Metastases to the dura and adjacent parenchyma occur in 1%-2% of patients with prostate cancer. Dural metastases manifest as subdural fluid collections and present as a chronic subdural hematoma. We present a patient with advanced prostate cancer who experienced a fall and a traumatic brain injury. Computer tomography (CT) of the brain revealed a bilateral subdural hematoma (SDH). During the follow-up examination, the patient’s mental status declined, and a follow-up brain CT showed an expansion of the SDH. Brain MRI with contrast demonstrated dural lesions suspicious for metastasis to the dura. Histopathologic examination of the lesions confirmed metastatic prostate adenocarcinoma.While uncommon, leptomeningeal-dural metastatic lesions stemming from prostate adenocarcinoma should be suspected in patients with known prostate cancer who present with subdural collections. This is even more significant if the patient with prostatic adenocarcinoma has sustained a recent head injury and presents with a subdural hematoma on neuroimaging. Brain MRI provides more data towards the differential diagnosis of these lesions and should be an essential part of the diagnostic workup. Biopsy and histopathologic examination of these lesions are indicated in the diagnostic workup of these uncommon lesions. Prostate adenocarcinoma is the most common cancer and the third most common cause of death due to cancer among males aged 80 years and older . GloballThe clinical course of prostate cancer is quite variable, ranging from low-grade and indolent lesions to high-grade, aggressive, and metastatic lesions at the time of diagnosis.The staging system is based on the extent of the primary tumor (T), involvement of the lymph node(s) (N), and the presence or absence of metastasis (M), along with the measurement of serum levels of prostate-specific antigen (PSA) and the histologic grade of the primary tumor .Prostate adenocarcinoma constitutes the most common type of prostate cancer and frequently metastasizes to the regional pelvic structures  and lymph nodes  and then to the bone, liver, and lungs. The bones of the axial skeleton are the predominant site of metastasis . MetastaA 65-year-old African American male presented to the emergency room with a worsening headache and fatigue. Past medical history was significant for diabetes mellitus and castration-resistant prostate cancer with metastasis to the cervical, thoracic, and lumbar spines. Prostate cancer was initially diagnosed at age 56 with a Gleason score of 9.0. The patient had completed radiation therapy and was receiving hormone-based chemotherapy. Three weeks earlier, the patient fell on the ground and sustained head trauma without loss of consciousness. Computer tomography (CT) of the brain without contrast revealed a bilateral subdural hematoma (SDH), and the patient was discharged with no further therapeutic interventions. Figure During the next three weeks, the patient’s neurologic status deteriorated with worsening headaches, confusion, and overwhelming fatigue. An MRI of the brain revealed expansion of the bilateral SDH, causing a midline shift, and the presence of hyperintense lesions in the subarachnoid space on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences. Brain MRI sequences are presented in Figure During the last presentation, laboratory workup revealed a serum PSA level of 3700 ng/mL (range of 0-4 ng/mL) and an alkaline phosphatase level of 450 U/L (range of 42-121 U/L). A craniotomy was performed, and right-sided subdural hemorrhage and collections were partially evacuated. (Figure Further examination of the tissue demonstrated positivity for CAM, 5.2, OSCAR, PSA, AMACR, and NKX1A and negativity for cytokeratin, AE1/AE3, CK7, CK20, GFAP, TTF-1, napsin, and CDX2. Histopathologic slides are presented in Figure Dural metastasis of the prostate adenocarcinoma is rare and may mimic acute or chronic SDH. Direct hematogenous spread, extension from bony skull metastases to the leptomeninges, and, in rare cases, dissemination from cerebral metastases are the mechanisms of metastatic spread. Clinically, patients present with non-specific symptoms such as headache and/or altered mental status . In addiHemorrhage within the subdural space may stem from a rupture of the vasculature within the metastatic lesions, mechanical obstruction of the dural veins, or hemorrhage from metastatic lesions. Most commonly, a subdural hematoma is diagnosed based on a head CT without contrast. In our patient, with a history of falls and head trauma, the presence of dural metastases was suspected on brain MRI and later confirmed following surgical resection and histopathologic examination of the resected tissue. Brain MRI with gadolinium infusion is a much more sensitive diagnostic tool for the diagnosis of dural lesions and provides significant data regarding the lesion's morphology, its dimensions and extent of growth, and its resectability . The advDural metastasis of prostate adenocarcinoma is rare and may mimic SDH. Brain CT is generally not helpful in the diagnosis of dural metastatic lesions, and brain MRI is far superior in showing dural metastasis in patients with advanced prostate adenocarcinoma, even with a history of falls and head trauma. Biopsy and histopathologic examination of the biopsied tissue play significant roles in the diagnostic workup. In addition, radiologically, expansion of the dural lesion on subsequent scans strongly indicates the presence of a metastatic lesion. Patients with advanced prostate adenocarcinoma and dural metastases generally have a poor prognosis.


Primary vitreoretinal lymphoma (PVRL) is an aggressive lymphoma that may present with protean features and represents a diagnostic challenge. Given that patients with PVRL are at high risk of CNS involvement with a high mortality and morbidity rate, prompt diagnosis is crucial to initiate treatment early in the disease course. A multimodality imaging approach including fundus photography, fundus autofluorescence (FAF), optical coherence tomography (OCT), fluorescein and indocyanine angiography, and electroretinography (ERG) can provide information to establish a diagnosis and provide objective measures for management. We review key findings seen via these imaging modalities in patients with PVRL.Fundus photography can highlight commonly seen patterns of PVRL including vitritis, subretinal disease, retinal pigment epithelial (RPE) abnormalities, optic nerve edema, retinal detachment, and less typical retinitis-like lesions. FAF can identify characteristic patterns of hyper- and hypoautofluorescent signal abnormalities in the macula. Spectral-domain OCT will demonstrate vitreous cells, RPE nodularity, and hyperreflectivity of the outer retina. The presence of a hyper-reflective band in the subretinal space and infiltrates between the RPE and Bruch’s membrane can assist in distinguishing PVRL from choroidal lymphoma. Vertical hyperreflective columns (VHRLs) are another pertinent finding that may represent microinfiltrates of the tumor. OCT has proven to be a particularly useful modality in assessing the progress of treatment in PVRL. Fluorescein angiography can show RPE changes, which include granularity, late staining at the RPE level, and blockage. Indocyanine green angiography (ICGA) primarily shows hypocyanescence, which corresponds to PVRL lesions on fundus photography and may occur secondary to loss of RPE and choriocapillaris.While PVRL remains a challenging disease to diagnose and follow, the use of a multimodality imaging approach may assist in establishing a diagnosis. Because of the anatomic spaces PVRL may affect, fundus photography, OCT, FAF, angiography, and ERG can identify key characteristics of the disease, differentiate PVRL from other diseases, and provide baseline information for targeted systemic and local therapies. Further assessment of anatomic and functional targets will aid our clinical application of multimodal imaging in the management of PVRL. Primary vitreoretinal lymphoma (PVRL), also known as primary intraocular lymphoma, is the most common intraocular lymphoma with approximately 380 incident cases in the United States annually . It is aPVRL is a well-known masquerade syndrome that may be challenging to diagnose . The meaClinical features of PVRL seen on fundus photography include vitreous haze or clumps, optic nerve edema, perivascular sheathing, sub-retinal pigment epithelium (RPE) lesions, cream-colored lesions, or serous retinal detachments . In an eIn addition to the typical findings of vitritis, subretinal lesions, and RPE change, fundus photography can also document atypical lesions. For example, PVRL and secondary vitreoretinal lymphoma (VRL) may rarely present with a retinitis-like picture –13. SuspA variety of fundus autofluorescence (FAF) patterns has been reported. During active PVRL, hyperautofluorescence of the sub-RPE lesions and alternating hyper- and hypoautofluorescence of the macula are the most commonly seen patterns , 14, 15.Importantly, a normal fundus autofluorescence does not rule out PVRL. In a report by Casady et al., seven of 18 eyes (39%) did not have any remarkable findings on FAF . Of thesOCT often demonstrates vitreous cells (100% of eyes), RPE nodularity 63%), and outer retinal hyperreflectivities (43%) , 18, 19 %, and ouBarry et al. describe specific findings that are highly suggestive of PVRL, including a confluent hyper-reflective band in the subretinal space and infiltrates localized between the RPE and Bruch’s membrane. These characteristics can help distinguish PVRL from choroidal lymphoma, which presents with infiltrates deep to Bruch’s .OCT is an excellent tool to monitor response to treatment in PVRL. There are multiple reports of hyperreflective subretinal lesions on OCT that likely represent lymphomatous infiltrate as they resolve or develop into subretinal fibrosis with treatment , 23–27. An OCT imaging finding termed “vertical hyperreflective columns” (VHRLs) was found in 58.3% of eyes with vitreoretinal lymphoma . Of noteAnterior segment OCT has been used to diagnose recurrence of PVRL in a previously vitrectomized patient . The patRPE changes from PVRL are highlighted on FA and are the most common finding. These changes include granularity, late staining at the RPE level, and blockage  Fig. 1BB1B. The PEDs in PVRL patients present with varying patterns on FA. Some demonstrate filling patterns typical for a serous PED: a discrete well-circumscribed area of fluorescence through the transit phase with pooling in the late phase. These findings are thought to result from injured or dead tumor cells with a resultant zone of hyperfluorescence or a serous PED with a sparse collection of tumor cells . PEDs maOne prior report described capillary dropout by FA in a patient with biopsy-proven PVRL . The FA Notably, more common evidence of active uveitis, including optic nerve staining/leakage, perivascular staining/leakage, and petaloid leakage of CME, are less prevalent in PVRL patients. Optic nerve leakage/staining was found in 4–45% of patients , 31. VasThe most commonly observed finding on indocyanine green angiography (ICGA) in PVRL is hypocyanescence. Hypocyanescent lesions were found in 77% of eyes in one study . AnotherOne case report of a patient with suspected PVRL demonstrated reduced cone and rod responses on full-field electroretinography (ERG) . The patPVRL can often mimic other ocular diseases, making diagnosis difficult and delayed. Identification of key findings on multimodality ophthalmic imaging modalities can help to identify pathologic lesions that raise the level of suspicion for PVRL, potentially triggering a definitive diagnostic procedure. Characteristic findings include vitritis and subretinal or sub-RPE lesions that may represent tumor infiltrates. Sub-RPE lesions can be hypo- or hyperautofluorescent and do not always correlate with disease activity. Granular fundus autofluorescent changes commonly present with a reversed pattern on FA.OCT can be used to assess disease activity. OCT can demonstrate a confluent hyper-reflective band in the subretinal space and infiltrates localized between the RPE and Bruch’s membrane. Active lesions can often present with outer retinal fuzzy borders, PED, and subretinal fluid, which resolve with treatment and may leave behind subretinal fibrosis, disruption of the outer retina, and retinal thinning.FA and ICGA also provide additional structural information about disease processes associated with PVRL. While FA findings including optic disc leakage, retinal vascular leakage or petaloid edema may be observed in other endogenous uveitis syndromes, their presence should not exclude the possibility of PVRL. Moreover, ICGA can help to distinguish PVRL from other uveitides with more characteristic ICGA findings.Given the advances in ultra-wide field imaging to document and follow lesions, complemented by OCT, fundus autofluorescence, and traditional angiography, multimodal imaging is a mainstay for the diagnosis and management of PVRL. There is a continued need for quantitative research using these methods, as well as functional assessments including ERG . Applyin


