Bladder paraganglioma is a neuroendocrine tumor that accounts for less than 0.1% of all bladder tumors. Symptoms caused by catecholamine release such as hypertension, palpitation, syncope, and macroscopic hematuria are the most common findings. Treatment modalities include transurethral resection, and partial or total cystectomy.A 38-year-old Turkish female patient was examined for hematuria that had been persisting for 6 months. Among the clinical findings, only hematuria was present. Absence of adrenergic symptoms such as hypertension, palpitations, and syncope at the first presentation made it difficult to consider bladder paraganglioma in the differential diagnosis. Therefore, cystoscopy and transurethral resection were performed with the thought of urothelial cancer. Findings such as hypertension and bradycardia that developed during diagnostic transurethral resection suggested that it might be bladder paraganglioma. After the radiological evaluation and endocrinological preparation, the patient underwent partial cystectomy.The rarity of cases having been reported in the literature leads to uncertainties in the management of bladder paraganglioma. Adrenergic symptoms developing during transurethral resection should suggest paraganglioma in the differential diagnosis. A multidisciplinary approach and medical treatment are mandatory to prevent life-threatening complications such as hypertensive crisis, vascular collapse, and multiple-organ system failure. We aimed to report the clinical presentation that includes only macroscopic hematuria mimicking urothelial cancer and to emphasize the multidisciplinary approach in the treatment. Bladder paraganglioma is a very rare malignant tumor originating from chromaffin cells and accounting for 0.06% of all bladder tumors . As seenAs a diagnosis and treatment method, the transurethral approach is applied as the first step. The tumoral lesion seen during cystoscopy can be excised by transurethral resection or holmium laser ablation. These methods can also be used in combination with the laparoscopic approach.Radical cystectomy is the standard treatment for bladder malignancies, especially muscle-invasive bladder tumors. The morbidities brought by the operation in patients with comorbidities have led to the search for alternatives to radical cystectomy. In selected cases, partial cystectomy can be performed by open, laparoscopic, and robotic methods with acceptable oncological results.A 38-year-old Turkish female patient was hospitalized for macroscopic hematuria persisting for 6 months. In the patient’s medical, family, and psychosocial history, it was found that she had undergone an operation due to multinodular goiter 7 years ago, her parents were healthy and had no history of chronic disease, and she was a housewife with two children. There were no symptoms related to the adrenergic system such as hypertension, palpitation, syncope, or flushing. Urogenital system examination findings were normal.In the laboratory tests, the fasting blood sugar was 107 mg/dl, and hemoglobin was slightly elevated at 14.2 g/dl. Microscopic hematuria was observed in the urine analysis. Urinary system ultrasonography showed that both kidney sizes and calyceal system were normal, and a solitary tumoral formation of approximately 5 × 6 cm in size, starting from the bladder dome and extending to the right lateral wall was detected . Contrast-enhanced tomography sections revealed a hyperdense lobulated mass lesion with a heterogeneous internal structure starting from the anterior wall of the bladder and extending to the right lateral wall, measuring approximately 66 × 55 mm Fig. . There wAfter endocrinological evaluation and alpha-blocker treatment, we decided to perform an open partial cystectomy. During the dissection of the mass, blood pressure increased to 216/117 mmHg and heart rate to 223/minute. The mass was excised from the bladder to a tumor-free area of approximately 1 cm Fig. . When thThe pathological evaluation of the tumor confirmed the diagnosis of vesical paraganglioma. Chromogranin, synaptophysin, S100, and gata-3 were positive on immunohistochemical staining Fig. . There wThe first control after the operation was carried out in the first month. On physical examination, the wound site was evaluated and wound healing was considered normal. Her blood pressure was 117/46 mmHg, complete blood count and biochemical values were normal, and there was no pathological finding on the urinary ultrasonography. No additional medication or recommendation was specified in the endocrinological consultation.The follow-up of the patient continues at 3-month intervals. It is planned to evaluate the possibility of recurrence and metastasis with contrast-enhanced CT and cystoscopy in the sixth month of the case course.et al. in 1953, and more than 200 cases have been added in the following years [As a rare tumor, bladder paraganglioma accounts for 0.06% of all bladder tumors . The firng years . BladderBladder paragangliomas are seen in the third decade of life, more frequently in women than in men . ParaganBladder paraganglioma should be considered in the differential diagnosis if symptoms associated with catecholamine discharge are found in patients with a solitary lesion in the bladder. However, symptoms related to catecholamine release may not be seen in every case of bladder paraganglioma. By manipulating the tumoral lesion, symptoms may or may not be observed at all. Therefore, cystoscopy should be performed in every patient and diagnostic biopsy should be performed.Imaging methods do not have superiority in the diagnosis of bladder paraganglioma from other bladder solitary tumors. Metaiodobenzylguanidine scintigraphy has high specificity, but less sensitivity than magnetic resonance imaging in the diagnosis . UltrasoThe main goal of treatment is the complete removal of the tumor. There are many surgical options with the use of open, laparoscopic, and endoscopic methods separately and in combination. Hemodynamic instability may develop during tumor manipulation. To prevent this situation, alpha-blocker treatment should be started 3 weeks before the operation.There is no clinical consensus on postsurgical follow-up. In the literature, tumor recurrence and metastasis have been reported 10 years later. In addition, the criteria for malignancy were not clear on histological evaluation. Therefore, imaging and cystoscopy-based follow-up should be applied.The rarity of paragangliomas causes the lack of sufficient information on how to treat and follow-up. At the diagnosis stage, clinical findings and imaging methods do not distinguish them from other bladder malignancies. Endoscopic procedures are mostly performed for diagnostic purposes and partial cystectomy is the most common treatment.Our study aimed to contribute to disease management in the future, with clinical presentation, diagnosis, and treatment strategies.


A 63‐year‐old man was initially diagnosed with stage IE  diffuse large B‐cell lymphoma (DLBCL). He received three cycles of R‐CHOP therapy  and involved field radiotherapy, followed by intrathecal methotrexate for the prophylaxis of central nervous system (CNS) involvement. After treatment, he achieved complete metabolic response (CMR) and maintained it for 8 years. At 72 years old, he presented with persistent fever and splenomegaly. Bone marrow biopsy (BMB) demonstrated the infiltration of DLBCL cells. He received six cycles of R‐CHOP therapy and achieved second CMR.However, 1 year later, he presented with thrombocytopenia, a high LDH level, and splenomegaly. Although no infiltration of lymphoma cells was noted on BMB, random skin biopsy revealed the infiltration of DLBCL cells in the lumina of small‐sized vessels of subcutaneous fat tissue. A hyper‐intense lesion in the pons (arrow) on brain magnetic resonance imaging (MRI) was observed on T2‐weighted imaging (T2WI) (A) and diffusion‐weighted imaging (dWI) (B)  and brain MRI findings . HoweverDai Maruyama reports honoraria and research funding from Chugai Pharmaceutical, outside the submitted work. Yo Saito, Akiko Miyagi Maeshima, Yuko Kubo, and Koji Izutsu have no conflict of interest.Yo Saito and Dai Maruyama wrote the initial draft of the manuscript. Dai Maruyama is the attending physician of this patient. Akiko Miyagi Maeshima contributed to pathologic interpretations. Yuko Kubo contributed to radiographic image interpretations. Koji Izutsu assisted in the preparation of the manuscript. The final version of the manuscript was approved by all authors.


