent with hemorrhagic VS. At the time of discharge, he had complete right hearing loss with right HB grade IV facial weakness and was able to walk without support.At 4 months follow up, MRI brain revealed small residue near right IAM E–G. On c3Historical background- Clinically significant hemorrhage in VS is a very rare occurrence in neurosurgical practice and requires urgent intervention. The incidence of acute neurological deterioration secondary to intratumoral hemorrhage (ITH) in VS is less than 1% ( than 1% . The fir than 1% . Till no than 1% . Out of  than 1% . Our casRisk factors and etiopathogensis for hemorrhage in Vestibular schwannoma- Possible risk factors for hemorrhage in VS may be anticoagulants uses, trauma, pregnancy, and tumor size >2.5 cm ( >2.5 cm . The pos >2.5 cm . Other f >2.5 cm . The patAnticipated Cranial nerve deficits- The reported incidence of CN VII palsy in all cases of VS is approximately 6%; whereas for the hemorrhagic VS, incidence of CN VII palsy is around 31.3% (nd 31.3% . The incnd 31.3% . CertainMortality- The mortality rate associated with VS is approximately 0.2%, whereas mortality rate reported in hemorrhagic VS is around 10% (ound 10% . With th4In conclusion, sudden spontaneous massive hemorrhage in VS is very rare but possible complication of VS. ITH may be provoked by anticoagulation status, trauma, rapid growth or previous radiation but in small subset of patients, hemorrhage may occur without any identifiable cause. Early microsurgical resection with clot evacuation in VS with ITH should be preferred management strategy for survival and better surgical outcome. The importance of pathological factors is of prime importance to study the pathophysiology of hemorrhage in vestibular schwannoma, which is a rare phenomenon in them.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Glomangiopericytoma (GPC) is a rare sinonasal tumor that behaves benignly with a long overall survival rate. It accounts for fewer than 0.5% of all sinonasal tumors.We report the case of a 64-year-old man who presented with recurrent episodes of epistaxis. Rhinoscopy revealed a left posterior nasal septal mass with active oozing. Computed tomography (CT) showed a well-defined soft tissue lesion in the left nasal cavity measuring 1.95 × 1.51 cm. Complete endoscopic resection was successfully performed. Histopathological findings favored the diagnosis of GPC as it revealed tumor cells positive for smooth muscle actin and β-catenin with immunopositivity for CD34.Presenting symptoms of GPC are predominated by epistaxis and nasal obstruction. Since CT and MRI merely lead to a presumptive diagnosis, histopathological findings are indispensable. Complete surgical excision of GPC remains the treatment of choice with excellent prognosis, especially when immunohistochemistry is positive for actin and CD34 immunostaining is negative.GPC is a rare indolent tumor of pericytes that has a macroscopic appearance of a nasal polyp, which may result in uncertainty in the initial diagnosis. In most cases, GPC warrants only local excision. This case report adds to the literature and helps galvanize the developing clinical guidelines for diagnosis and treatment. •Glomangiopericytoma (GPC) is a rare sinonasal tumor that behaves benignly with a long overall survival rate.•GPC has a macroscopic appearance of a nasal polyp, resulting in uncertainty in the initial diagnosis.•The utilization of histopathological findings to diagnose GPC is indispensable.•Complete surgical excision is the mainstay of treatment.•Regular postoperative lifelong follow-up is strongly recommended. Notab2A 64-year-old man presented to our department with a history of diabetes mellitus, hypertension, and septoplasty conducted 6 years previously. He had presented with epistaxis to the primary health care emergency center multiple times over 3 years. Multiple anterior nasal packing at different times helped control the epistaxis initially. Thereafter, the patient presented to our emergency department in a tertiary facility with active epistaxis. Transnasal flexible scope showed left posterior nasal septal mass with active oozing from the mass, which was managed by a merocele nasal pack and surgicel absorbable hemostat to stop the bleeding . Compute3GPC of the nasal cavity constitutes a rarity among all nasal neoplasms as it accounts for less than 0.5% of nasal tumors . GPC seeIn addition to previous reviews, we conducted a literature review of cases published between 2018 and 2022 to investigate the characteristics, findings of CT and MRI scans, surgical approaches, and the treatment outcomes of patients with GPC ,19. Of t4GPC is a rare indolent sinonasal tumor with low malignant potential. The diagnosis of GPC necessitates a high index of suspension because of its rarity and ambiguity of clinical and radiological signs. Furthermore, our case report supports the medical evaluation of GPC. Histopathological tissue sampling is the diagnosis of certitude. The mainstay of treatment is complete surgical excision with regular monitoring. Consistent reporting of rare cases of GPC is crucial as it provides guidance for diagnosis, follow-up, and treatment outcome, since GPC is rarely discussed in the medical literature.The ethical committee approval was not required given the article type is a case report. However, the written consent