This case report presents the challenges of diagnosing such disorders.A G3P2A0 woman came at 32 weeks of pregnancy with a referral for foetal ovarian cyst. Ultrasound revealed a singleton breech pregnancy, estimated foetal weight 3528 g. A septate abdominal cyst measuring 11.31 × 7.17 cm and polyhydramnios were present. Elective caesarean section delivered a female baby weighing 2820 g and measuring 43 cm. Neonatal examination revealed a right lateral suprapubic mass and a rectovestibular fistula. A sinoscopy revealed a suspected hydrocolpos. An abdominal hydrocolpos drainage was performed; a patent urachus and normal bilateral adnexa were present.Hydrocolpos is a rare congenital disorder due to distal obstruction of various etiologies. It may be mistaken with other pathologies, including fetal ovarian cysts. A genitourinary congenital abnormality may occur in conjunction with other abnormalities, including gastrointestinal tract anomalies. The presence of imperforate anus and/or fistula should alert the clinician of a possible association with VACTERL syndrome.Hydrocolpos is a rare congenital genitourinary disorder with various differential diagnoses. Simultaneous presence of other abnormalities is likely, with possible association to other syndromes. •Hydrometrocolpos is a rare congenital disorder due to distal obstruction of various etiologies.•Genitourinary congenital abnormality may occur in conjunction with other abnormalities, including gastrointestinal tract anomalies.•The presence of imperforate anus and/or fistula may be associated with VACTERL syndrome. After 30 weeks of gestation, the most likely female abdominal anomaly is an ovarian cyst (with a high regression rate), but splenic cyst, gastrointestinal duplication, anorectal malformation, hydrometrocolpos, and liver cysts should be included in the differential diagnosis. This case report presents and discusses misdiagnosis of anorectal malformation and hydrocolpos as ovarian cyst.2https://www.researchregistry.com/register-now#home/registrationdetails/63007e3216a0ef0021cf2325/).This case is reported in line with the SCARE 2020 Guideline . This caA G3P2A0 woman came to the Maternal-Foetal Medicine Unit for prenatal screening at 32 weeks of gestation. Patient came with a referral diagnosis of a foetal ovarian cyst. An obstetric ultrasound was performed, with the result of singleton pregnancy, breech presentation with estimated fetal weight (EFW) of 3528 g. On foetal abdominal ultrasound examination , the stoOn the neonate's physical examination, a mass was found on the right lateral suprapubic area. On anogenital examination, a rectovestibular fistula was found .Fig. 2NeAfter physical examination, an abdominal ultrasound was performed and a pelvic cystic mass was found with debris and internal echo was found that connected to the vagina and uterus. Liver, gallbladder and spleen ultrasound within normal limits. The baby underwent a sinoscopy with intraoperative findings of suspected hydrocolpos. Since cervical hydrocolpos drainage could not be performed, an abdominal hydrocolpos drainage was performed. Intraabdominal findings were patent urachus, with bilateral adnexa within normal limits , Fig. 4.3Foetal ovarian cysts are the most common congenital abdominal anomalies with an estimated incidence of about 1 in 2600 pregnancies. After 30 weeks of gestation, the most likely diagnosis in females is an ovarian cyst (with a high regression rate). Antenatal diagnosis of FOCs has been increased by the widespread use of ultrasound screening, with the diagnosis usually being made at around 31–32 weeks' gestation. They are usually asymptomatic and rarely accompanied with malformations, but large cysts may present with complications. Spontaneous regression of FOCs has been reported [1.The presence of a cystic structure, usually located in one side of foetal abdomen2.Identification of normal genitourinary tract 3.Identification of a normal gastrointestinal tract 4.Female fetusAlthough the pathophysiology of ovarian cysts has not yet been fully elucidated, they are usually benign functional anomalies resulting from excessive stimulation of fetal ovaries by placental and maternal hormones. Ovarian cysts are common in pregnancies complicated by maternal diabetes, pre-eclampsia or rhesus isoimmunisation. They are frequently diagnosed during the third trimester, especially after 28 weeks of gestation [Differential diagnoses are very important and can be factored out by identifying the organ of origin, observing the anatomy and placement of the cyst. Gastrointestinal, renal, and genital anomalies are commonly misdiagnosed as ovarian cysts . When anOther differential diagnosis that are commonly associated with FOCs are urachal cyst, intestinal duplication abnormalities, hydrometrocolpos, liver cysts and mesenteric cysts . An inteIn this case, the patient was previously referred with the diagnosis of foetal ovarian cysts. Only after the physical examination was done with the findings of rectovestibular fistula, that another differential diagnosis other than FOC was finally evaluated. An abdominal ultrasound revealed a pelvic cystic mass with debris and internal echo that connected to the vagina and uterus. The neonate then underwent a sinoscopy with intraoperative findings of suspected hydrocolpos. Hemato/hydrocolpos is a condition in which menstrual blood or secretory fluid accumulates in the vagina due to vaginal obstruction caused by congenital urogenital anomalies or acquired vaginal occlusion due to infection, trauma, or sexual abuse. Hydrocolpos due to congenital urogenital anomalies are a rare condition which make diagnosis is often missed or delayed due to its rare incidence and nonspecific symptoms. Hydrometrocolpos occurs in the female fetus due to dilatation of the uterus and vagina as a result of mucus secretions in the genital tract. When only the vagina is distended, it is termed as hydrocolpos, but if there is associated uterine distension it is termed as hydrometrocolpos. After abdominal hydrocolpos drainage was performed in this case and an enlarged uterus with hydrocolpos was found, the diagnosis shifted into hydrometrocolpos.There is no data on fetal presentation of hydrometrocolpos due to the rarity of the disease and the difficulty in prenatal diagnosis. The prevalence of congenital dilatation of the uterus and vagina causing hydrometrocolpos is less than 1 per 30,000 births with the first report published in 1856 [Hydrocolpos may be caused by an imperforate hymen, a transverse vaginal membrane, vaginal atresia or cloacal malformation. In case of a cloacal malformation, there is a common channel for the urethra, vagina and anus. The obstruction of urinary, genital and intestinal secretions caused by these malformations blocks drainage, leading to dilatation of the proximal structures. The content of fluid accumulating may be clear (urine) or turbid with a fluid-debris level on sonography , vaginal atresia or duplication, hydronephrosis, renal agenesis, imperforate anus, polycystic kidneys, esophageal atresia and sacral hypoplasia .anal canal and rectum are important for prenatal counselling.Prenatally the presence of a fluid–debris level inside a pelvic cystic anechoic mass must be considered a crucial finding. Multiple internal echoes are due to thick mucoid cervical or vaginal secretions. This finding must alert the treating clinician to the possibility of the presence of a persistent urogenital sinus. Prenatal cystic dilatation of the vagina is often misdiagnosed as a distended bladder, as the bladder is displaced anteriorly by the vagina making it difficult to identify. Prenatal ultrasound therefore has a definitive role in detecting an obstructed genital tract, allowing rapid postnatal treatment to drain the vagina and relieve the urinary tract obstruction . HydrocoIf early diagnosis and treatment are done early, the long-term outcomes generally yield a good result. But, without early and proper treatment, late complications such as tubal infection, adhesion, pelvic endometriosis, infertility, and renal failure secondary to hydronephrosis can develop. Ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) used to evaluate patients with hydrocolpos. MRI is preferred because of its high-resolution, soft tissue contrast, and provides useful information for the differential diagnosis of obstructive causes and management decisions. Surgical treatment is necessary for patients with hydrocolpos due to congenital vaginal obstruction. Although drainage of accumulated blood or secretions in the vagina should be done, long-term effect of transvaginal drainage must be considered because it may increase the risk of retrograde infection .When physical examination of this case was performed, a mass was found on the right lateral suprapubic area. On anogenital examination, a rectovestibular fistula with an imperforate anus was found. Anomalies of the anus and rectum have usually been explained as caused by the caudal descent of the urorectal septum toward the cloacal membrane between 4 and 8 weeks of gestation. At 4–6 weeks the cloacal membrane becomes partitioned into the anterior urogenital sinus and the posterior anorectum by the cranial to caudal growth of mesoderm-derived urorectal septum. The mesoderm-derived urorectal septum is composed of the midline Tournex fold and two lateral Rathke folds. The lower third of the anal canal is derived from the ectoderm of the anal pit. Failure of Rathke folds to develop results in arrest of the inferior urorectal septum, resulting in a persistent cloaca in the female. This arrest in Rathke folds usually occurs just below the paramesonephric duct, but a more caudal arrest in Rathke folds could result in a high rectovaginal fistula in a female. In the female it is more likely to result in a cloacal anomaly or duplicated vagina and uterus. The malalignment of Tourneaux and Rathke folds may also result in vestibular fistula in females. Despite normal descent of Tourneaux and Rathke folds, the lack of an ectodermal anal pit results in imperforate anus. Failure of the anal membrane to resorb or incomplete resorption despite formation of the anal pit results in rectal atresia or stenosis, respectively [Imperforate anus is a common congenital anomaly with an incidence of 1:1,500 to 1:5,000 in neonates. It may either be a solitary anomaly without any malformation or, in many cases, be associated with multiple congenital anomaly subsets, such as VACTERL association or trisomy 21. Imperforate anus, with other serious anomalies, can lead to significant morbidity and mortality .Although imperforate anus is a relatively common malformation, it cannot be accurately diagnosed prenatally. Imperforate anus can occur as a solitary abnormality but is likely to have accompanying malformations. Hence, when a foetal imperforate anus is suspected, referral to a tertiary center that can provide accurate diagnosis and adequate management is necessary. Several factors, including the presence of an anocutaneous or anovestibular fistula and well developed anal sphincters, which can be visualized as an image similar to the normal anal sphincter and canal mucosa, may account for difficulties in diagnosing certain cases of imperforate anus. Conversely, even if one malformation associated with vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities (VACTERL) association is detected prenatally, more detailed ultrasonography examinations should be performed regarding the presence of imperforate anus.There are three types of imperforate anus according to the distal rectal pouch and the puborectalis muscle : the higEven without considering other accompanying anomalies (except imperforate anus), the exact anatomical type of atresia and the existence of a fistula should be carefully examined. This is important because it determines the appropriate timing for corrective surgery as well as the surgical stages. Urgent reconstructive anorectal surgery is not necessary; however, immediate evaluation is important, and urgent decompressive surgery may be necessary. If a diagnosis is suspected prenatally, it is essential for the surgeon to provide appropriate guidance to the pregnant woman and to make a delivery plan to prepare for the possibility of neonatal operation. Thus, detecting the presence of an imperforate anus via prenatal ultrasonography is important for obstetricians, pediatric surgeons, and pregnant women to plan for an early treatment .4Hydrometrocolpos is a rare congenital disorder due to distal obstruction of various etiologies. It may be mistaken with other pathologies, including fetal ovarian cysts. A genitourinary congenital abnormality may occur in conjunction with other abnormalities, including gastrointestinal tract anomalies. The presence of imperforate anus and/or fistula should alert the clinician of a possible association with VACTERL syndrome.The following information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated.The institutional review board has determined that our study is exempt from ethical approval as it is a review.The authors declared that we did not receive any external funding for our study.All authors were responsible for the conception and design of the study. FZ, CRZB, and NK collected patient data. MAA, TS, NLA, and KDT drafted the manuscript. All authors reviewed and approved this final version for publication.researchregistry.com is researchregistry8219.The study's registration on https://www.researchregistry.com/register-now#home/registrationdetails/63007e3216a0ef0021cf2325/).(Muhammad Alamsyah Aziz as the first author is the guarantor of this study.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.The authors declare that we do not have any conflicts of interests.