A 49-year-old female patient, without previous medical history, underwent a thoracic CT due to SARS-CoV2 infection. This exam revealed a heterogeneous mass in the anterior mediastinum with 11 × 8.8 cm in close contact with main thoracic vessels and pericardium. Surgical biopsy documented a B2 thymoma. This clinical case reminds the importance of a systematic and global look of the imaging scans. Years before the thymoma diagnosis, the patient underwent a shoulder X-ray due to musculoskeletal pain, where an irregular shape of the aortic arch was visible, probably related to the growing mediastinal mass. An earlier diagnosis would allow a complete mass resection without such extensive surgery and less morbidity. Thymomas are the most common primary tumor of the mediastinum in adults , 2.Despite its usual slow-growing pattern, thymomas may require an extensive dissection and aggressive treatment in order to achieve its complete resection—the most important prognostic factor for local control and survival.This clinical case reminds the importance of a systematic and global look of the imaging scans and its impact on early diagnosis and treatment.A former smoker (20 pack-years) 49-year-old female patient, without relevant previous medical history, underwent a thoracic CT due to a SARS-CoV2 infection . This exAfter recovery from SARS-CoV2 infection, the patient remained asymptomatic and the only sign on the physical exam was a slight jugular venous engorgement.The patient was referred to a thoracic oncology center and proposed to induction chemotherapy due to tumor size and vessel proximity. Given the significant mass reduction, surgery was proposed. The patient was submitted to en bloc thymectomy, pleuropneumonectomy, partial resection of the left venous brachiocephalic trunk, partial resection of diaphragm and pericardium, and pericardial reconstruction. Postoperative period went without major complications, and the patient was discharged 22 days after surgery.Pathologic analysis of the mass confirmed the diagnosis of a B2 thymoma stage IVa, which is completely resected. In the postoperative multidisciplinary meeting, it was decided to propose adjuvant radiotherapy.Thymomas are the most common primary tumor of the mediastinum in adults , 2. Its In this particular case, preoperative chemotherapy was important to reduce the compressive effects over the vascular structures and allows a safer procedure. However, due to the large size and proximity to major blood vessels, an extensive dissection was needed to ensure complete mass resection, given its impact as a prognostic factor.The curious aspect of this clinical case reminds us of the importance of a systematic and global look of the imaging scans. Years before the thymoma diagnosis, the patient underwent a shoulder X-ray  due to lVideo_1_rjad084Click here for additional data file.


Craniopharyngioma (CP) is a rare benign tumor that develops from the residual epithelial cells of the craniopharynx, accounting for < 5% of intracranial tumors. It is common for CPs to grow in the sellar/parasellar region and extend suprasellar. The pathology classifies CPs into adamantinomatous craniopharyngiomas (ACP) and papillary craniopharyngiomas (PCP). The PCP is mainly solid and occurs only in adults. ACP is predominantly cystic and more common in childhood and adolescent. Multilocular cystic ACP involving the anterior, middle, and posterior cranial fossa is rare in adults. Here, we report a case of a 46-year-old adult male patient who presented with recurrent headaches for 1 year with choking and hoarseness. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed multiple cystic masses in the anterior, middle, and posterior cranial fossa. Initial hypotheses included the following: CP, colloid cyst, enterogenous cyst, epidermoid cyst, and dermoid cyst. Subsequently, the patient underwent surgery and postoperative histopathology diagnosed ACP. Adults with ACP involving the anterior, middle, and posterior cranial fossae are uncommon. This is a rare condition that radiologists should be aware of. A 46-year-old male patient presented with recurrent headaches for 1 year, choking cough, hoarseness of voice without nausea, vomiting, orofacial distortion, and visual field defects. Laboratory test results were normal. CT images of the head suggested multifocal cystic masses in the anterior, middle, and posterior cranial fossa. The tumor was slightly high density in the anterior cranial fossa, slightly high density in the middle cranial fossa with marginal discontinuous calcification, and low density in the posterior cranial fossa , and theClinical manifestations of CP include decreased vision, growth retardation, irregular menstruation, increased intracranial pressure, visual field defect, diabetes insipidus, abnormal hormone secretion, and so on. The symptoms of headaches are not specific. When symptoms such as choking and coughing on drinking water, asphyxia, and hoarseness occur, the possible injury of the recurrent laryngeal and superior laryngeal nerve should be considered first. In addition, when the tumor compresses the posterior cranial nerves, it may lead to choking and hoarseness, such as meningioma in the rear cranial fossa. Our patient presented with recurrent headaches for 1 year, choking, coughing on drinking water, and hoarseness.According to the theory of embryogenesis, CP may occur anywhere in the migration of Rathke's sac , such asWorld Health Organization (WHO) classified CP into ACP and PCP . The PCPCT and MRI scans are essential to diagnosing and differentially diagnosing CPs. In our case, the density and signal of the anterior, middle, and posterior fossa tumors were diverse, possibly due to differences in protein or crystalline content concentrations in the tumors. MRI contrast-enhanced scan showed a noticeable enhancement of the mass wall of the middle and posterior cranial fossa, indicating that the marginal vessels of the mass in the middle and posterior cranial fossa were abundant. In addition, on CT, small calcification foci were seen along the edge of the tumor wall in the middle cranial fossa. Therefore, the radiologist first hypothesized that it was a craniopharyngioma. However, some of the manifestations in our case are similar to colloid cysts. Colloid cysts showed high density on CT images and hyperintense or hypointense on T2WI but mainly showed hypointense on T2WI and often occurred in the third ventricle . The T2WDifferentiating CP from intracranial enterogenous cysts, epidermoid cysts, or dermoid cysts is essential. Intracranial enterogenous cysts are very rare, often in the ventral side of the spinal cord, occasionally in the brain parenchyma and clivus of the posterior cranial fossa, and rarely in the suprasellar, quadrigeminal cistern and anterior cranial fossa . The T1WTo summarize, we report a rare case of ACP involving adults' anterior, middle, and posterior cranial fossa. Its imaging features are not typical. In general, the more significant focus of CP is in the suprasellar cistern. Unlike our case, the tumor in the anterior cranial and posterior cranial fossa is larger and creeping, while those in the suprasellar cistern are smaller. Multilocular cystic ACP involving the anterior, middle, and posterior fossa is rare in adults. This study may be helpful for radiologists in the diagnosis and differential diagnosis of CP by analyzing the imaging features of intracranial cystic tumors.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.BT: manuscript writing. ML: pathological review. XD, HZ, and KZ: manuscript revision. SL: conception and critical review. All authors contributed to the article and approved the submitted version.


Introduction. Torsion of the ovary, tube, or both is estimated to be responsible for 2-7% of all gynaecological emergencies. Oophorectomy is commonly performed for adnexal torsion with a possible negative impact on fertility in women of reproductive age. Case Presentations. We report two cases of teenage girls presented with adnexal torsion describing their laparoscopy features. Detorsion without additional surgical intervention could save their ovaries. Discussion. Detorsion is a more conservative surgical approach that should be considered in all younger women with ovarian torsion. Ovarian torsion refers to the full or partial twisting of the ovary around its suspensory structures, leading to the compromised blood supply to the ovary. The resultant ischemia can cause tissue necrosis with a potential loss of the affected ovary permanently. Oophorectomy was the standard treatment for many decades due to the presumed risk of thrombosis, infection, peritonitis, and reperfusion injury following untwisting of the twisted ovary . The preThis paper summarises similar case reports of two, young girls presenting with adnexal torsion where the visual inspection was highly suggestive of nonviable ischaemic necrosis of the tissues. However, proceeding to conservative laparoscopic surgery resulted in a successful outcome.A 15-year-old, previously healthy, Sri Lankan, Muslim ethnic girl presented with severe lower abdominal pain of two days duration. The pain was gradually getting worse. Her menarche was four years ago, and she had regular periods with no dysmenorrhoea. On direct inquiry, she has had three similar episodes during the last six months, but less severe in intensity. On examination, the abdomen was tender, mainly in the left iliac fossa. Urine human chorionic gonadotrophin was negative. Ultrasound revealed