to publish the clinical data of the patients were given and is available to check by the handling editor if needed.This case report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.AMA, MKA, and FKA conceived the study design. AMA and FKA performed the literature review. AMA, MKA, AAA, and TT prepared the components of the case presentation. FKA drafted the manuscript. AA and FKA designed the tables. MKA, AAA, and TT performed surgery and provided bedside care. AQA performed histopathological diagnosis. All authors approved the final version of the manuscript.This is a case report.https://orcid.org/0000-0002-8981-411X Tel: +966548104118 Email: FirasAlmarri@gmail.com.Firas K. Almarri, College of Medicine, Imam Mohammed Ibn Saud Islamic University, Riyadh, Saudi Arabia ORCID: Our patient responded positively to the surgical and medical management offered by the medical team as his condition improved drastically. Therefore, he is grateful to the Otorhinolaryngology-Head & Neck Surgery department for assisting him in his recovery.Not commissioned, externally peer-reviewed.The authors state that they have no conflicts of interest for this case report.


Emphysematous cholecystitis (EC) is an acute infection caused by gas-forming organisms and is considered a surgical emergency. The presenting symptoms of EC are often difficult to distinguish from those of uncomplicated acute cholecystitis, necessitating the use of CT for diagnosis. EC is associated with higher rates of gangrene and perforation of the gallbladder compared to typical acute cholecystitis. It is also associated with significantly higher rates of mortality.3. A CT of the abdomen and pelvis was ordered, which demonstrated air in the gallbladder lumen with extraluminal air adjacent indicating ruptured EC.In this report, we discuss the case of a 57-year-old African American female who presented to the emergency room with nausea, non-bloody vomiting, and abdominal pain for three days. Physical examination showed a soft but tender abdomen, especially in the right upper quadrant, and labs showed leukocytosis of 15.5/mm Emphysematous cholecystitis (EC) is a rare complication of acute cholecystitis characterized by the formation of gas inside the lumen or wall of the gallbladder. Due to the high mortality rates associated with perforated EC, it is considered a surgical emergency. Compared to acute cholecystitis, male patients are twice as likely to develop a perforated EC than their female counterparts, with the majority of patients having comorbidities such as diabetes mellitus . PhysicaA 57-year-old African American female patient presented to the emergency room complaining of right upper quadrant abdominal pain, nausea, and non-bloody vomiting for three days. The patient stated that she had tacos three nights ago, and she believed that her symptoms were food poisoning-related. Her abdominal pain had been getting worse, and she denied any aggravating or relieving factors related to her pain. The patient stated that the abdominal pain was generalized but was more prominent in the upper abdominal region. She denied diarrhea or chills. The patient had tried bismuth subsalicylate for symptom relief but it had been ineffective. She denied any travel history or contact with sick individuals.3. Abdominal and pelvic CT with contrast indicated air in the gallbladder lumen with adjacent extraluminal air, compatible with ruptured EC  scan was ordered to rule out biliary tract leakage. After consulting with the multidisciplinary care team, the primary care department and infectious disease department believed that the patient was having transaminitis. Viral hepatitis was considered unlikely since the hepatic viral panel was negative, but it was felt that the etiology could be due to antibiotics and acetaminophen. After nearly a week of medical management, the patient was discharged on postoperative day seven. She was seen in the office one week postoperatively and was doing fine with a nicely healed incision site. Her biopsy results were negative for any malignancy, which was communicated to her.Cholecystitis with or without cholelithiasis is the most common cause of gallbladder perforation. In elderly patients, spontaneous gallbladder perforation can result from a decrease in its blood supply, which can be due to atherosclerosis, focal vasospasm, or localized vasculitis . Acute bNiemeier  establisThe most likely mechanism of gallbladder perforation in acute cholecystitis is cystic duct obstruction , which causes intraluminal secretions to be retained, resulting in an increase in intraluminal pressure. This increased intraluminal pressure impairs the gallbladder's lymphatic and venous outflow, which ultimately leads to gallbladder rupture and necrosis . The facSince there are no conventional symptoms and indicators of gallbladder perforation, clinical identification can be challenging and sometimes delayed or overlooked. According to Pedrosa et al. , gallblaGallbladder perforation is a rare and emergent medical condition that indicates acute surgical care based on imaging modalities such as a CT scan. Early diagnosis and an emergent cholecystectomy can considerably reduce morbidity and mortality, as in our case. The clinical encounter of a ruptured gallbladder always warrants an aggressive investigation to rule out etiologies such as malignancy.