Inflammatory fibroid polyp (IFP) or Vanek's tumor is a rare and idiopathic pseudotumor arising from the submucosa of the gastrointestinal tract. The underlying cause of IFP remains unclear. Many factors have been incriminated such as intestinal trauma or eosinophilic gastroenteritis. Small bowel involvement is the second most common location of IFP after the stomach. Intestinal IFP is most often revealed by intussusception or obstruction. The mainstay treatment is surgical, which consisted of a segmental intestinal resection. The histological appearance may be a differential diagnosis with other spindle cell lesions, especially with stromal tumors. The definitive diagnosis is confirmed by immunochemistry examination. Herein, we report the clinical case of a 62-year-old female, with no notable medical history, who presented with nausea and vomiting associated with abdominal acute pain and distension evolving for about seven days. The physical examination showed a heart rate of 90 beats per minute, blood pressure of 120/70 mmHg, and body temperature of 37.5°C. The abdominal examination revealed a slightly tympanic abdomen with diffuse tenderness. Computed tomography (CT) scan of the abdomen revealed dilated small bowel loops proximally of an ileo-ileal intussusception. The wall of the invaginated loop shows an irregular, symmetrical, and short parietal thickening, enhanced after contrast and measuring 36 x 24 mm. The patient underwent an urgent midline laparotomy. Surgical exploration revealed an ileo-ileal intussusception, localized at 70 cm proximal to the ileocecal valve and causing dilatation in the intestine proximal to the intussusception. Manual disinvagination revealed intraluminal polypoid mass (star) obstructing the lumen with parietal umbilication. Segmental resection of the intussuscepted ileum and side-to-side stapler ileal anastomosis were performed. The patient had an uneventful recovery. Histological findings showed bland spindled cells, small vessels, and eosinophil-rich mixed inflammatory infiltrates. Immunohistochemical staining was positive for CD34 and negative for CD 117, DOG1 and S-100 protein. Therefore, a final diagnosis of an inflammatory fibroid polyp was made.


Peripheral osteoma is a benign neoplasm, with low recurrence rate. Its incidence is rare in the jaws and the mandible is more affected than the maxilla. In most cases it is discovered during routine radiographic examinations.The aim of this study is to show the author's experience regarding the treatment of this neoplasm.A retrospective study from January 2002 to December 2007 including ten cases of peipheral osteoma in the maxillofacial region which were treated surgically by removal of the lesion followed by histological confirmation. None of the cases were correlated with Gardner's syndrome.In this series the incidence of this neoplasm was higher in females (1.5:1) with a mean age of 39, without age preference. One of the patients had lesion recurrence two years after the first surgery, having been submitted to another intervention, with no signs of relapse after three years and six months of follow-up.Surgical treatment is effective for peripheral osteoma with a low recurrence rate. Some authors consider it a true neoplasia, while others consider it a hamartoma,,These lesions are usually small and asymptomatic, usually spotted as radiographic findings, or upon tissue expansion, causing facial asymmetry or functional disorder,,Multiple maxilla osteomas associated to other disorders are characteristics found in the Gardner Syndrome,,,,Peripheral osteomas of the craniofacial region happen more frequently in the paranasal sinuses. Other locations include the external auditory canal, the orbit, the temporal bone and the pterygoid processesThe traditional radiographic image is usually enough to diagnose an osteoma. It is presented as a radiopaque mass with density similar to that of a normal bone. The panoramic x-ray, that of Waters or CT scan usually shows the location and the benign nature of the lesion,Histologically, osteomas have two distinct variants. One is made up of relatively dense compact bone with scarce medullary tissue, while the other has lamellar or cancellous bone trabeculae with abundant medullary spaces of fibrous-adipose tissue. Osteoblastic activity is usually prominent,,Osteoma treatment is based on complete surgical removal, on the base, where the bone cortical is located. There are no reports of osteoma malignant transformation,Osteomas are believed to be relatively uncommonThe goal of the present study was to carry out a retrospective investigation of single peripheral osteomas located in the maxillofacial region, treated in our institution.From January of 2002 through December of 2007, 10 patients with peripheral osteomas were operated in the Maxillofacial surgery ward of the Surgery Department of the Medical Sciences School of the Santa Casa de São Paulo. Upon reviewing the charts, the following items were assessed: gender, age, location, symptoms, functional involvement, aesthetic involvement and recurrence.Inclusion criteria were: peripheral osteomas of the maxillofacial region with clinical, image and histopathology diagnosis, with full charts and followed for a minimum period of 12 months.Exclusion criteria were: peripheral osteomas associated with Gardner's syndrome.The study was approved by the Ethics in Research Committee of the Irmandade da Santa Casa de Misericórdia de São Paulo, under protocol # 295/08, approved on August 28, 2008.We assessed the charts from ten patients, six women, with a female/male ratio of 1.5:1. Age varied between 11 and 61 years, with a mean value of 39 years, without predilection for any age range. They all had a past of facial trauma and the time of follow up varied between one and six years.All the patients were submitted to excisional biopsy. In one case, it was necessary to rebuild the temporomandibular joint with costochondral graft.There was one recurrence two years after the surgery . A new sThe three cases located in the condyle caused facial asymmetry, dental malocclusion and consequent functional deficit .Figure 4The results from this study are in agreement with the opinion given by Ogbureke et al.According to Bosshardt et al.,,We agree with the literature in that, when peripheral osteomas affect gnathic bones, they are more frequent in the mandible than in the maxilla. However, just like Bodner et al.Cutilli & QuinnAccording to Bodner et al.According to Bosshardt et al.In image exams, they are usually described as an oval or round mass, limited to a large base. One large single osteoma may look like a parosteal osteogenic sarcomaThe CT scan is the best image exam for the diagnosis of peripheral osteomasSurgery is the treatment of choice; intra or extraoral approaches can be used for the mandible. Intraoral approach is always preferable whenever possible, because it prevents damages to the facial nerve. However, we agree with Longo et al.In those cases involving the mandible, despite the immediate improvement in the post-op and an almost normal mouth opening, the patient will require long term follow up and physical therapy for the masticatory muscles,,Recurrence after osteoma surgery is rarePeripheral osteoma is a rare neoplasia in the maxillofacial region and it more frequently involves the mandible, where the condyle is the preferred site. Females have a higher incidence when compared to males, with no predilection for any specific age range.Although conventional x-rays provide sufficient information for the diagnosis, today the CT scan is the exam of choice for surgical planning purposes. Surgery with complete lesion removal is the most adequate treatment, with low recurrence rates.