a 12 cm complex pelvic mass. The overall picture was suggestive of a twisted ovarian cyst with features of surrounding oedema.She underwent laparoscopy with consent for the removal of the affected ovary. At laparoscopy, an adnexal twisting due to a left ovarian cyst was confirmed. The left tube was grossly edematous. Both ovary and the tube appeared congested, dark blue-black in colour, and gross appearance suggestive of nonviable tissues. Adnexa was untwisted and ovarian cystectomy was done. At the end of surgery (one hour), significant improvement of appearance and perfusion was noted. Her recovery was uncomplicated with low molecular weight heparin and early mobilisation. The extracted cyst wall was compatible with a benign serous cystadenoma.Three months later, an ultrasound scan on day-15 revealed a corpus luteum in the left ovary. A 13-year-old, previously healthy, Sri Lankan, Sinhala ethnic girl presented with worsening lower abdominal pain of 36 hours duration. Her menarche was one year ago. She was uncertain in her last period. On examination, she had severe right-sided lower abdominal tenderness. Urine human chorionic gonadotrophin was negative. An ultrasound scan revealed a large 6 cm complex right adnexal cyst with possible surrounding oedema.At laparoscopy, a twisted para-ovarian cyst and fallopian tube were noted. There was significant tissue edema and the fallopian tube distal to the torsion was dark blue-black in colour and appeared nonviable. Right ovary was not involved in the torsion. Left adnexa was normal. The fallopian tube was untwisted, and removal of cyst was carried out. At the end of surgery (45 minutes), significant reperfusion was noted in the fallopian tube. The patient had an uncomplicated recovery. Cyst wall histology revealed a benign serous cyst with foci of haemorrhage. Adnexal torsion is an uncommon gynaecological emergency presenting with worsening lower abdominal/pelvic pain . Some woIn our experience, high-resolution transvaginal ultrasound  is an extremely useful tool available at the clinic setting. We use colour Doppler to assess limitations on the blood flow due to torsion. We aim for a presentation-to-surgery time of less than 6 hours, which is usually feasible. Diagnosis is challenging but early diagnosis and treatment can prevent catastrophic complications . AlthougLaparoscopic cystectomy during torsion in a case of complex cyst might pose a potential concern due to possible oncologic problems. However, the age-adjusted incidence of ovarian malignancy is very rare, 1.072 per 100,000 per year in girls aged 10–19 years . In addiPreexisting adnexal cysts and ovarian hyperstimulation are considered to increase the risk of torsion. Torsion may happen in all age groups, but is more common in the younger, reproductive-age females . ComplicAs the edematous, ischemic, distorted adnexal tissue is extremely friable, laparoscopic detorsion is a delicate, time-consuming process. The slow process is likely to be beneficial as gradual detorsion is thought to be protective in reducing reperfusion injury of the ischaemic adnexa . Most ofThe present account consisting of images provides a novel insight and supports conservative management. Both patients recovered with no peri-operative and postoperative complications. An immediate change in colour was obvious at laparoscopy in both cases. There is a paucity of robust data on the long-term follow-up of conservatively managed adnexal torsion. However, some recent reports showed that long-term outcomes were good , 14. Casn = 33) has compared laparoscopic surgical versus conservative organ-sparing management [A study discussing long-term follow-up experience of conservative management has mentioned successfully managed two similar cases. The first patient has normally delivered her baby, and the other one is in her seventh month of pregnancy . Anothernagement . In thisnagement . Out of Potential drawbacks of the conservative option are possibility of adhesion around the tube and ovary, tubal occlusion, and procedure-related complications such as laparoscopy . One casPrompt intervention to preserve ovarian function should be laparoscopic wherever possible. Detorsion should be the treatment of choice in young girls and women of reproductive age whose families are not complete, regardless of the colour and appearance of the ovary at the time of surgery. The two cases presented could be an interesting starting point for larger studies on conservative treatment in young patients with adnexal torsion.


Acute abdomen comprises several emergencies. Hemoperitoneum associated with uterine fibroids, which can present as acute abdominal pain, is rare and difficult to diagnose. Especially, spontaneous hemorrhage from the rupture of the superficial vessels overlying a uterine fibroid is extremely rare, and its diagnosis and management have not been established.We report a case of a 55-year-old woman who presented at our hospital with acute abdomen. After performing a computed tomography scan, we conducted a laparoscopic examination and diagnosed hemoperitoneum of ambiguous origin. We treated the patient surgically, performing a laparoscopic myomectomy to remove the origin of the hemorrhage. The patient recovered well.We report a case of hemoperitoneum of ambiguous origin that was diagnosed laparoscopically and treated by laparoscopic myomectomy to remove the origin of the hemorrhage. Surgeons should rapidly diagnose and manage acute abdominal pain in women with a history of uterine fibroids to prevent severe morbidity or even mortality. Therefore, laparoscopic surgery is recommended in patients with stable hemodynamics.The online version contains supplementary material available at 10.1186/s12905-022-01970-0. Uterine fibroids are the most common benign pelvic tumors in women of reproductive age . The typAcute abdomen comprises several emergencies; however, surgical and medical emergencies should be differentiated. Clinical symptoms arise mainly from peritoneal irritation caused by blood effusion, and the differential diagnosis includes ectopic pregnancy, adnexal torsion, neoplasm, and pelvic inflammatory disease , 7. HemoHerein, we report the first case of hemoperitoneum associated with spontaneous hemorrhage from the rupture of the superficial vessels overlying the uterine fibroid that was diagnosed and enucleated laparoscopically, despite a preoperative suspicion of torsion of a subserosal uterine fibroid. This case is reported in accordance with the SCARE criteria .A 55-year-old gravida 2 Japanese woman presented to the emergency department with complaints of acute-onset lower abdominal pain on day 30 of her menstrual cycle. She reported a history of regular menstrual cycles with 4–5 days of bleeding each month. She had a medical history of uterine fibroids and no remarkable family history. Her heart rate, blood pressure, and temperature were 103 beats per minute, 111/81 mm Hg, and 36.8 °C, respectively. Physical examination revealed generalized tenderness and a positive Blumberg sign around the right iliac fossa. Vaginal ultrasonography revealed a pelvic mass with hyperechoic fluid filling almost the entire abdominal cavity. On admission, the total white blood cell count was 7900/μL, and the C-reactive protein level was 0.2 mg/L. The patient was transfused with four units of packed red blood cells since she had a reduced hemoglobin level (6.6 g/dL) and hematocrit (22.3%). An abdominal contrast-enhanced computed tomography scan showed a heterogeneous pelvic-abdominal mass that measured 7.9 cm with uterine mass lesions (Fig. In the current case, we successfully managed to diagnose spontaneous hemorrhage from the rupture of the superficial vessels overlying a uterine fibroid and subsequently treated the uterine fibroid by laparoscopic enucleation to remove the origin of the hemorrhage.In literature, intra-abdominal hemorrhage due to uterine fibroids is rare with approximately 125 cases reported so far , 12. As A precise preoperative diagnosis is extremely difficult due to the rarity of this entity , 21. ImaWhile supportive and resuscitative measures play a crucial role in the management of patients with massive intra-abdominal bleeding, surgeries such as hysterectomy and myomectomy should be performed immediately. The preferred procedure is hysterectomy for women who are postmenopausal and myomectomy for women of child-bearing age, since preserving the uterus should be a priority. If bleeding cannot be controlled, a hysterectomy must be considered . In the To our knowledge, this is the first report of a case in which a hemoperitoneum of ambiguous origin was laparoscopically diagnosed and treated by laparoscopic myomectomy for the removal of the origin of hemorrhage. However, a previous report has described the use of laparoscopy to diagnose the source of the bleeding and excision of the uterine fibroid by laparotomy .In conclusion, although acute complications of uterine fibroids that require surgical intervention are exceptionally rare, hemorrhage from the rupture of the superficial vessels overlying a uterine fibroid should be included in the differential diagnosis of an unexplained hemoperitoneum. Surgeons should rapidly diagnose and manage women with acute abdominal pain and a history of uterine fibroids to prevent severe morbidity or even mortality. Based on our experience with this case, we recommend laparoscopic surgery in patients with stable hemodynamics.Additional file 1. The entire laparoscopic procedure followed for this case.