Hemangiopericytomas (HPCs) are rare tumors derived from mesenchymal cells with pericyte differentiation. About 5% of head and neck HPCs occur in the nasal cavity and paranasal sinuses. Due to its rarity, rich vascularity and variable biological behavior, its management is a challenge in itself.We report a case of sinonasal HPC in a Jehovah's Witness patient and discuss the obstacles and care related to the restrictions and therapeutic challenges involved in the approach to the patient. The patient was successfully treated by endoscopic endonasal approach with all per‐operative care and restrictions being respected and attended.The management of HPC by itself involves challenges and when associated with other restrictive conditions attention and care are required. They have smooth muscle characteristics, being responsible for regulating the caliber of the vessels due to their contractile capacity, and thus, modulate the flow and vascular permeability.The HPC can affect different anatomic sites of the body, involving more frequently the lower limbs, pelvis and the retroperitoneum.As a possible and rare paraneoplastic syndrome likely to occur, there is the tumor‐induced osteomalacia (TIO), characterized by the secretion of fibroblast growth factor 23 (FGF23) mainly by benign mesenchymal tumors and sometimes by malignancies. Patients with osteomalacia complain of progressive bone pain, muscle weakness, walking disability, and other symptoms.Correctly diagnosing the HPC is not an easy task, however it is essential for an efficient treatment. Because of its rareness and unpredictable biological behavior, this infirmity may cause confusion and uncertainty regarding its treatment and is a significant problem not only for pathologists, but also for surgeons who conduct the case. A long‐term follow‐up of the patient is essential to predict the behavior of the tumor.However, due to its rare occurrence and unpredictable biological behavior, this disease generally triggers confusion and uncertainty regarding its treatment and conduct.The purpose of this article is to report a case of sinonasal hemangiopericytoma (SNHPC) in a Jehovah's Witness who was treated with preoperative embolization and endoscopic resection. Our aim is to add our experience to the growing body of literature on this disease, as there are a few cases reported in the literature and to report the first reported case of SNHPC in a patient who could not receive a blood transfusion due to religious issues and to discuss the challenges involving management in this situation and the need of a multidisciplinary approach.2A total of 68 years old female was referred to the Head and Neck surgery specialist evaluation after intense epistaxis. Three years ago, she started to present nasal obstruction, more pronounced on the right nostril, associated with sporadic episodes of epistaxis, which became more frequent and intense over the subsequent months. She reported having already undergone previous cauterizations in other hospitals to stop the bleeding. The patient had systemic arterial hypertension (use of amlodipine and losartan), diabetes (use of metformin and glibenclamide) and coronary disease with necessity of three stens (last placement over a year ago). Besides that, there was the fact that the patient refuses treatments that could use blood components by religious belief.For the Jehovah's Witnesses, the violation of this moral principle means disobeyment and disloyalty to its creator and giver of life. Their faith represents a challenge for the surgeons, who must have basic knowledge and be comprehensive of their doctrines to minimize and control the loss of blood in these patients.Nasal endoscopy was performed and revealed a gray‐pink to red, soft, hemorrhagic mass that occupied the entire right nasal cavity without identifying the lesion's pedicle that impeded the progression of the endoscope.To progress the investigation, a NMR of the face was performed and showed an expansive formation with a polypoid aspect occupying the entire length of the right nasal cavity, measuring 8.6 cm. The lesion caused an enlargement of the ipsilateral nasal cavity, without bone erosion or soft tissue infiltration, medially bulging the nasal septum and laterally repelling the right nasal turbinates. Posteriorly, it insinuates itself in the nasopharynx, reducing its light. Figure .An angiotomography was made, revealing an hypervascular lesion, irrigated by branches of the right maxillary artery. There were no major branches of the ophthalmic artery feeding the lesion. Figure .As the diagnostic hypothesis was a vascularized sinonasal tumor, a surgical approach was planned. The surgery without the possibility of use of blood components required a thorough preoperative planning from the entire team, including a detailed clinical history  and evaluation of exams with the intent to identify coagulation abnormalities and pre‐existing anemia.In view of the high risk of intraoperative bleeding due to the hypervascular lesion, and the patient's