Parsonage-Turner syndrome (PTS) is a rare disease process in which one develops acute-onset shoulder pain, followed by progressive weakness of the upper arm and shoulder girdle musculature. PTS is difficult to diagnose as it mimics similar presenting pathologies, most commonly, cervical radiculopathy (CR). Clinical presentation and diagnostic tests are particularly important to identify this rare syndrome, as the treatment for similar conditions may be more invasive. We present an interesting case of a 32-year-old female with severe unilateral shoulder pain, followed by weakness of her upper extremity musculature. The etiology of her symptoms cannot be concluded for certain; however, the aim of this case report is to increase awareness of this rare but potentially debilitating syndrome while also educating providers on the importance of differentiating PTS from the more commonly diagnosed CR. Parsonage-Turner syndrome (PTS) was reported as a distinct diagnosis in 1948 when Parsonage and Turner described 136 cases of patients with sudden-onset shoulder pain, followed by flaccid paralysis of the shoulder girdle as the pain resolved . Most caA 32-year-old female presented to an outpatient spine center with right upper extremity (RUE) weakness. Past medical history was notable for Tourette’s syndrome, attention-deficit/hyperactivity disorder, and anxiety. She had severe neck and shoulder pain that had begun one month prior, lasted one to two weeks, and ultimately resolved following a course of oral steroids. This painful phase was immediately followed by persistent right arm and shoulder weakness that worsened as the day progressed. There were no reported inciting or traumatic events other than a possible viral infection in the month leading up to her symptoms. Review of systems was notable for weakness, numbness, and tingling of the right shoulder and right thumb. She denied any recent fevers, chills, night sweats, falls, or episodes of incontinence. A physical exam showed a pleasant young female in no acute distress. There was no tenderness to palpation over the paraspinal musculature or spinous processes on musculoskeletal examination. The right shoulder had a full range of motion, and provocative tests specific for shoulder pathology were unremarkable. Neurological exam revealed normal reflexes, intact gait, and a negative Spurling’s and Tinel’s test. Utilizing the Medical Research Council (MRC) grading system, her RUE strength was noted to be a 4+/5 with shoulder abduction, 3/5 with elbow flexion, 4/5 with internal and external rotation, and 4/5 with supination. Cervical spine radiographs demonstrated straightening of the normal cervical lordotic curvature, multilevel degenerative changes with prominent anterior spurring, and notable foraminal narrowing at C3-C4 and C4-C5 Figure . T2-weighted magnetic resonance imaging (MRI) of the cervical spine demonstrated a moderate diffuse disc bulge, mild central canal stenosis, and moderate to severe bilateral neural foraminal narrowing at C4-C5 Figures .The initial plan was to hold off on any spinal injections given that the patient's symptoms consisted only of a painless weakness. There was also the additional high risk of iatrogenic injury secondary to her Tourette’s syndrome. Electrodiagnostic studies (EDx) and a prescription for physical therapy were ordered. EMG results demonstrated severe chronic active right C5 radiculopathy. There was abnormal spontaneous activity seen in all C5-C6 innervated muscles tested, which included the deltoid, biceps brachii, and brachioradialis. Nerve conduction studies (NCS) were normal, which included the lateral antebrachial cutaneous nerve (LAC). After two months of physical therapy, she continued to have persistent RUE weakness and underwent repeat imaging which again demonstrated severe bilateral foraminal stenosis from C4-C6, worse at C4-C5. Cervical radiculopathy (CR) and PTS were the two leading diagnoses at this time; however, CR was ultimately deemed the official diagnosis given the EMG findings consistent with a C5 radiculopathy and MRI findings notable for severe right C4-C5 foraminal stenosis. After discussions with neurosurgery, the patient underwent a total disc replacement (TDR) at C4-C5 to try and relieve her symptoms. Follow-up visit one month post-TDR revealed unchanged RUE weakness. The physical exam at this visit revealed an MRC grade of 4-/5 throughout the RUE muscle groups, which was similar to her pre-surgical strength exam. She was instructed to continue physical therapy and follow-up in two months with neurosurgery.PTS and CR are similar presenting pathologies; however, the latter is more commonly diagnosed. Both conditions are characterized by unilateral neck, shoulder, and upper extremity pain, often with associated sensory abnormalities and weakness. Furthermore, both conditions commonly occur without antecedent trauma. PTS tends to present as a more acute process compared to the more insidious onset of CR, although it is not uncommon to see an acute onset of CR . The timThis case illustrates a patient who presented to an outpatient clinic with a clinical picture indicative of PTS; however, the MRI and EDx were consistent with CR. It can be difficult for a provider to conclude a diagnosis of CR or PTS when faced with mixed history and imaging results. In cases where the diagnosis may not be certain, examination of select muscle groups and specific diagnostic testing can be of utmost importance. A study by Scalf et al. concluded that MRI is sensitive for detecting signal abnormalities in the affected muscles of PTS, specifically intramuscular denervation changes including edema and atrophy . This stEDS can also be an important extension of the physical exam to further narrow in on the correct diagnosis. Muscles and nerves that are not commonly tested with EDS, specifically the supraspinatus and infraspinatus muscles, and the lateral antebrachial cutaneous nerve (LAC), can help differentiate the two conditions. The suprascapular, long thoracic, and axillary nerves have been documented in the literature to be the most affected peripheral nerves in PTS ,9. The LThe difference in treatment of PTS and CR ranges from conservative to surgical options. Conservative options for treating PTS include a combination of pain management and rehabilitation. Interestingly, a small study by the Korean Orthopedic Association proposed that steroids can improve recovery time and faster return to daily life when used specifically in the weakness phase . A studyThe treatment of CR is comparable to PTS in that many patients can improve with conservative measures, specifically physical therapy. Despite success with conservative management, many patients continue to be burdened by prolonged symptoms. Worsened or continued symptoms following conservative measures may prompt patients to seek more invasive management including an epidural steroid injection or even surgical intervention. The most common surgical intervention for CR is an anterior cervical diskectomy and fusion (ACDF). According to a study by Epstein, this procedure does have morbidity rates ranging from 13.2% to 19.3% [This case report highlights the importance of obtaining a detailed history, performing a comprehensive strength examination, and ordering proper electrodiagnostic testing when faced with the similar presenting pathologies of PTS and CR. Being able to differentiate between these two conditions may limit unwarranted surgical procedures, surgical complications, and healthcare costs. PTS should always remain on the differential in patients who present with unilateral shoulder pain and weakness.


Diverticulosis of the appendix is an uncommon clinical entity, and a preoperative diagnosis is often difficult. Herein we report an unusual case of appendiceal diverticulosis.A 72-year-old male was referred to our hospital to examine the cause of hematochezia. A colonoscopy study showed a protruding lesion resembling a submucosal tumor (SMT), approximately 20 mm in diameter, at the site around the appendiceal orifice of the cecum. An abdominal computed tomography and magnetic resonance imaging showed a cystic lesion at the appendiceal base. The lesion was clinically diagnosed as a cystic tumor of the appendix, but the possibility of a malignant tumor could not be excluded. Therefore, a laparoscopic ileocecal resection with lymph node dissection was performed. The pathological examination of the resected specimen revealed that the lesion was a diverticulum (pseudodiverticulum) occurring solitarily at the appendiceal base, in which the mucosal layer of the appendix was invaginated into the submucosa of the adjacent cecum, thus forming an SMT-like lesion.To our knowledge, this is the first case report in the English literature showing that an appendiceal diverticulum can manifest as an SMT-like lesion in the cecum. This condition should be recognized as a differential diagnosis for such lesions. Diverticulosis of the appendix (DA) is an uncommon clinical entity, and it can present with symptoms similar to appendicitis. It is usually diagnosed after an appendectomy due to the difficulty in visualizing DA on imaging , 2. WhilA 72-year-old male was referred to our hospital because a fecal occult blood test was positive at the routine health check-up. His past medical history included a gastrectomy due to gastric ulcers at the age of 26 years, and a colonic polypectomy at the age of 66 years. His body height and weight were 163 cm and 67 kg, respectively. He presented with no symptoms of abdominal pain, vomiting or nausea. His abdomen was flat, soft and had no tenderness. His blood pressure, pulse rate and body temperature were 136/72 mmHg, 68 beats/min and 36.4 °C, respectively. Laboratory profiles including a complete blood count, and biochemical parameters, including the C-reactive protein level and tumor markers such as CEA and CA19-9 were all within normal limits.During the colonoscopy, a benign polyp was observed at the transverse colon, and it was endoscopically resected. And no diverticulum was observed on the entire colon. In addition, an SMT-like lesion, approximately 20 mm in diameter, with a smooth mucosal surface and a positive cushion sign was found in the cecum Fig. a. The leAn enhanced abdominal computed tomography (CT) revealed a cystic lesion at the appendiceal base, and it occluded the cecal wall from the outside Fig. a. The apThe resected specimen grossly showed an SMT-like lesion, 20 × 20 mm in size, protruding out of the cecum at the site around the appendiceal orifice Fig. c. The cyHistologically, the muscularis propria of the appendix was disrupted at the origin of the cyst wall, which was more clearly observed in the sections of tissues that were immunostained for alpha-smooth muscle actin Fig. c–f. The DA is an uncommon clinical entity, and the incidence of DA found in appendectomy specimens ranges from 0.004 to 2.1% , 6. DiveDA has been classified into 4 distinct subtypes by Phillips et al. . Type 1 The challenge in diagnosis of DA preoperatively is mainly due to the difficulty in visualizing the DA on imaging , 2. TherAlthough an acquired diverticulum is usually small in size (2–5 mm), this case exhibited a large cystic lesion  . It has , we could not exclude the possibility of malignant tumor, especially mucinous neoplasm. Appendiceal mucinous neoplasms include mucinous adenocarcinoma (MAC) and LAMN according to the World Health Organization classification of tumours [As for this case, although there were few findings to doubt malignancy tumours . We doub tumours . In othe tumours .A rare case of DA with unusual endoscopic and pathologic futures was reported. Based on its characteristic appearance during colonoscopy, the lesion was first suspected to be SMT of the cecum. To our knowledge, this is the first case report in the English literature showing that DA can manifest as an SMT-like lesion in the cecum. This condition should be recognized as a differential diagnosis for such lesions.


Hepatopancreaticoduodenectomy (HPD) is one of the most complex procedures, and it is very rarely reported. Laparoscopic HPD (LHPD) is even rarer. To date, there are only 3 reports of LHPD for locally advanced gallbladder cancer (GBC) or extrahepatic cholangiocarcinoma (ECC). This is the first report of LHPD for synchronous GBC and ECC.A 75-year-old female patient complained of jaundice for 2 weeks without fever or abdominal pain. She was diagnosed with synchronous GBC and ECC. After a comprehensive preparation, she underwent a laparoscopic pancreaticoduodenectomy and resection of hepatic segments of IVb and V, and her digestive tract reconstruction followed Child’s methods. She was discharged on the 12th day postoperatively without pancreatic leakage, biliary leakage, or liver failure.LHPD is safe and feasible for selected cases of GBCs or ECCs. Hepatopancreaticoduodenectomy (HPD) is one of the most complicated operations which includes hepatectomy and pancreaticoduodenectomy. This operation was first reported in 1974 by Kasumi for locally advanced gallbladder cancer (GBC) , 3 for tA 75-year-old female patient complained of jaundice without fever or abdominal pain for 2 weeks and was diagnosed with ECC with GBC by enhanced CT and MRI. She denied any history of cardiovascular or pulmonary system problems. Her physical examination was negative except for jaundice of her skin and sclera. Her routine laboratory tests were as follows: hemoglobin 108 g/L, total bilirubin 222.8 μmol/L, direct bilirubin 158 μmol/L, plasma albumin 35.2 g/L, ALT 297 U/L, AST 192 U/L, ALP 403 U/L, and γGGT 394 U/L. Her tumor markers were normal, except for a mildly elevated Ca19-9 of 34.06 U/ml. Her hemostatic function was normal. An enhanced CT and MRI revealed that there was irregular thickening of the common bile duct wall and the gallbladder . Her recovery was smooth without pancreatic leakage, biliary leakage, or liver failure. She was discharged on the 12th day postoperatively. The pathology revealed synchronous adenosquamous carcinoma of the gallbladder and common bile duct. This pathological result was finally given after a comprehensive discussion. The diagnosis of adenosquamous carcinoma was based on immunohistochemistry which showed both squamous cell carcinoma and adenocarcinoma. The diagnosis of dual original carcinoma instead of GBC with seeding metastasis to a common biliary duct was based on the fact of extensive lesion of the lower biliary duct without a clear boundary.The indications for hepatopancreatoduonectomy (HPD) are locally advanced gallbladder cancer (GBC) and locally advanced extrahepatic cholangiocarcinoma (ECC) . HPD is As laparoscopic techniques have progressed, more and more complicated operations are completed by laparoscopy , 14 withAccording to the published cases and our experience, LHPD is safe and feasible by specially skilled surgeons. LHPD should be an option for selected patients with GBC or ECC.