Scapulothoracic bursitis, a rare lesion of the thoracic wall, usually presents as a cystic mass growing at the scapulothoracic interface. Histopathologically, it is characterized by the presence of synovial cells lining the interior of the thickened fibrotic cystic wall and capillary proliferation. A 48-year-old male patient was admitted to our clinic with a complaint of swelling in the back. The magnetic resonance imaging of the lung and mediastinum showed a 43 mm × 130 mm axial lesion in the left infrascapular area between the external muscles and the serratus anterior muscle, hyperintense on T2 sequence, not suppressed on fat-suppressed sequences, with a peripheral minimally contrasted septated collection area. The patient underwent surgical total excision and was discharged on the second postoperative day with no morbidity. Histopathology of the tissue was reported as soft tissue compatible with an inflamed cyst wall with prominent fibroblastic proliferation. Scapulothoracic bursitis lesions can be treated with non-invasive or minimally invasive methods. However, when it becomes a giant lesion occupying space on the thoracic wall and has hemorrhagic content, surgical excision is the treatment of choice. Scapulothoracic bursitis, a rare lesion of the thoracic wall, usually occurs as inflammation of the bursa as a result of mechanical stress, sports, or trauma . MovemenA 48-year-old man noticed swelling in his back one week ago and had difficulty moving his arm. Thorax tomography was performed on the patient who applied with the complaint of increasing swelling in his back. A smooth circumscribed hypodense space-occupying lesion measuring approximately 15 cm × 4.5 cm × 13.5 cm extending inferiorly along the posterolateral wall of the thorax starting from the anterior left scapula. The lesion was fluctuating on palpation and a hemorrhagic fluid was aspirated on puncture. The patient was admitted to Ondokuz Mayıs University Faculty of Medicine, Department of Thoracic Surgery, for further examination and treatment. The magnetic resonance imaging of the thorax showed a 43 mm × 130 mm axial lesion between the external muscles and serratus anterior muscle in the left infrascapular area, hyperintense in T2 sequence, not suppressed in fat-suppressed sequences, with a septated collection area with minimal peripheral contrast (Figure Single-lumen intubation was performed under general anesthesia. In the right lateral decubitus position, subcutaneous fatty tissues were crossed with a 10 cm skin incision made from the inferior left scapula. The giant cystic lesion was reached by dissecting the latissimus dorsi and serratus anterior muscles in the direction of the muscle fibers. The lesion was delivered by separating the capsule from the surrounding tissues with blunt and sharp dissection. The lesion stalk was excised with ligasure Figure .One hemovac drain was placed between the tissues. The tissues were closed duly. The patient was discharged on the second postoperative day with no morbidity. Histopathology of the tissue was reported as soft tissue compatible with an inflamed cyst wall containing prominent fibroblastic proliferation Figure .Scapulothoracic bursitis is a lesion caused by abnormal biomechanics between the scapula and the thoracic wall. It can occur posttraumatically, idiopathically, or as a result of thoracic wall surgery ,5.Kuhn et al. defined two major and four minor bursae in the scapulothoracic joint . Major bBursitis occurs with bursa inflammation after mechanical stress, sports, or trauma . ScapuloThe first option in the treatment of scapulothoracic bursitis is systemic non-steroidal anti-inflammatory drugs, physiotherapy, local steroid, and analgesia injection . SurgicaScapulothoracic bursitis lesions can be treated with non-invasive or minimally invasive methods. However, when it becomes a giant lesion occupying space on the thoracic wall and has hemorrhagic content, surgical excision is the treatment of choice.In conclusion, although local treatments are recommended in cases of scapulothoracic bursitis, surgical excision should be performed in large lesions. In the differential diagnosis, elastofibroma, abscess, hematoma, and sarcomas such as malignant fibrous histioma, liposarcoma, and lymphangioma should be kept in mind.


Mesenteric cysts are rare benign abdominal lesions that possess the risk of malignant transformation in 3% of reported cases. Most cysts are asymptomatic and diagnosed incidentally or during the management of their complications. In the majority of cases, they arise from the mesentery of the small bowel, followed by the mesocolon. We present a case report of a 20-year-old female with an abdominal mesenteric cyst. Mesenteric cysts are rare benign abdominal lesions that possess the risk of malignant transformation in 3% of reported cases -4. They Cysts can occur in any part of the mesentery but most frequently originate from the mesentery of the small bowel (ileum: 60%) and mesocolon (ascending colon: 24%) . These fThe etiology of mesenteric cysts is unclear, but a failure of the lymph nodes to communicate with the lymphatic or venous systems or the blockage of the lymphatic system as a result of previous pelvic surgery, trauma, pelvic inflammatory disease, infection, endometriosis, or neoplasia have been suggested as contributing factors ,9. A young 20-year-old unmarried female consulted our hospital, King Faisal Hospital, for a painless abdominal swelling in the right upper quadrant, lasting three months, increasing gradually in size, and associated with nausea and anorexia.There was no history of pain, vomiting, bowel habit changes, hematemesis, melena, or urinary symptoms. Additionally, there was no fever or history of abdominal trauma. She had a history of weight loss over the past several months associated with noticeable pallor but without a history of dizziness or palpitations. She had regular menstrual cycles; there was no family history of a similar mesenteric disease, malignancy, or any congenital anomalies. Her past medical history was unremarkable, with no previous history of surgery or medication use.On clinical examination, she was conscious, oriented, and not pale. Her vital parameters were found to be within normal limits. On abdominal examination, there were no signs of abdominal distension or swelling, but a round mobile cystic mass was palpated in the right hypochondrial region, which was more prominent when she lay on her left side. It was not tender and about 7 × 10 cm in size; bowel sounds were positive. There were no skin changes or dilated veins. On digital rectal examination, no external pathologies were found; no masses were palpable. There were also no palpable lymph nodes.Blood tests were normal, with a hemoglobin of 12.4 g/dl. Liver function tests showed direct bilirubin of 0.02 mg/dl, total bilirubin of 0.23 mg/dl, alanine aminotransferase (ALT) of 11 IU/L, and aspartate aminotransferase (AST) of 12 IU/L. An abdominal CT scan showed a large well-defined cystic lesion (8.5 × 6.5 cm) with a peripherally enhancing wall seen in the right upper quadrant compressing the second part of the duodenum and exerting a mass effect on the adjacent large bowel loops, mainly at the hepatic flexure , CT, nuclear MRI) -9,11-13.The etiology of mesenteric cysts is unclear, but a failure of the lymph nodes to communicate with the lymphatic or venous systems or the blockage of the lymphatic system as a result of previous pelvic surgery, trauma, pelvic inflammatory disease, infection, endometriosis, or neoplasia have been suggested as contributing factors ,9. Complete surgical excision is the first-choice therapy to avoid recurrence and the possible risk of malignant transformation and may require the removal of part of the mesentery with the mass. The removal of the cyst can be achieved via laparotomy or laparoscopy .The decision of surgery type depends on the dimensions of the cyst, its relationship to the major abdominal structures, as well as the surgeon’s experience .In this case, laparotomy was the procedure of choice. The patient underwent complete surgical resection of the cyst, necessitating partial colon resection due to the adherence of the cyst to the colon and its mesentery.The results of the patient's preoperative diagnostic examination strongly suggested the presence of a mesenteric cyst; intraoperatively, the position and size of the cyst corresponded to the preoperative radiographic findings. The histological examination displayed a benign cyst with a fibrous wall infiltrated by inflammatory cells and lymphoid aggregates. The lumen shows macrophages with no malignant cells. Thus, complete resection of the lesion with partial resection of the colon was performed. The treatment of choice for mesenteric cysts is complete surgical excision.