religious belief, it was opted for embolization of the tumor nourishing artery 2 days before surgery, aiming the complete resection of the tumor with safety.Embolization was performed by catheterization of the right common femoral artery, with angiographic series made with contrast in the following arteries: right internal and external carotid arteries and right internal maxillary artery. The lesion had afferent branches mainly from the right sphenopalatine artery, but it also had ones from ethmoidal arteries, right ophthalmic artery and left sphenopalatine artery. The embolization of the distal branches of both sphenopalatine arteries was selectively performed with 300‐500u PVA microparticles until the complete exclusion of tumor enhancement by iodinated contrast. , although the patient was aware that external access  could be necessary if the first attempt was not enough to completely remove the tumor.During surgery we faced a reduced size lesion compared to the one sight on imaging exams (reflex of embolization), with precise limits and little local bleeding, easily controlled by cauterization. The tumor was completely removed by endoscopy, and after reviewing the hemostasis, an absorbable hemostatic was placed on the surgical bed and a nasal plug was put on the nose. The patient stand under clinical care, maintaining blood pressure levels, cardiac function and blood glucose within the normal range. Both the nursing and medical team maintained intensive monitoring to identify and quantify any bleeding.The entire surgical team remained on standby to intervene in the event of postoperative bleeding. The patient remained stable throughout the hospital stay, with the nasal plug up to the 7th postoperative day, without presenting epistaxis, being safely discharged.3, the lesion was represented by mesenchimal proliferation consisting of polygonal cells, arranged in solid sheets, expansive. The neoplastic cells were isomorphic, free of atypia, containing areas of myxoid degeneration of the matrix. Vascularization was exuberant with endothelial cells flattened by a large number of capillaries with perivascular hyalinization, as well as irregular “deer antler” branching, a hemangiopericytoid pattern.The tumor was sent in formaldehyde to the pathology service, being included in paraffin blocks. Measuring 7.5 × 6.8 × 2.0 cmOn immunohistochemistry test (IHC), the tumor cells were positive for vimentin, CD 34 and Ki67 limited to the endothelium. Based on these finding, the diagnosis of HPC could be made  are nonspecific in the initial phase, and the histological diagnosis is confounded with other diseases . The cases of TIO caused by SNHPC are extremely rare, representing less than 0.5% of all cases and about 5% from HPCs from other sites. However, it is advisable to remember this differential diagnosis in cases of osteomalacia of unknown cause in patients with nasal polypoid masses.The preoperative evaluation requires detailed evaluation of imaging tests (CT and NMR).Although embolization presents risks—ischemia of other organs, facial flushing, thrombotic complications during catheter implantation—these are less likely than the massive hemorrhage that can occur during surgery, especially if performed with a meticulous angiographic technique, taking care of the possibility of reflux of thrombolytic agents to unwanted areas. The angiographic study of a hypervascularized tumor must be considered, even without the previous diagnosis, for the performance of preoperative embolization, as it provides more safety in the surgery and less blood loss in the procedure.Diagnostic confirmation of SNHPC is performed by anatomopathological examination, complemented by immunohistochemistry. Before the routine use of such exams, the diagnosis was commonly confused with other types of tumors, due to the similar vascularization that these diseases present, which are the blood vessels in the shape of “deer's antler”.The therapy of choice for SNHPC is undoubtedly broad surgical resection with safety margins. Neck dissection is not indicated because cervical metastasis rarely occurs in the HPC. Although there appears to be no difference in the therapeutic outcome between endoscopic resection and conventional open surgery , the endonasal endoscopic approach offers some advantages compared to the external approach. Among them, the endonasal approach shows a wide and magnified view of the entire lesion and the structures of the rhinopharynx, helping to accurately assess the insertion of the SNHPC, as well as the margins and surrounding tissues. Other benefits include preservation of nose physiology and reduced risk of damaging the lacrimal apparatus.The size and infiltration of the tumor are prognostic factors that influence the survival of patients with SNHPC. This fact is aggravated in cases of extensive tumors located on the head and neck because, due to the complexity of their anatomical structures, it is rarely possible to perform a radical resection with safety margins. Even with all these adversities, the