The patient underwent a radicalization surgery and reconstruction with microsurgical great dorsal and anterior serratus flap. To our knowledge, this is the biggest inguinal melanoma treated with surgical excision described so far.A 53-year-old woman came to our attention with a giant inguinal mass that was growing in the last 5 months, so she underwent a total body CT-scan that showed a 25 × 16 × 21cm mass of the right inguinal region which was compressing the femoral vessels and infiltrated the omolateral rectum muscle, pulmonary embolism and thrombosis of the right femoral vein. We performed a tru-cut biopsy that was consistent with an undifferentiated round-cell sarcoma. So, we performed a wide excision of the mass and a reconstruction with a pedunculated muscular flap of the tensor muscle of the fasciae late, a graft of omologous fasciae late and a graft of the great saphena vein onto the superficial femoral artery. The histological examination of the specimen demonstrated instead an “ •Giant primary melanoma is generally accepted as greater than 10 cm, and almost associated with extensive metastatic disease.•It is important the patients don't present with such a clinical challenge, the surgery could impact the quality of life.•Patients with growing mass must be referred quickly to a diagnosis to obtain a less extent of surgical intervention. It is important to reduce the number of patients that present themselves with such a clinical challenge, because the extent of the surgical demolition could impact the quality of life, since in some cases it could lead to even limb or organ amputation. In our case, the mass was spreading to the exterior genital organs and we had to perform a wide excision over the vulvar labia majora. This case report has been reported in line with the SCARE criteria [2A 53 years-old female, after an accidental fall, was visited at the emergency department, where it was discovered a mass that the patient described as a neoformation that had been growing in the previous 5 months A. She unThe histological examination of the specimen demonstrated not a sarcoma, but a rare case of an atypical amelanotic sarcomatoid malignant melanoma with rabdoid aspects A–D, withAt this moment we planned to perform the radicalization surgery and subsequently the closing of the defects in the same operating session. Therefore, the patient underwent a radicalization surgery and a surgical reconstruction  with a m3To our knowledge, this is the biggest melanoma treated with surgical excision described so far. The adjective “giant” referred to melanoma is generally accepted as “greater than 10cm”, and in our case the mass was a very large one. It is important to reduce the number of patients that present themselves with such a clinical challenge, because the extent of the surgical demolition could impact the quality of life, since in some cases it could lead to even limb or organ amputation. In our case, the mass was spreading to the exterior genital organs and we had to perform a wide excision over the vulvar labia majora.The largeness of the mass impairs not only the demolition, but also the reconstruction of the defect. Using a dermal substitute, we could obtain two different advantages: on one hand, in a more reconstructive setting, we could partly reduce the greatness of the defect, since it has been demonstrated that dermal substitute has an impact on the process of scar tissue forming. On the other hand, in a more oncological aspect, we could delay the defect closure while waiting for the histological analysis of the specimen, since it is important to spare skin that can be used for a definitive closure after a radicalization, if it is already predicted that a wide excision has to be performed.4In conclusion, patients with growing mass must be referred to a medical examination to arrive at a diagnosis while the mass itself is more manageable in terms of both demolition and reconstruction to obtain a less extent of surgical intervention, not only in an oncological setting, but also to maintain a higher quality of life. Since these interventions have a higher risk of complication and pitfalls, it is mandatory to discuss these unique cases in a multidisciplinary approach.This case report is exempt from ethical approval.This research received funds to “Ricerca Corrente 2022” to cover publication costs.MR, CDP wrote the report; PDF prepared the figures and re-viewed the report. PDF provided the pathology images and interpretation. VV, FB and MS supervised as the attending physicians in the care of this patient, and approved the final version of the report.Not applicable.Dr.Marco Rastrelli.Written informed consent was obtained from the patient for publication of this report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


Lymphangioma is a rare diagnosis in adult patients and typically presents in early infancy. These tumors are a result of malformation of the lymphatic vessels and usually involve the head, neck, and axilla.We report the case of a 28-year-old African female who recently immigrated from East Africa and presented to our surgical breast clinic with a large and rapidly growing left axillary mass. Initial history and evaluation were concerning for hydatid cyst; however, on surgical excision, gross appearance was consistent with cystic lymphangioma. Diagnosis was confirmed on pathology review.Although lymphangiomas are typically found in young children, adults may develop these tumors in response to unknown triggers. Surgical excision is the preferred treatment. Lymphangiomas are uncommon benign congenital malformations of the lymphatic system that typically present in childhood. Of lymphangiomas, 50% are present at birth, with 90% of lymphangiomas presenting by 2 years of age . These tEchinococcus granulosus occur worldwide, with prevalence of up to 10% in hyperendemic areas of East Africa [Meanwhile, hydatidosis and infections with t Africa , 9. HydaA 28-year-old African female with history of three prior pregnancies with full-term deliveries and recent immigration from East Africa presented with a large, tender left axillary mass. The patient noted the initial appearance of the mass 3 years prior, at which time, the mass was small and nontender. The initial appearance of the mass was 6 months after having an etonogestrel implant device placed within the left arm for contraception, 8 months after her most recent pregnancy and delivery, and 2 years after immigrating to the USA from East Africa. The mass continued to grow slowly for 2.5 years without any pain, drainage, overlying skin changes, or changes in sensation or strength of the left arm. The patient did not experience any difficulty with breastfeeding. Six months prior to presentation, the patient noticed rapid growth and increasing tenderness of the axillary mass that prevented full arm adduction. The patient reported having her etonogestrel implant device removed and replaced 2 months prior to the onset of rapid growth. She denied any breast tenderness, abnormal discharge, or arm weakness. The patient also denied any preceding trauma or infection in the area. The patient had no other significant past medical history or family history, and no recent environmental or employment-related exposures. Social history was significant only for immigration from East Africa 5 years prior to presentation. The patient had no alcohol, tobacco, or illicit substance use and took no regular medications other than the etonogestrel implant device. On initial presentation to our clinic, physical examination demonstrated a protruding, nonreducible, mobile, softball-sized mass in the left axillary fossa with overlying skin striations. The patient did not have any cervical or clavicular lymphadenopathy. She had no vascular or neurological deficits of the left arm, and both sensory and motor function were intact. Due to the size of the mass, the patient was unable to fully adduct the left arm and had mild discomfort with adduction. Vital signs, physical examination, and neurological examination were otherwise unremarkable.3 multiloculated subcutaneous cystic lesion in the left axilla. There was displacement but no invasion of surrounding structures, no intrathoracic communication, and no axillary lymphadenopathy. Based on this imaging, lymphangioma was suspected, but hydatid cyst could not be ruled out given the patient’s history of immigration from an endemic location. To further classify the lymphatic and vascular involvement of the mass, MR lymphangiogram was obtained by injecting contrast media subcutaneously into each interdigital web space of the left hand.Prior to presentation to our clinic, the patient had undergone magnetic resonance imaging (MRI) with and without contrast, which demonstrated a 16 × 11 × 11 cmEchinococcus was considered but deferred since the diagnosis was not confirmed.Lymphangiogram showed no evidence of active lymphatic communication with the mass. Lymphatics in the left upper extremity drained to nodes overlying the large cystic mass Fig. . AdditioAfter review of the images and laboratory results, treatment options including percutaneous drainage and surgical excision were discussed with the patient. Given the large size of the mass with presence of overlying stretched skin, surgical excision was recommended. The patient consented and underwent complete surgical excision of the mass along with the overlying skin. Given the possibility that the mass was a hydatid cyst, the surgical field was prepared with sterile 20% hypertonic saline-soaked gauze as a protoscolicidal agent, as reentry of immature tapeworms into the patient would cause anaphylaxis. Intraoperatively the mass was found to be translucent with very thin walls, and drainage demonstrated typical yellow cystic fluid. The appearance of the cyst and fluid on direct visualization ruled out hydatid cyst, which would appear with thicker, opaque white walls. Therefore, cultures of the cystic fluid were not sent. After excision of the mass there was a large pocket within the axillary tissue, and a Jackson–Pratt drain was placed to prevent seroma development . Blood cultures collected at this time were negative. Based on drain culture susceptibilities, the patient was started on standard dosing of oral amoxicillin/clavulanate and ciprofloxacin, with rapid resolution of infection. The drain was subsequently removed. At 6 month follow-up, the patient does not have any re-accumulation