Neuroendocrine tumors (NEN) are a type of heterogenous, slow-growing tumors, that only in about half of the cases can be found in the gastrointestinal tract. Half of these is in the small intestine. The ampullary NENs are rare, accounting for less than 1% of gastroenteropancreatic NENs. Gastrointestinal stromal tumors (GIST) are a more common type of tumors of the gastrointestinal tract that consist of pacemaker cells. The occurrence of both tumors simultaneously is rare, but in patients with neurofibromatosis type 1, the co-existence of NEN and GIST is more often. Here we report a case of simultaneous occurrence of a well-differentiated NEN and a GIST in a patient without neurofibromatosis. Also, we provide a short review of the current knowledge and treatment strategies regarding these tumors. The expanding use of upper gastrointestinal endoscopy in the last decade has led to an increase in the diagnosis of duodenal neuroendocrine tumors (NEN) . NENs arGIST can develop anywhere in the gastrointestinal tract, from the esophagus to the rectum, with a higher incidence in the stomach (60%) and lower incidence in the duodenum and rectum (5%) . The preThe simultaneous existence of an NEN of the duodenal ampulla and a GIST of the proximal jejunum is rare, with some cases of co-occurrence of these types of tumors being reported in patients with neurofibromatosis type 1 (NF1) . Thus, wA 48-year-old Caucasian patient was referred to our service for an echoendoscopy to elucidate the nature of a jejunal tumor formation shown on CT in another clinic. A subepithelial tumor of the small intestine was suspected in this patient.The patient complained of pain in the left hypochondrium, bloating and weakness. The symptoms started three years previously and were exacerbated by exertion or orthostatism. Initial laboratory findings showed unusual high levels of gamma-glutamyl transferase (GGT) (53 U/L), elevated serum C-reactive protein levels (0.55 mg/dL), high neutrophils count (79.5%), low lymphocyte count (15.1%), elevated number of leukocytes and low level of serum iron (55 mcg/dL). CgA and neuron-specific enolase were normal.Abdominal ultrasound examinations showed a hypoechogenic tumoral mass, well delimited and with vascular pedicle, at the jejunal level .The CT of the abdomen and pelvis identified a tissue node (21 mm AP/22 mm LL/24 mm CC) in the proximal jejunum, near the Treitz angle and duodenum, that was inhomogeneous, with necrotic core and ill-defined margins. The appearance suggested a possible gastrointestinal stromal tumor (GIST). No lumbar, aortic, or iliac lymphadenopathy was observed .The upper GI endoscopy showed a periampullary ulceration but no subepithelial jejunal lesions were observed intraluminal. The duodenal papilla at the second portion of the duodenum (D2) was normal. A superficial ulceration coated with fibrin, 12 mm in diameter, adjacent to the papilla was observed. Tissue samples (biopsy) were taken for histopathological examination. The other parts of the duodenum and proximal jejunum showed no changes in the mucosa or other subepithelial tumors .Endoscopic ultrasound identified a 17 mm periampullary tumor. Doppler-US and elastography revealed the central vascularization of the tumor and its rigidity. EUS-FNA (fine needle biopsy) was performed, and two samples were taken. In addition, we noticed an inhomogeneous, 6 mm spherical mesenteric ganglion in the vicinity of the tumor .In the proximal jejunal we observed another subepithelial tumoral mass of 2.3 cm, rigid and well vascularized . EUS-FNAEUS results concluded that the proximal subepithelial, periampullary and jejunal tumors were most likely NENs due to their appearance, vascularity and elastographic features.A subepithelial tumor was observed in the proximal jejunum and a biopsy was performed. Another tumor was observed in the duodenal papilla and a biopsy was performed.2. Lymphatic tumor emboli and perineural invasion were present, but no venous invasion. With immunohistochemistry, the tumor cells stained positive for Synaptophysin, Chromogranin A and Cytokeratin7; the KI-67 proliferative index was assessed at 2%. Those findings were consistent with a neuroendocrine tumor, G1. The tumor cells infiltrated the submucosa and the muscularis propria of the duodenum, extending into the peripancreatic tissues, with minimal invasion of the pancreatic acini. Duodenal mucosa covering the tumor was ulcerated.Upon microscopic examination, a proliferation of neoplastic medium-sized cells with salt-and-pepper nuclei, organized in nests and trabeculae was observed. Mitotic activity was estimated as 2–3 mitoses/2 mmConclusion: The histological aspect correlated with immunohistochemistry argues for a well-differentiated NEN located in the duodenal mucosa.Diagnostic: Periampullary and proximal jejunal subepithelial NENs.After the patient was informed regarding the treatment options , she decided on surgery with excision of intestinal tumors and gastrojejunal anastomosis, Roux-en-Y anastomosis (R1 resection).Other intestinal lesions that had not been observed before were identified . Mesenteric lymphadenopathy has also been observed. On palpation, an intraluminal tumor and periduodenal lymphadenopathy were identified.-a duodenal NEN, well delimited, with a lymph node metastasis pT3N1L1V0Pn1R1;-four jejunal GISTs, three low-grade fusocelular and one low-grade mixed GIST .Tests for histopathological examination revealed:The characteristics of the NEN and GISTs samples examined are shown in Final diagnostic: Periduodenal NEN, well delimited pT3N1L1V0Pn1R1. Jejunal GIST three low-grade fusocelular and one low-grade mixed.The postoperative evolution, both immediate and distant, was favorable, without complications and with the resolution of symptoms. Remote evolution depends on the incomplete resection of the periampullary NEN. The follow-up period was at nine months. At that time, no recurrence was determined by CT, PET-CT, endoscopy and echoendoscopy. Two periduodenal nodes were identified at CT, but the biopsy demonstrated their inflammatory origin.Our patient was 48 years old, and the symptoms started three years previously. The age for the occurrence of GIST is lower comparative to the average age previously identified for this type of tumor. A systematic review that collected data over 14 years highlighted several GIST features: the predominant age was 60 years, over 80% had symptoms, and the most common location was in the stomach and small intestine . A similBleeding is the most common symptom in patients with GIST  because For the diagnosis of gastro-duodenal NEN and GIST, upper digestive endoscopy and digestive echoendoscopy remain the reference methods , while iEUS-FNA was a useful examination in the present case since we obtained adequate samples for histopathological examination. Thus, a preliminary diagnosis was established before surgery. EUS-FNA is recognized as an important method that plays an important role in the diagnosis and classification of GISTs and its combination with specific biomarkers can lead to tumor differentiation .For our patient, the type of NEN was supported by histopathological examination, immunohistochemistry and positive NEN markers such as Syp and CgA. In addition to CgA and Syp, other first-generation neuroendocrine markers such as differentiation cluster 56 (CD56) and neuron-specific enolase (NSE) or second-generation neuroendocrine markers such as ISL1, INSM1 or Secretagogin, can be used for NEN diagnosis .Syp and CgA are traditional markers for NEN and gold standard in endocrine pathology, with Syp being more sensitive and CgA more specific. Over time, Ki67 immunohistochemistry has become essential for determining the grade of NEN ,20. The Histology and immunohistochemistry are also essential for the diagnosis and classification of GIST. The immunohistochemistry markers used for the determination of GIST are c-kit, SMA, CD34, DOG1, desmin, S100 protein etc. . In our After establishing the diagnosis , the therapeutic management was discussed: surgical treatment vs. “watch and wait”. Medical treatment  was excluded because the case did not meet the protocol criteria; the tumor was not poorly differentiated, and the patient showed no clinical signs of carcinoid syndrome.Endoscopic resection of duodenal NENs is not a feasible therapeutic strategy due to the periampullary location . ConservCephalic duodenopancreatectomy (Whipple procedure) and segmental enterectomy for jejunal tumor with gastro-jejunal, common bile duct-jejunal and Wirsung-jejunal anastomosis in Y a la Roux. This intervention was then ruled out because our patient was young, with well-differentiated NEN, low Ki-67, without dilation of the common bile duct and Wirsung duct, and DPC is a surgery with many associated complications and high mortality and morbidity rates ;Lateral duodenotomy with periduodenal NEN resection and segmental resection of the small intestine and duodeno-jejunal anastomosis. This intervention is less radical, but with an increased risk of acute pancreatitis and of incomplete NEN resection. However, this technique is more opportune because of the pancreatic tissue is preserved and it is a low risk for the occurrence of postoperative pancreatic fistula. Due to these advantages and because this technique is recommended for curative purposes for patients without distant metastases , locoregTwo surgical treatment options were considered:For patients with duodenal GIST, surgery with or without pharmacological treatment should be considered. An optimal standard surgical procedure for these cases is not yet defined due to the anatomical features of the site . RegardiAlthough both NENs and GISTs are rare tumors and their simultaneous existence is very rare, these clinical entities should be considered in the diagnostic approach of a patient with nonspecific digestive symptoms, as they require prompt specific treatment.Duodenal GISTs may be omitted or confused with other types of tumors  based on imaging criteria.