importance of disease‐free surgical margins is recommended in the treatment of HPC. Another prognostic factor is the histological degree of the lesion; mitotic rare is the most frequently cited pathological feature to distinguish benign or low‐grade tumors from the malignant or high‐grade ones. In comparison with the well and/or moderately differentiated HPC, the poorly differentiated presents with more than four mitoses per microscopic field, being an unfavorable prognostic factor for the patient's survival.Wushou et al. in his metanalysis of 116 head and neck's HPC cases mention, among the main findings, that surgery is the first treatment choice, resulting in a good prognosis, while the therapeutic results of surgery associated with adjuvant radiotherapy were not superior to surgery alone. For other authors, the decision to add radiotherapy to surgery can increase disease‐free survival and decrease the rate of recurrence, especially in cases of extensive and deep HPC in which complete resection was not possible, or which have poorly differentiated tumors, or the ones who were primarily operated with partial tumor resection or patients with compromised margins.Chemoradiotherapy as an exclusive treatment has limited efficacy and should be reserved as a palliative treatment for cases whose surgical resection presents a very high risk of death or in cases of advanced metastases.Tanigawa et al. described a case of SNHPC successfully treated with recombinant interleukin 2 (rIL‐2). It is believed that rIL‐2 attacks directly the tumor cells, as well as activates natural killer cells (NK cells), triggering anti‐tumor effects. In this case, after administration of rIL‐2, increased activity of NK cells and reduction of tumor size were also observed. Thus, a broad external approach  could be performed, after previous selective embolization of the tumor‐nourishing artery to obtain a good visualization and en‐bloc resection of the entire lesion, showing it to be an alternative for the treatment of SNHPC.The HPC located in the nasal region is often characterized by a benign nature, with a low tendency to metastasize. However, even in the context of a surgical resection of the tumor, whether through the endoscopic or open route, the SNHPC local recurrence rate remains high, around 26.7%, with an overall survival in 2 and 5 years of 93% and 86%, respectively.The HPC prognosis is still not predictable, neither by the clinical aspect, nor by histological findings. Local recurrence can occur after a prolonged disease‐free interval, with an average of 46 months after surgical resection, with cases reported in the literature that relapses 26 years after the initial surgery. Depending on the size of the SNHPC, its infiltrative nature and time of evolution, a new surgery is considered the standard treatment. Recurrence, when present after a primary resection, indicates a poor prognosis and often precedes the development of distant metastases, which in certain cases, may be the only way to find out about the malignant nature of SNHPC.Distant metastasis of head and neck HPC is infrequent, appears late and can, with some frequency, affect the brain, lung, mediastinum, chest wall, bones, abdomen and liver; a rare case of thyroid metastasis is reported in the literature.The SNHPC should be better assessed preoperatively as a tumor with malignant potential than a properly benign one, due to its possible capacity for more aggressive behavior and distant metastases. Thus, strict and frequent surveillance throughout the life of patients with HPC should be mandatory.3We report here a rare case of an extent sinonasal HPC of a female patient who, in addition to her limiting clinical conditions, had restrictions on blood components by religious belief. In order for the concept of bloodless surgery to be applied, a multidisciplinary effort was required, which included, in addition to all the strategies and techniques available to prevent blood transfusion, the inclusion and commitment of the entire team, from the preoperative evaluation of the patient to the day of her hospital discharge. In this case report, endoscopic tumor surgery linked to preoperative embolization proved to be an excellent treatment method for complete resection of SNHPC, providing us with conditions for better hemostasis, which is essential to avoid large bleedings and risk of blood transfusion, mainly in this select group of patients. This appears to be the first case report of SNHPC in a Jehovah's Witness patient as well as the first to discuss the challenges inherent in managing this situation.The authors declare no conflicts of interest.Francisco de Souza Amorim Filho: Conceptualization ; supervision ; writing – original draft ; writing – review and editing . Flávio Mignone Gripp: Supervision ; writing – review and editing . Guilherme Souza de Faria: Writing – original draft . Mateus Capuzzo Gonçalves: Writing – original draft . Lincoln Miyahira: Conceptualization ; supervision ; writing – original draft ; writing – review and editing .