of fluid or signs of infection.Approximately 1 month after surgery, the patient developed a surgical-site infection, which presented as a change in the quality of the JP drain output from serous to purulent. Drain fluid cultures were collected with resulting growth of Adult presentation of lymphangioma is extremely rare. Therefore, in our patient who had recently immigrated from a hyperendemic area of East Africa, an echinococcal hydatid cyst was high on the differential for this rapidly growing axillary cystic mass. While literature reports of adult-onset lymphangioma are already limited, this case is additionally unique as the surgical team had to prepare for a potentially life-threatening intraoperative anaphylactic reaction if direct visualization confirmed the mass to be a hydatid cyst rather than a benign lymphangioma.Echinococcus IgG antibody testing. MRI demonstrated a large multiloculated cyst in the left axilla with low T1 and high T2 intensity, an appearance most consistent with lymphangioma. Imaging was not consistent with typical appearance of abscess, simple cyst, or hydatid cyst. Typical active hydatid cysts have a complex appearance with daughter vesicles and internal layering due to the hydatid sand that forms with rupture of vesicles [Echinococcus. Based on the combination of imaging and equivocal IgG results, hydatid cyst could not definitively be ruled out.Initial differential diagnoses for this case also included simple cyst, abscess, and cavernous hemangioma. To differentiate these diagnoses, we obtained MRI imaging as well as vesicles . Additiovesicles . IgG tesIntraoperative rupture of a hydatid cyst was a significant concern during excision, as hydatid fluid is highly toxic and direct exposure can cause a fatal anaphylactic reaction . TherefoThe exact etiology of adult lymphangioma is not clear. However, it has been proposed that adult presentation and growth of lymphangiomas may be related to a predisposing trigger, such as trauma, infection, or iatrogenic. In older children, it is also thought that puberty can serve as a trigger for growth of lymphangiomas, possibly because of rapid physiological and hormonal changes . Given tLymphatic malformations can be classified based on their radiographic features into three groups: macrocystic, microcystic, and mixed. Differentiation is based on the size of the fluid-containing tissues within the malformation. The macrocystic type  is made up of large cysts > 2 cm in diameter, while the microcystic type (lymphangioma circumscriptum) is composed of cysts < 2 cm in diameter . Our pat


Periosteal osteosarcoma is a rare variant of osteosarcoma arising from cortical of long bone, mostly from femur and tibia. It is an intermediate-grade tumor and current treatment included neo-adjuvant chemotherapy and wide tumor resection even though the role of chemotherapy still unclear. Wide tumor resection with adequate surgical margin is the cornerstone of treatment of periosteal osteosarcoma. Surgical treatment prognosis is good with survival rate 83 % 2A 20-year-old female presented with a less pain mass over her right clavicle, which had been gradually increasing in size over the last 3 months. There was no fever or weight loss and decreased appetite. She has no history of malignancy or trauma, and she has no familial history of tumor also. Local examination revealed a 4 × 6 cm × cm firm, tender mass anteriorly and superiorly over the right clavicle. Tumor was smooth and well defined margin. The tumor is not fixed to the skin but inseparable from underlying clavicle bone. There was no local increase of temperature and erythema. The patient had full shoulder active range of motion (AROM), normal strength compare with unaffected side, and no neurovascular deficit.Radiograph demonstrated a defined, surface based lesion arising from the mid shaft of the right clavicle. There was cortical thickening inferior and superior surface of clavicle on AP view. Codman's triangle lesion, irregular and ill-defined lytic bony lesion of mid shaft clavicle outer surface .Fig. 1A MRI revealed a circumferential soft tissue mass around clavicle, which was low signal intensity on T1W, hyper-intense on T2-W sequences and heterogenous enhanced with contrast. There was a few intramedullary hypointense lesion on T1, hyperintense on T2W and enhanced by contrast agent, suggesting either bone marrow edema or intramedullary invasion of tumor. Chest and abdominal CT-scan does not showed any sign of metastasis .Fig. 2X Open biopsy was performed. Histology showed tumor tissue with hyperplagia of osteoblast with various degrees of nuclear atypia. There was large amount of well differentiation chondro cytes with various sizes. The matrix was composed of mature bone and chondro tissue. These features were considered most consistent with periosteal osteosarcoma .Fig. 3MRDiagnosis was made based on clinical symptoms, imaging and histology. The patient underwent three episodes of preoperative chemotherapy by Doxorubicin-Cisplatin. There was no remarkable change in size of the lesion after neo-adjuvant chemotherapy. A right total clavicle resection was performed by the first author – an experienced surgeon in orthopaedic oncology. No-touch technique was applied to avoid violation of the tumor mass. Local wide resection of tumor and surrounding tissue with respect to sub-clavicle neurovascular structure. The tumor was split along its long axis showing a 31 × 34 × 73 mm whitish tissue surrounding the mid shaft clavicle cortex with few focal necrosis. Post-operative histology reconfirmed diagnosis of periosteal osteosarcoma with significant tumor necrosis resulting from neo-adjuvant chemotherapy. The patient's right shoulder was immobilized post-operatively and pain-killer was given to her. The post-operation was uneventful. The wound healed with no complication. A further 3 episodes post-operative chemotherapy using the same agents was completed .Fig. 4MiThe patient had been reassessed at 1-2-3 6-12-24 and 32 month post-operative. At 32nd month, no evidence of local or metastasis was found on clinical examination and CT-scan . Pain free, full active range of motion was achieved. Patient could returned to work with no limitation. Patient usually felt uncomfortable when grasping heavy object for several minutes or lifting object weight >3 kg. Clinical observation and X ray revealed Right scapula and humerus head dropped in relatively with Left shoulder. The Constant Score was 81 and 90 in affected and unaffected side respectively , Fig. 6.3This case report is compliant with the SCARE Guideline 2020 44.1Periosteal osteosarcoma (PEO) is a surface osteosarcoma among with parosteal osteosarcoma and high-grade surface osteosarcoma. Ewing was the first one to describe this disease in 1939 and Lichenstein reported it as an opposite one of inter-medullary osteosarcoma 4.2The clinical presentation of periosteal sarcoma is usually pain and swelling in the site of tumor. The tibial meta-diaphysis, especially proximal third is the most affected region, following the middle and distal third of femur 4.3Because of the diaphyseal or metadiaphyseal location of the tumor and the advance of surgical technique, wide resection is the method of choice in PEO management. Amputation is only preserved for big and medullary invaded tumor or in case of recurrent after primary resection P = 0.73) The role of chemotherapy is inconclusive, both with neo-adjuvant and adjuvant therapy. Revell et al. reported 17 cases with periosteal osteosarcoma under tumor resection and patients went under chemotherapy if tumor showed high grade histological features or if medullary involvement was present. Among these patients, 14 patients were received chemotherapy with dororubixin and cisplatin and 3 patient did not enrolled in the therapy. In the chemotreated-group, 10 patients also received neo-adjuvant chemotherapy while 4 patients only received adjuvant chemotherapy. After the mean follow up of 52 months, none of 17 patients had distal metastasis, and two patient had good respond to neo-adjuvant chemotherapy (90 % necrosis), tumor-related death was not reported. The authors of this study recommended the use of neo-adjuvant chemotherapy for high-graded tumor and medullary involvement 4.4Prognosis of periosteal osteosarcoma depends on many factors such as medullary involvement, the time of diagnosis. In general, PEO metastates mostly to lung and pleura 4.5Wide local resection is recommended treatment for periosteal osteosarcoma of the long bone. The current treatment is a combination of adjuvant chemotherapy and limb-preserve surgery. In case of tumor arise from clavicle, total claviculectomy procedure is a good option if a definitive treatment is the target for clavicle malignant management. Claviculevtomy is relative rare procedure, it can be used in some condition like infection, trauma or tumor… Clavicle bone provides structural, protective and cosmetic function. Traditionally, clavicle, fibula and rib are called expendable bones. Some reports have documented good oncological and functional outcome with subtotal or total claviculectomy and most of authors recommended resection without reconstruction. Bio-mechanic testing in patient after en-block claviculectomy revealed some weakness in shoulder abduction, flexion, and adduction but not in internal rotation, external rotation, or extension. These weaknesses may be clinically insignificant to the patient, depending on the level activities of daily living The authors received no financial support for the work, authorship, and/or publication of this report.This report was conducted in accordance with the World Medical Association Declaration of Helsinki.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.Son Hoang Do Le: conceptualising the plan for surgery, performing the surgery, follow up patient's recovery, writing the literature review for case report, reviewing the manuscript.Huy Hoang Quoc: Assisting in planning and in the surgery, writing the draft for case report.Bach Nguyen: Assisting the surgery, writing the literature review, taking note of postoperative function.Binh Le Nguyen: taking note and data visualisation perioperatively.Vinh Pham Quang: reviewing the paper, Assisting the surgery, prepare the neccessary equipments: Analyzing the radiology and MRI.None.Vinh Pham Quang MD, PhD.Not commissioned, externally peer-reviewed.The authors declare no conflicts of interest in this work.