Paracecal hernias are a rare form of internal hernias. This is a case of a spontaneous paracecal retroperitoneal hernia in an elderly patient. A 73-year-old male, a known patient of adenocarcinoma of the rectum, who had undergone neoadjuvant radiotherapy and chemotherapy a year ago, presented with a 2-day-history of exacerbated colicky peri-umbilical and right-sided non-radiating abdominal pain, with associated progressive abdominal distension, which were aggravated by feeding. A contrasted abdominal computed tomography scan showed features of small bowel obstruction. An exploratory laparotomy revealed herniation of gangrenous small bowel ~30 cm through a small, tight opening just below the base of the cecum. Resection and anastomosis and closure of the retroperitoneal pouch were done. Patient recovered and was discharged on the fourth post-operative day. Spontaneous retroperitoneal hernias can occur in elderly patients with additional risk factors like neoplasms, with a high risk of bowel ischemia, hence the urgent need for surgical intervention. Internal hernias occur rarely, involving protrusion of intra-abdominal organs or mesentery into abnormal anatomic spaces . They caA 73-year-old male, a known patient of adenocarcinoma of the rectum for 1 year, who had undergone neoadjuvant radiotherapy and chemotherapy a year prior and got lost to follow-up, presented at our hospital with a 2-day-history of exacerbated colicky peri-umbilical and right-sided non-radiating abdominal pain, with associated progressive abdominal distension, aggravated by feeding. These were preceded by 2 weeks of difficulty in passing stool and gas , nausea and vomiting, initially bilious then overt fecal contents, loss of appetite and generalized body weakness. Two weeks before admission to our hospital, he had been managed nonoperatively for ‘appendicitis’ at a peripheral health facility without improvement, hence the referral. He had no history of any previous surgeries. Physical examination at admission was remarkable for a moderately distended abdomen with marked peri-umbilical and right iliac fossa tenderness, with reduced bowel sounds. On digital rectal exam, the rectum was empty with a tipped polypoid mass high up, ~8 cm from the anal verge. A contrasted abdominal computed tomography (CT) scan was done, which reported features of small bowel obstruction, rectal neoplasm with local metastases to the prostate and urinary bladder and mild pleural effusion with bilateral basal consolidation .Laboratory investigations performed at admission are presented in An exploratory laparotomy under general anesthesia was done. Intraoperatively, we found a large right retroperitoneal mass formed by a tuft of bowel that had herniated through a small tight (1.5 cm wide) opening just below the base of the cecum, creating a retroperitoneal pocket full of hemorrhagic fluid (~600 ml) and gangrenous ileum of ~30 cm, cecum and appendix. There was an associated ileal perforation ~15 cm from the ileocecal junction . The ganWe are currently following him up closely to avoid a repeat of the loss to follow-up to make the most of his chance at having the best possible outcome for the rectal cancer treatment.. These hernias can be categorized according to the anatomical areas they occur into six groups—paraduodenal, pericecal, intersigmoid, transmesenteric, pelvic and supravesical and those through the foramen of Winslow. Furthermore, the pericecal can be sub-categorized into superior ileocecal recess, inferior ileocecal recess, paracolic sulcus and retrocecal recess [A retroperitoneal hernia is a form of internal herniation that occurs rarely and poses difficulty with diagnosis. Since the first description of such a hernia by Treitz in 1857, a few case reports, especially of the adulthood-acquired form, have been reported in the literature  and nephl recess . The parl recess .. However, the peritoneal cavity and posterior peritoneal structure are complicated, and it is challenging to identify the abdominal ligaments, mesentery and peritoneum on the CT scan. The small intestine has relative freedom of movement, and its position is variable, making the pre-operative diagnosis even more difficult [.Internal hernias rarely cause intestinal obstruction, accounting for only 4% of all cases of small bowel obstruction. However, they can be fatal with mortality up to 50% if managed untimely, making early diagnosis very vital in preventing gut ischemia  The inciifficult .Our patient had a paracecal hernia that was spontaneous, presenting with features of small bowel obstruction and gangrenous bowel. It is elucidated in literature that paracecal hernias could be as a result of tissue weakening due to age, high intra-abdominal pressure and retroperitoneal adhesions among other factors . Most prWe present a unique case in terms of the spontaneous nature of a paracecal hernia unlike those reported following trauma or surgery. Age and neoplastic processes may lead to tissue weakening and may cause protrusion of organs through otherwise strong tissues. Therefore, presentations of acute abdomen or features of intestinal obstruction among the elderly should ring a bell for internal hernias and warrant immediate surgical management.None declared.No funding was received for this case report.Data used in this case report is available upon appropriate request from the corresponding author.


Myxomatous liposarcoma is an extremely rare type of mediastinal tumour that manifests in a manner comparable to other lung pathologies. Chest pain, shortness of breath, and dysphagia are the common presenting complaints. Radiological examinations or postoperative histological examinations provide the majority of the diagnostic evidence. The cornerstone of therapy consists of surgery and sometimes chemotherapy. Those who are afflicted have a better chance of experiencing favourable outcomes if they receive a diagnosis and treatment quickly. The most frequent type of malignant soft tissue tumour is liposarcoma, and it is mesenchymal in origin . It accoAn increase in the MDM2 and CDK2 genes that are located on chromosome 12 is a distinguishing feature of the tumour . In addiThis type of tumour occurs in the fourth and fifth decades of life . Of indiWith this review, we aim to shed light on this relatively unknown malignancy. We want to document a comprehensive review of the literature, which will help future clinicians accurately suspect, diagnose, and manage myxoid liposarcomas.We reviewed the existing literature using Google Scholar and PubMed. The keywords utilised in the search were myxoid and liposarcoma. These keywords yielded 22,900 results on Google Scholar and 1655 results on PubMed. We further narrowed the search to include the keywords “thorax, thoracic, mediastinal, case reports, and case series”, which gave us 7030 results on Google Scholar and 56 on PubMed. To narrow our search on Google Scholar, we used the advanced search option in which the same keywords were applied but this time limited to the title. This resulted in 10 results.McLean et al. reported a case of myxoid liposarcoma in the anterior mediastinum in 1989 . The patThe most common symptom reported in the literature is dyspnea, but Hamanaka et al.  and MaruOrtega et al. reported three patients with varying symptoms such as weight loss, dyspnea, and dysphagia . All thrZheng et al. published the findings of their experience with a patient who was a 14-year-old male . He was The two instances described in a case report by Hahn et al.  did not An interesting presentation of mediastinal liposarcoma was reported by Schweitzer et al. . The patThe longest RFS reported in the literature was reported by Miura et al., which was 51 months. They also reported the highest age in their case series, which was an 84-year-old female. Another notable exception in their case series was the use of the chemotherapeutic agent doxorubicin in the treatment of a 78-year-old male. All other patients cited in the literature have received surgery as initial treatment. However, doxorubicin was deemed ineffective, and two weeks later, he passed away as a result of respiratory failure. An examination of the patient's body after death indicated that the tumour was a dedifferentiated liposarcoma. However, the oesophagus, trachea, and major blood arteries had not been immediately penetrated by cancer .Similar age ranges, symptoms, treatment methods, and recurrence patterns have been cited by Fukai et al. , Hirai eMyxoid liposarcoma can be distinguished from other kinds of liposarcoma by the presence of a substantial myxoid matrix. In contrast to conventional liposarcomas, which have well-differentiated areas composed of mature or normal-appearing adipocytic elements, the tumour is made up of scattered round to oval-shaped non-lipogenic small cells that are admixed with a variable number of signet-ring lipoblasts embedded in an abundant myxoid stroma. In addition, the cells are scattered throughout the abundant myxoid stroma . It is aThe clinical presentation varies from person to person. There are no clear clinical signs in the early stages. Pain, oedema, and other symptoms appear when the tumour grows in size and location and creates pressure or invasion of the surrounding tissues. Displacement of intrathoracic structures causes signs such as shortness of breath, chest discomfort, wheezing, hoarseness, superior vena cava compression, and arrhythmias, as well as heart failure.Imaging studies such as chest radiography, CT, or magnetic resonance imaging (MRI), as well as results from histopathology, are used to diagnose liposarcoma. There is a possibility that tracheal deviation will be visible on chest radiography. It is possible to see, using CT and MRI, a fatty mass that also contains varying components of soft tissue .Excision of the tumour with surgery is the recommended course of therapy for liposarcoma . This enChemotherapy and radiation are not likely to be effective in treating the tumour . CDK2 inThe histological subtype of cancer has a significant role in determining the likely outcome of the disease. The least aggressive types of cancers are those that have been well-differentiated or undifferentiated. Both myxoid and pleomorphic subtypes are aggressive; they can spread to the pleural, pericardial, and diaphragmatic surfaces of the body and continue to grow. In addition to this, there is a significant rate of recurrence among these tumours . Age at In myxoid liposarcomas, the presence of a larger fraction of the round cell component is associated with an increased risk of developing a metastatic illness. In most cases, the metastases will take place in extrapulmonary locations. The 10-year death rate rises to between 30% and 60% in cancers that have a greater proportion of round cell components .Patients need to be evaluated periodically but the frequency of these evaluations should vary according to the kind of tumour present, the estimated rate of recurrence, and the degree to which the surgical excision was inadequate. Correct diagnosis helps choose the best treatment. MDM2 antibodies can aid with well-differentiated liposarcoma/atypical lipomatous tumour and dedifferentiated liposarcoma, although MDM2 amplification is suggested in unclear cases. Rarely, the hypercellular myxoid liposarcoma requires molecular testing to validate the DDIT3 gene rearrangement. Myxoid liposarcoma is an ambiguous diagnosis that may be applied arbitrarily due to a lack of a molecular signature or immunohistochemical profile. More research is needed to establish its diagnostic criteria. There are several odd or uncommon varieties that require education for correct identification.Myxomatous liposarcoma is a rare mediastinal tumour with a similar presentation to other lung pathologies. Mediastinal liposarcomas vary in morphology and can be aggressive and fatal. The diagnosis is mostly radiological or based on post-operative histology. Surgery is the mainstay of treatment. Prompt diagnosis and management can lead to favourable outcomes for those affected.


Subdural haemorrhage (SDH) as result of a traumatic brain injury (TBI) is a common cause of death in cases of fatal physical abuse. Since intracranial bleeding is a common finding in elderly due to age-related intracranial changes or increasing prevalence of anticoagulant medication, differential diagnosis between inflicted and non-inflicted head injury is challenging. A case of an elderly woman’s death caused by TBI is reported. Autopsy showed multiple polychromatic bruises and a frontoparietal hematoma with bilateral subacute SDH. History excluded paraphysiological or pathological non-traumatic conditions that could justify SDH, while iatrogenic factors only played a contributory role. Since polychromatic bruises distributed on the face, the upper extremities and the chest were consistent with forceful grasping/gripping or repeated blows and SDH can form in absence of impact or by mild/minor blows, SDH was considered the result of repeated physical abuses. Differential diagnosis between traumatic and non-traumatic SDH is still challenging for forensic pathologists. As largely accepted in the pediatric population and occasionally described also in adults, however, violent shaking should be also considered as a possible mechanism of SDH—especially in elderly who do not have any sign of impact to the head. In most countries, 65 is commonly the age of eligibility for retirement and old-age social programs and, therefore, this is the age at which individuals are mostly considered elderly ,2. In thElder abuse, also called elder mistreatment or elder maltreatment, is a violation of human rights. Article 25 of the Charter of Fundamental Rights of the European Union (adopted in Nice on 7 December 2000) recognizes and respects the rights of older people to lead a life of dignity and independence and to participate in social and cultural life. Elder abuse is defined by the World Health Organization (WHO) as a single or repeated act, or a lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person .It includes different categories: physical abuse—that is, a violent act carried out with the intention to cause physical pain or injury to an older adult; sexual abuse, defined as nonconsensual sexual contact of any kind; psychological or verbal abuse—that is, a violent non-physical act intended to cause emotional pain to the elder; financial exploitation, defined as misappropriation of an older person’s money or property; neglect—that is, intentional or unintentional failure by a caregiver (active or passive caregiver neglect) or oneself (self-neglect) to provide the elderly with proper care. The National Aging Resource Center on Elder Abuse (NARCEA) also comprises a miscellaneous group including violation of an individual’s rights, such as exclusion from decision-making processes dealing with health, personal issues and marriage ,10,11.Elder maltreatment is a widespread, though often underestimated, phenomenon ,11,12,13Among the additional reasons for under-reporting, there are also problems of identifying elder abuse. Elder adults are in fact frequently reluctant to tell of the mistreatment they suffer. A lack of education and formal training among healthcare workers in recognizing abuse and the protocols for reporting abuse to judicial authorities as required by law have also been mentioned. However, one of the main reasons is also the following: the identification of abuse is mostly an uncertain diagnosis, which increases practitioner’s fear that they may do more harm by taking action.Kleinschmidt in particular emphasized that physicians often have fear of offending patients and their families . Clarke Physical abuse and neglect are forms of abuse that are frequently seen among deaths from elder maltreatment .Physical signs of abuse may overlap with the symptoms and outcomes of various diseases or side effects of medications ,10,11. FUnfortunately, ischemic strokes and non-traumatic intracranial bleeding including subdural hematomas, intraparenchymal hemorrhages, subarachnoid hemorrhages may mimic the effects of blunt trauma, with similar symptoms such as headache, altered mental status or focal neurological deficits ,29,30,31We report a case of an elderly woman’s death caused by TBI and the difficulties related to differential diagnosis between inflicted and non-inflicted traumatic injuries in elderly people in judicial cases.A 82-year-old Caucasian woman living with her husband and a caretaker was found at home unconscious and unresponsive. The caretaker said the old woman had been put to bed about two and a half hours before. Soon after the reported finding, the woman was transported to a third level hospital’s Emergency Department. A medical history of widespread cortical atrophy, progressive cognitive impairment, depression, hypertension, hypercholesterolemia, osteoporosis, megaloblastic anemia and mild renal insufficiency was reported. The therapy adopted before the hospitalization was represented by antidepressants such as trazodone, medications for treating high blood pressure such as anti-calcium channel blockers (amlodipine) and platelet aggregation inhibitors such as ticlopidine. A cranioencephalic CT-scan showed a right parieto-temporal subdural hematoma (SDH), 21 mm thick, compressing the right lateral ventricle and third ventricle, causing a midline shift of about 9 mm. Additional findings were represented by a left temporo-occipital SDH, 8 mm thick, right temporo-basal intraparenchymal hemorrhages and blood in the fourth ventricle A. No fra2. She was 149 cm high and 41 kg in weight. Subcutaneous tissue was low. Multiple bruises were found on the head and face, neck, thorax and upper and lower extremities : no eye opening; no verbal response; no motor response. The GCS was permanently equal to three until brain death was pronounced, four days after unsuccessful intensive care. At a post-mortem examination, the patient was under-weight, with a Body Mass Index (BMI) of 18.47 kg/mremities A–C.Over the sacrum there was a small area of skin loss resembling a bedsore at a very early stage. In total, 56 small bruises associated with macroscopic bleeding into the skin were detected. Bruises of different sizes were represented, mostly oval/round in shape, ranging from 0.5 cm up to 6 cm in diameter, and from red through purple to yellow/green in color. Cranial bruises were mostly located on the vertex but also on the root of the nose and on the left side of the face . Multiple contusions were also distributed in the dorsal and lateral surfaces of the upper extremities and lateral breast on both sides, consistent with forceful grasping/gripping or repeated blows. At autopsy, a frontoparietal hematoma, 4 × 3.5 cm in dimension, was associated with a bilateral subacute SDH, approximately 2 cm thick, with fresh coagulated blood between the arachnoid and dura mater. No skull fractures and no traumatic injuries of the hyoid bone were found. Unfortunately, no ophthalmic examination was performed; neither the optic nerve nor the eyes were removed at autopsy. At the neck, no hemorrhages of the soft tissue were found. The heart showed coronary atherosclerosis with mild non-obstructive plaques. Toxicological analyses were negative for alcohol and common illicit and licit drugs in peripheral blood samples as well as in hematoma blood samples. Microscopic examination of bruises and SDHs was performed using basic histological stains such as hematoxylin-eosin. The main purpose of the histological examination was to search for tissue characteristics useful for determining the age of the brain and skin injuries. In fact, although bruises cannot be aged by their color, the color may enable one to suspect whether a skin injury is fresh or not fresh, to then be confirmed by conventional histology. According to the histological examination of the scalp, face, chest and upper and lower extremities, skin samples were collected and more than 10 bruises were assessed to be older than 5 days. These were from blue/purple to yellow/green in color and were located at the face, the breast and the upper limbs. The main microscopic findings were the detection of granulation tissue with new capillary blood vessels, dense collagen fibers with fibroblasts and scar tissue and the infiltration of macrophages and lymphocytes . These hThe SDHs showed histological findings consistent with subacute hemorrhages older than 5 days but less than a week, as represented by the formation of granulation tissue with associated breakdown of erythrocytes and some siderophages. A thin layer of fibroblasts was observed between the dura and the clot, and the latter was invaded by new capillary blood vessels . IntenseDeath was finally assessed to be due to a mechanical closed brain injury, represented by SDHs causing cerebral compression, in a frail elderly woman with cognitive impairment. Based on this assessment, the TBI was the result of a physical abuse by slapping, pushing, shaking and kicking according to the multiple bruises in different anatomical regions.TBI is a common cause of death in all age groups, mostly resulting from an impact suffered in traffic or sport accidents, accidental falls, violent blows delivered by hands, feet or different types of weapons  or objects falling on the head. However, closed brain injury can also be the result of a non-contact trauma associated with a violent head motion due to acceleration/deceleration and rotational movements, as occur in shaking. In violent shaking, rapid acceleration/deceleration movements of the skull in relation to the trunk are inflicted to an individual held by the upper extremities or the thoracic region. The mechanism of shaking as a significant mechanism of brain injury has been widely accepted in the pediatric population and is better known as “Shaken Baby Syndrome” (SBS), a definition that has been changed by a consensus statement to “Abusive Head Trauma” (AHT). The etiology of AHT is multifactorial, including shaking, shaking with impact, impact alone, etc. . The claAs above mentioned, rapid deceleration/ acceleration of the head or rapid changes in rotation and angular forces can easily occur during a violent shaking, resulting in tears of the bridging veins that drain blood into the dural venous sinuses ,31 in adIn the discrimination of falls versus blows, the hat brim rule can be a moderately valid tool—especially if associated with other criteria . AccordiElder abuse is associated with significant morbidity and mortality. Although SDH is commonly the result of a TBI, it can be also related to non-traumatic intracranial bleeding. Therefore, the traumatic and non-traumatic origin of SDH is still a challenge for forensic pathologists. As largely accepted in the pediatric population and also occasionally described in adults, violent shaking should be also considered a possible mechanism of SDH—especially in elderly individuals who do not have any sign of impact to the head. Intracranial age-related changes and the common use of anticoagulant/antiplatelet medications can be factors contributing to tears in bridging veins and space-occupying hemorrhages such as SDH, even after a minor head trauma. The possibility of a minor or occult head impact should be always considered in elderly people with SDH, as in the present case. However, according to the main biomechanical aspects of SDH, non-contact mechanisms such as violent shaking can also cause intracranial bleeding, and they should be taken into account when no skin wounds or skull fractures are present. The opportunity to perform an accurate death investigation is strongly recommended, as it should necessarily proceed with a forensic autopsy ,51.