Cryptococcus neoformans, an opportunistic fungal pathogen, seldom causes infection in immunocompetent people. Cryptococcal osteomyelitis is an uncommon condition in which Cryptococcus invades the bone. It usually occurs as part of a disseminated infection and rarely in isolation. The spine has been reported as the most common site of cryptococcal osteomyelitis; however, isolated case of sacrum involvement in immunocompetent patients has never been reported.Cryptococcus neoformans infection sensitive to fluconazole. Postoperatively, the persistent radiating pain and numbness in the legs resolved. After 12 consecutive weeks of antifungal therapy, all his symptoms resolved. The patient remained without any signs of recurrence at the 8-month follow-up.We report the case of a 37-year-old man without underlying disease who presented with progressive low back and sacrococcygeal pain. The patient was initially diagnosed with sacral tumour by a local doctor, and subsequently, after admission, was diagnosed with sacral tuberculosis. He was empirically treated with antitubercular drugs. The patient failed to respond to antitubercular drugs and complained of worsening low back pain. Additionally, he developed persistent radiating pain and numbness in his legs. For further diagnosis, we performed a computed tomography-guided puncture biopsy of the sacrum, which revealed granulomatous inflammation with massive macrophage infiltration and special staining revealed a fungal infection. We performed sacral debridement and drainage and obtained purulent specimens for pathological examination and microbial culture. Microbial identification and drug susceptibility tests revealed a We reported a rare case of isolated sacrum cryptococcal osteomyelitis in an immunocompetent patient. Furthermore, we identified and reviewed 18 published cases of spine cryptococcal osteomyelitis. Immunocompetent individuals are also at risk for cryptococcal osteomyelitis. Clinical manifestation and imaging are insufficient to diagnose cryptococcal osteomyelitis of the spine, and invasive examinations, such as puncture biopsy and fungal examinations, are needed. Antifungal therapy yields satisfactory results for the treatment of cryptococcal osteomyelitis of the spine, however, if the infective lesion is large, especially when it compresses the spinal cord and nerves, a regimen combining aggressive surgery with antifungal therapy is indispensable. Cryptococcal neoformans, an opportunistic invasive fungus, is abundant in topsoil, rotten food, and bird droppings, especially pigeon droppings [Cryptococcus neoformans seldom causes infection in immunocompetent people and mainly afflicts immunocompromised hosts, such as patients with acquired immune deficiency syndrome (AIDS), lymphoma, organ transplantation, tuberculosis, or patients undergoing steroid therapy [roppings –3. As th therapy , 5. As r therapy , 4.Cryptococcus invades through the respiratory tract [Cryptococcus can localize in the lungs and cause cryptococcal pneumonia or disseminate hematogenously, affecting other extrapulmonary infection sites [Generally, ry tract . After ion sites . Althougon sites , 3, 8. Oon sites . Cryptocon sites , 10, 11.on sites –14.Herein, we report a case of isolated cryptococcal osteomyelitis of the sacrum in an immunocompetent patient and review the literature on cryptococcal osteomyelitis involving the spine in the last 30 years. We hope these studies can help other clinicians manage similar cases.A 37-year-old man presented to the Department of Oncology in our hospital with a 3-month history of progressive low-back and sacrococcygeal-pain, with occasional pain radiating bilaterally to the legs. He did not have fever, headaches, cough, or night sweats. Additionally, he had no history of AIDS, diabetes, tuberculosis, leukaemia, lymphoma, or immunosuppressive treatment. He initially visited a local county hospital, where lumbar vertebra magnetic resonance imaging (MRI) was performed. Findings showed osteolytic lesions of the S2–S4 vertebral body accompanied by paravertebral soft tissue masses, with mixed hyperintense signal on T2-weighted imaging (T2WI), and low signal intensity on T1-weighted imaging (T1WI). His preliminarily diagnosis was a sacral tumour, and he was referred to another hospital for further treatment.9/L  with 88% neutrophils , 6% lymphocytes , and 0.2% eosinophils . Erythrocyte sedimentation rate (ESR) was 22 mm/h  and C-reactive protein (CRP) level was 116.98 mg/L . Tumour markers were not elevated, and all other test results were normal. Radiographs revealed a patchy osteolytic lesion in S2–S4 with an unclear boundary, without periosteal reaction and rim sclerosis . For further diagnosis, we performed a CT-guided puncture biopsy of the sacral lesion and a blood culture. Hematoxylin and Eosine staining of pathologic samples revealed granulomatous inflammation with massive macrophage infiltration . At the follow-up, the low back and sacrococcygeal pain had progressively alleviated. Six months after surgery, his back pain completely resolved, and his ESR, CRP level, and blood cell count were normal. The patient recovered completely without radiological evidence of relapse at the 8-month follow-up (Figs. The patient underwent surgical sacral debridement and negative drainage through the anterior approach under intravenous titration of fluconazole. Intraoperatively, we observed that the anterior cortical bone of the sacrum had multi-point destruction, and the lesion was unequal in size and depth. Moreover, several honeycombed abscesses filled with weak pus were observed in the presacral space. The sacral nerve roots were compressed by cystic abscesses. Samples from the abscesses were sent to the laboratory for pathological examination, microbial culture, identification, and drug susceptibility tests. Postoperatively, the persistent radiation pain and numbness in the legs resolved. The postoperative pathological examination revealed granuloma formation containing large quantities of multinucleated giant cells, with some round, slightly stained, thin-walled ing Fig. . Moreoveup Figs.  and 8.Cryptococcus infection remains unclear. On reviewing all English language reports of cryptococcal osteomyelitis involving the spine since 1992, we identified 18 related cases (Table Cryptococcosis in immunocompetent people is infrequent, and isolated cryptococcal osteomyelitis is extremely rare , 15, 16.We found only three published cases of cryptococcal osteomyelitis involving the sacrum , 20, 21.Common clinical manifestations of spine cryptococcal osteomyelitis include local pain, tenderness, and oedema, sometimes accompanied by fever, weakness, and other manifestations of spinal cord compression , 26. ImaOur patient was a young man without underlying disease and had no history of abnormal immune function. He was an immunocompetent individual, and not in a susceptible population. His main symptom was low back pain and clinical examination revealed local tenderness and percussion pain. His blood tests were nonspecific, only showing elevated inflammatory markers. In addition to bone destruction, his imaging findings revealed sizeable soft tissue masses around the sacrum, similar to some primary sacral tumours, such as chordoma and giant cell tumours of the bone. Therefore, he was misdiagnosed with tumour and bone tuberculosis. Finally, an accurate diagnosis was made by a timely puncture biopsy and postoperative microbial culture.The confirmative diagnosis of cryptococcal osteomyelitis relies on positive culture and histological examination of the infective lesion specimens , 7, 21. Isolated cryptococcal osteomyelitis is the infection of one or more adjacent bones without extra skeletal lesions, while disseminated cryptococcal osteomyelitis is the infection of more than two non-contiguous bone sites or bone lesions with extra skeletal lesions , 15, 28.Candida albicans sacral osteomyelitis. Therefore, they advocate for early and aggressive surgery combined with long-term antifungal medication therapy for fungal osteomyelitis of the sacrum. Similar to these cases, our patient had occasional radiating pain in the legs on admission and subsequently, during the treatment, developed persistent pain and numbness. It was inferred that his sacral nerve roots were becoming affected; hence, surgical intervention was performed. Intraoperatively, we confirmed compression of the sacral nerve roots. Neither surgical nor nonsurgical treatment is universally applicable. The degree of spinal stability impairment and risk of spinal cord nerve injury is critical in deciding whether surgery is necessary for spine cryptococcal osteomyelitis. Generally, antifungal treatment alone is sufficient for cryptococcal osteomyelitis [It is widely accepted that antifungal therapy is indispensable for the treatment of cryptococcal osteomyelitis , 30, butmyelitis , 32. HowIn summary, we report a rare case of isolated sacrum cryptococcal osteomyelitis in an immunocompetent patient and reviewed 18 published cases of spine cryptococcal osteomyelitis. Immunocompetent individuals are also at risk for cryptococcal osteomyelitis. Due to atypical clinical symptoms and imaging findings, these alone may be insufficient for diagnosing spine cryptococcal osteomyelitis; hence, invasive examinations like puncture biopsy and fungal examinations are needed. Generally, nonsurgical therapy proves satisfactory for treatment of spine cryptococcal osteomyelitis. However, when the infective lesion is large, especially when it compresses the spinal cord and nerves, a regimen combining aggressive surgery with antifungal therapy is indispensable.


Encephalocraniocutaneous lipomatosis (ECCL) or Haberland syndrome is a neurocutaneous disorder of the skin, eye, and central nervous system. A three-month-old girl was referred to our center for further management of a large left eye corneal dermoid. At birth, a small lesion was noted. Magnetic resonance imaging (MRI) around the first week of life showed an extraocular dermoid cyst measuring 1 mm x 7 mm, dysplasia of the left greater wing of sphenoid, closed-lip schizencephaly of the left parietal lobe, and polymicrogyria. During examination under anesthesia at our center, we found that the corneal dermoid had grown in size to 17 mm x 16 mm, with posterior embryotoxon, a hazy cornea, and intraocular pressure of 26 mmHg. With the anterior segment dysgenesis and secondary glaucoma, we started Gutt Timo-Comod BD. Serial MRI imaging at four months of age revealed further enlargement of the dermoid, a new left retrobulbar mass, and multiple intracranial lipomas. A diagnosis of ECCL was made at this point based on the MRI and clinical findings. A multidisciplinary meeting was held among ophthalmology, neurosurgery, radiology, and otorhinolaryngology (ORL) teams, which concluded that surgical intervention such as tumor debulking might cause more harm than benefit. Hence, she was planned to undergo close monitoring with serial MRIs and only for surgical intervention, in the presence of airway compression or any neurological deficits. The ophthalmologist should be aware of the specific radiological and clinical findings in ECCL as management of the condition would be best through a multidisciplinary approach. Encephalocraniocutaneous lipomatosis, also known as Haberland syndrome, is a rare, sporadic neurocutaneous disorder with skin, ocular, and central nervous system involvement . It is aOur patient was born at 37 weeks of gestation, with spontaneous vertex delivery at a primary care center. Her mother had attended antenatal follow-ups regularly as she had gestational diabetes, placenta previa type 2, and anemia during the pregnancy. At birth, the mother noticed a small mass on the left eye. The child was seen by a pediatric ophthalmologist on day 1 of life and was noted to have a left eye corneal dermoid as well as alopecia and a subcutaneous lipoma on the frontal scalp.She underwent an examination under anesthesia on day 5 of life, which revealed a corneal dermoid involving the entire circumference of the cornea. A contrast-enhanced computed tomography (CT) scan of the brain and orbits showed the dermoid cyst measuring 2 mm x 10 mm (anteroposterior length [AP] x width [W]), and the globe and optic nerves were intact. The radiologist proceeded with an MRI brain and orbits; this showed the dermoid cyst at the medial angle of the left eye measuring 1 mm x 7 mm (AP x W), with no extension to the posterior extraconal space. The lens and vitreous were normal, but there was also dysplasia of the left greater wing of the sphenoid, parietal closed-lip schizencephaly, and polymicrogyria. On direct examination of the oral cavity, a small fibrous alveolar soft tissue mass with a broad base about 10 mm in size was also found. The oral-maxillofacial team planned to biopsy this lesion if it increased in size.At two months of age, the parents noticed that the lesion had increased in size slightly, and there was slight bleeding from the angle of the left eye due to irritation of the nasal conjunctiva. Subsequently, at three months of age, the patient was referred to our center for consideration for surgical intervention and further follow-up. Another examination under anesthesia at this point found that the corneal dermoid now measured 17 mm  x 16 mm , covering almost the whole cornea, while another small dermoid measuring 1 mm x 1 mm was also seen temporally , progressively enlarging non-encapsulated fat containing a retrobulbar mass extending to the cavernous sinus and sphenopalatine area, a left frontal extra-axial intracranial lipoma with adjacent left frontal cortical polymicrogyria, a small fronto-basal extra-axial paramedian lipoma, as well as the involvement of the nasopharynx  and neurosurgical teams. Although the airway was still patent, a flexible nasolaryngoscope examination of the left nasal cavity revealed nasopharyngeal bulging, which covered almost 90% of the posterior choana. Audiometry showed severe left-sided hearing loss. A multidisciplinary meeting was held among ophthalmology, neurosurgery, radiology, and ORL teams, which concluded that the lesion was benign but aggressive. Treatment options were discussed, including the risk of recurrence from the biopsy of the anterior part of the lesion, and it was decided that debulking surgery would be destructive and may lead to cranial nerve palsies or bleeding from carotid arteries. Hence, she was planned for close monitoring with serial MRIs. From an ophthalmology point, we decided that exenteration might be needed in the future once the growth was stable, especially for cosmetic purposes.This patient had repeat MRI scans at six months and nine months of age. There was no significant progression at six months, while there was a minimal anteroposterior increment of the left retrobulbar encapsulated mass at nine months. Other findings were the same as preceding MRIs. Clinically, the child was active and developing well, without any episodes of seizures.ECCL is a rare, sporadic, congenital neurocutaneous disorder that involves ectomesodermal tissue such as skin, eyes, and central nervous system . The terAlthough progression or late development of prosencephalic cysts, cerebrovascular aneurysms, and cystic bone lesions has been reported, the hallmark of the disease is benign central nervous system (CNS) lipomas that are generally stable throughout life . In ECCLThe ocular manifestations of ECCL include dermolipomas, corneoscleral anomalies, anterior chamber abnormalities, ocular or palpebral colobomas, aniridia, microphthalmia, and calcification of the globe . VasculaComplications also include those related to CNS malformations. There is a risk of neoplasms such as juvenile extra-nasopharyngeal angiofibromas of gingiva, jaw tumors, papillary glioneuronal tumors, and low-grade gliomas/astrocytomas ,3. The jOur patient fits in with the diagnosis of ECCL as shown in Tables The differential diagnosis for her condition includes proteus syndrome, oculoectodermal syndrome, oculocerebrocutaneous syndrome, Goltz syndrome, and Goldenhar syndrome ,5. ProteSo far, there is no effective treatment for ECCL. Ophthalmic management may include excision of the choristoma, lamellar keratoplasty, and visual rehabilitation . There hAs the child grows, she will need psychosocial support as the tumor can be disfiguring. Not only are they able to provide psychosocial support, but they also try to improve the quality of life for patients. Finally, this child might also need to attend a special needs school as she has both visual and hearing impairment on her left side.Encephalocraniocutaneous lipomatosis is a neurocutaneous syndrome with a specific set of radiological and clinical findings. The ophthalmologist has to be vigilant as the eye findings might precede other clinical findings. Early recognition, early imaging, and a multidisciplinary approach to treatment may not only ensure a better quality of life for patients but even increase the life expectancy of patients. More case reports and case series are necessary to understand the nature of this disease and to explore the treatment options that are available for these patients.