Mycobacterium marinum, in a young, immunocompetent patient, with a prolonged evolution, diagnosed through a skin lesion culture (from a spindle biopsy of the skin). The patient was treated with multidrug therapy, including clarithromycin, doxycycline, and rifampicin, due to the lesion extent, with satisfactory results. A brief review of the literature is also provided.The number of skin infections caused by atypical mycobacteria has increased in recent decades. They usually appear after contact with wounds and interruptions in the integrity of the skin. The present report describes a case of cutaneous infection by  The number of skin infections caused by non-tuberculous mycobacteria (NTM) has been increasing in recent decades.The cutaneous disease usually arises after the contact of interruptions in the integrity of the skin (such as wounds caused by trauma or surgery)Its diagnosis is difficult and requires clinical suspicion due to a history of local trauma with subsequent contamination, which is confirmed by culture of the lesion.3The treatment is prolonged. When possible, it should be based on the susceptibility rates of the bacteria causing the infection.Mycobacterium marinum addressing its diagnostic difficulty and therapeutic management.The authors of the present study report below a case of cutaneous infection by th left finger (LF) 15 years before, after trauma with a perforating-cutting tool. It developed a papule and exudation, with subsequent progression of the lesion to the dorsal aspect of the hand, forming an erythematous-verrucous plaque with nodules and crusts and evident atrophy of the 5th finger .3Clinical suspicion is necessary for the diagnosis to be made. A biopsy with histopathological analysis and culture of the lesion should be performed.The treatment depends on the species, extent of the lesion, and the patient's immunological status.3Mycobacterium marinum with a long evolution and difficult diagnosis, emphasizing the importance of clinical suspicion, and of performing multiple biopsies of the lesion for culture and histopathological confirmation.This case report describes a case of skin infection caused by None declared.Angélica Seidel: Design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature.Daniel Holthausen Nunes: Approval of the final version of the manuscript; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Camilo Fernandes: Approval of the final version of the manuscript; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Gabriella Di Giunta Funchal: Approval of the final version of the manuscript; critical review of the manuscript; design and planning of the study.None declared.


Liposarcomas are rare mesenchymal tissue tumors and are divided into subtypes based on their histopathological characteristics. They are mostly well-differentiated neoplasms with the tendency to recur locally. Lymph node involvement or distant metastases have been reported as extremely rare. Common manifestations are progressive dyspnea, dysphagia, choking, and stridor. Surgical excision of laryngeal liposarcomas is considered the gold standard treatment modality for disease eradication. In persistent or recurrent cases, a total laryngectomy should be performed. There is much controversy regarding the role of radiotherapy which is mostly used as adjuvant treatment in specific cases. We present a case of dedifferentiated laryngeal liposarcoma with multiple recurrences and metachronous transformation to a neoplasm with myxofibrosarcomatous elements.  Squamous cell carcinoma is the most common neoplasm of the larynx . Non-squSurgical excision is considered the gold standard treatment modality . Total lA 78-year-old, non-smoker male presented to the Otolaryngology Department with the chief complaint of a two-month history of progressive dyspnea. Hoarseness, difficulty in swallowing, and loss of appetite were also reported as accompanying symptoms. The patient’s medical history included ischemic heart disease and benign prostate hyperplasia. He was hemodynamically stable with mild inspiratory stridor.A thorough physical examination was performed. Inflexible laryngoscopy revealed a large supraglottic mass. The vocal cords were barely visible, without clear glottis involvement. A neck examination did not reveal palpable lymph nodes. Laboratory tests were normal. Magnetic Resonance Imaging (MRI) revealed a 5.3cm x 3.9cm mass in the supraglottic laryngeal region with inhomogeneous paramagnetic contrast agent uptake and repulsion of adjacent anatomical structures. No infiltration was noted Figure . A biopsy via direct microlaryngoscopy was performed. Histology indicated the presence of a malignant tumor with elements of an atypical lipomatous tumor/well-differentiated liposarcoma  and restricted areas comprising a non-lipomatous sarcoma, establishing the diagnosis of dedifferentiated liposarcoma. Immunohistochemistry showed S-100 and CD34 positivity in alt/wdl constituents, while desmin and H-caldesmon stained the non-lipomatous sarcoma areas of the neoplasm Figure . Subsequently, the tumor was extracted via a transoral approach, under general anesthesia and the histology report confirmed the diagnosis of dedifferentiated liposarcoma.Two months later, the patient presented for his follow-up appointment and local recurrences were detected. A smooth outlined 3cm lump was firmly attached to the thyroid cartilage, and a second mass in the right arytenoid cartilage was found. Both masses were excised and concomitant histopathological examination reconfirmed the initial diagnosis of dedifferentiated liposarcoma.Twelve months later, the patient presented again to our Emergency Department with stridor, dyspnea, and occasional choking episodes. Flexible nasolaryngoscopy revealed a huge mass occupying almost the whole larynx. A tracheotomy under local anesthesia was performed to secure the airway and the tumor was resected under direct microlaryngoscopy. The histology report described the presence of a foci with myxofibrosarcomatous elements among the sarcoma, evident in the alcian blue histochemical stain Figure . Our hospital's multidisciplinary team (MDT) recommended adjuvant neck radiotherapy due to the tumor's persistence and histopathological characteristics. The patient received a total dose of 4200 cGy in 14 sessions. Twelve months after radiotherapy, the patient remained free of disease. He died eight months later due to a heart attack episode.Liposarcomas are malignant mesenchymal tissue neoplasms, emerging from the adipose tissue and represent the second most common soft tissue sarcoma . Less thMost of these cases involve the supraglottic larynx . The maiMRI is a helpful tool in establishing the diagnosis to distinguish liposarcomas from lipomas. However, imaging studies are not always adequate to determine the diagnosis . HemorrhEndoscopic resection should be performed only in limited cases, due to the recorded tendency of well-differentiated liposarcomas to recur at an extremely high rate , 7, 8. TDedifferentiated liposarcomas have typically the appearance of undifferentiated pleomorphic or spindle cell sarcomas and arise de novo or in association with a preexisting well-differentiated liposarcoma . In neopHead and neck liposarcomas constitute a rare clinical entity. They should be included in the differential diagnosis of laryngeal masses, especially in middle-aged or older patients. A timely diagnosis and treatment require high clinical suspicion. Wide surgical excision is reported to be the most appropriate treatment modality. More studies are required to clarify the role of radiotherapy and chemotherapy. To the best of our knowledge, this is the first case of dedifferentiated laryngeal liposarcoma with a metachronous transformation into a neoplasm with myxofibrosarcomatous elements.