Follicular lymphoma is the most common indolent non-Hodgkin’s lymphoma and is usually initially detected in lymph nodes. Primary extranodal NHL is most commonly primarily localized in the gastrointestinal tract. We present one unusual case of ileum FL with ascites as the first clinical sign. The 73-year-old female patient was presented to the emergency department for evaluation of mild abdominal pain and abdominal swelling that had been going on for three days followed by bloating and occasional pain in the spine. The abdominal contrast-enhanced CT revealed the contrast stagnation in the distal part of the ileum. The ileum wall about 11 cm in length was thickened up to 2.9 cm and the tumor mass infiltrated all layers of ileum mesenteric lymphadenopathy up to 2 cm in diameter and significant ascites. On the upper ileum wall, the vegetative mass was described 3 cm in diameter. The patient had an emergent laparotomy with the ileocolic resection and latero-lateral ileocolic anastomosis. The microscopy finding of terminal ileum and the regional lymph nodes showed domination of cleaved cells with irregular nuclei which correspond to centrocytes. There were 0–15 large non-cleaved cells corresponding to centroblast in the microscopy high-power field. The final diagnosis was follicular lymphoma, the clinical stage 2E and histological grade by Berard and Mann criteria 1–2. Follicular lymphoma (FL) is the most common indolent non-Hodgkin’s lymphoma (NHL) in the Western world and is usually initially detected in lymph nodes . Extrano9/L, with a predominance of granulocyte). The serum levels of aspartate and alanine aminotransferase, gamma glutamyl transferase, albumin, amylase and lipase were normal (0–160 U/L). The level of lactate dehydrogenase was high, 410 U/L. Her medical history revealed that she had myocardial infarction two years ago and that she suffers from cardiomyopathy, anemia, hypertension, diabetes and stage 2 chronic kidney disease.The 73-year-old female patient was presented to the emergency department for evaluation of mild abdominal pain and abdominal swelling that had been going on for three days followed by bloating and occasional pain in the spine. Physical examination of the patient revealed normal vital signs, distended and painless abdomen on deep palpation without rebound tenderness, guarding or palpable masses. Her initial labs showed normal electrolytes with a normal coagulation profile, presence of normocytic anemia, elevated d-dimer 4420 ng/mL, elevated markers of inflammation  was performed. The abdominal contrast-enhanced CT revealed the contrast stagnation in the distal part of the ileum where the ileum wall about 11 cm in length was thickened up to 2.9 cm and the tumor mass infiltrated all layers of the ileum A. On theAscites is evacuated and cytological analysis of ascites showed the presence of atypical lymphocytes.The patient had an emergent laparotomy. Macroscopic finding showed ileum infilration with vegetative mass . IleocolConsidering that the bone marrow biopsy did not show lymphoma involvement, the final diagnosis of follicular lymphoma, the clinical stage 2E and histological grade by Berard and Mann criteria 1–2 were made and the patient was started with G-CVP regimen .Most cases of gastrointestinal FL are classified using the Ann Arbor staging system or the Lugano staging classification of gastrointestinal lymphoma, which is a modified version of the Ann Arbor staging system for gastrointestinal NHL . Unlike Follicular lymphoma cells are composed of small to medium-sized cleaved cells (centrocytes) and large non-cleaved cells (centroblasts) . By BeraUsing Southern blotting, the polymerase chain reaction (PCR) and fluorescence in situ hybridization (FISH), t   were found in approximately 60–70% of cases of PG-FL, similar to nodal FL. This translocation causes bcl-2, an anti-apoptotic protein, to be overexpressed, which is thought to be one of the causes of lymphomagenesis . In apprFor PG-FL, four treatments are used: watch and wait strategy, radiation therapy, rituximab monotherapy and immunochemotherapy . Conside


Spindle cell rhabdomyosarcoma (SC-RMS) is an unprecedented version of embryonal rhabdomyosarcomas (RMSs) that emerges from the mesenchyme with the capacity to differentiate into skeletal muscle cells. Retroperitoneal RMS is extremely rare in the adult population. We present the case of a primary spindle cell retroperitoneal RMS with compression features. Investigation-based diagnosis of RMS is difficult due to the lack of specificity of clinical findings. Radiology does not help in making an accurate diagnosis. Surgical removal of the tumor followed by chemotherapy and radiotherapy is the best possible treatment for RMS in adults. SC-RMS has a poor long-term prognosis. To our knowledge, such cases of retroperitoneal SC-RMS compressing the abdominal viscera and resulting in hydroureteronephrosis have never been reported before. Soft-tissue sarcomas arising from the rhabdoid muscle are referred to as rhabdomyosarcoma (RMS); however, almost 47% of the RMSs do not originate from these muscles. Retroperitoneal RMS is uncommon in the adult population ; consequSpindle cell RMS (SC-RMS) makes up <10% of adult rhabdomyosarcomas and the most common site is the head and neck; however, it is found at variant locations, such as the diaphragm, paratesticular region, and uterus. Rare anatomical sites include the solid organs and retroperitoneum, and only three cases of retroperitoneal rhabdomyosarcomas have formerly been presented . To our A 48-year-old male patient presented to the hospital’s surgical outpatient department (OPD) complaining of pain in the abdomen and lower back. Detailed history revealed that the patient was having dull and aching pain in the umbilical region and lower back for two months. The pain was mild in intensity but aggravated on bending and lifting weights. It was however relieved with the use of over-the-counter non-steroidal anti-inflammatory drugs.Physical examination of the inguinoscrotal region and abdomen was unremarkable, except for mild left flank tenderness. During his evaluation, an ultrasound of the abdomen and kidney, ureter, and bladder (KUB) was ordered, which revealed a heterogenous soft tissue mass, predominantly hypoechoic measuring 120 X 154 mm and reaching up to a maximum depth of 137 mm in the umbilical region. Left-sided hydronephrosis and hydroureter (maximum diameter of 18.3 mm) were also noted. However, it showed absent vascularity on Doppler. Laboratory investigations were unremarkable. A CT scan of the abdomen and pelvis confirmed the large soft tissue mass measuring 12 X 17 cm, showing patchy post-contrast enhancement and areas of subtle necrosis, and a possibility of neoplastic etiology. CT scan also showed a significant mass effect along the course of the ureter with resultant upstream mild hydroureteronephrosis and a delayed left pyelogram. Small free fluid was seen in the perisplenic and perihepatic regions. However, no evident lymphadenopathy and lytic or sclerotic lesions were seen in the visualized skeleton  classification divides RMSs into four groups: alveolar RMA, embryonal RMA, spindle cell/sclerosing RMA, and pleomorphic RMA. Adult RMS begins in the major skeletal muscle . It origPreoperative diagnosis is challenging due to unclear symptoms. Preoperative imaging contributed little to the final diagnosis, showing a nonspecific mass with patchy enhancement . SC-RMS The size and consistency of RMAs vary widely. These tumors are well-circumscribed but unencapsulated and generally have a tendency to infiltrate widely into adjacent tissues . SectionHistopathology is dominated by the constant cellular proliferation of elongated spindle cells arranged in fascicles or spirals in a herringbone growth pattern similar to leiomyosarcoma. The nucleus is centrally located, with blunt or fusiform ends, the nucleoli are small to inconspicuous or prominent, and the cytoplasm is eosinophilic. Mitotic figures are easy to understand, including atypical forms . RMS on RMS can be treated in three ways including surgery, radiation therapy to control residual large or small tumors, and systemic combination chemotherapy for primary cytoreduction and eradication of large and micrometastases. Surgery is the fastest way to erode the disease but it should always be performed if subsequent functional or cosmetic damage is not greatly affected. Surgery consists of complete resection of the primary tumor and margins of surrounding uninvolved tissue during the initial surgery and any subsequent surgery. After the initial excision, if the microscopic residual disease is found, the area should be re-excised before any other nonsurgical treatment. Debulking surgery is of no value because neoadjuvant therapy and initial biopsy result in tumor shrinkage, allowing complete resection in a second observational surgery ,11.Sultan et al. reported that adults with RMA have a considerably lower prognosis than children . Adult tumors were more certain to be located at a critical site (65% vs 55% in children) . AccordiSC-RMS produces vague clinical features, especially when they arise in the retroperitoneum, which leads to advanced disease at the time of presentation. Noninvasive diagnostic modalities including radiology play little role in making a final diagnosis. Histopathology, however invasive, can be conclusive. A high degree of suspicion remains a significant factor in the diagnosis of such rare tumors. Treatment includes a three-prong strategy with resection of the tumor followed by chemotherapy and radiotherapy.