Renal angiomyolipoma (AML) are benign tumors, often incidentally diagnosed with rupture being the commonest complication and cause of mortality. These tumors are rare with a higher prevalence among patients with tuberous sclerosis and female predominance. Management is dependent on tumor size and whether or not the tumor has ruptured.32-year-old female presenting with sudden right flank pain with shock without history of prior trauma or surgeries. Underwent imaging revealing a suspected ruptured AML thus underwent emergent nephrectomy with admission to intensive care.Wunderlich syndrome manifests as the Lenk triad, which includes acute flank pain, flank mass, and hypovolemic shock with signs of internal bleeding such as hematuria. It is a rare manifestation signifying spontaneous renal hemorrhage. Due to the instability of the patient had to undergo emergency laparotomy and nephrectomy.Renal AML occur as a rare benign phenomenon which when ruptured are associated with high mortality rate if not treated promptly in a setting with specialized treatment and intensive unit care. We hope that through our experience patients presenting with Lenk's triad are identified early for adequate intervention. •Suspicion index for patients with Lenk triad•Rarity of spontaneous rupture of angiomyolipoma•Clinical implications for spontaneous tumor rupture•Awareness of flank pain with hypotension However2A 32-year-old female presented with sudden right flank pain for 2 h to the Accidents & Emergency Department without prior history of trauma. Also had nausea and vomiting however no episodes of visible hematuria, fevers, unintentional weight loss, easy fatiguability nor shortness of breath reported. She did not have any significant drug allergies, family history of malignancies, comorbid nor prior history of surgeries. She was nulliparous, on her third day of menstrual cycle, did not smoke nor consume alcohol.On examination she was alert, afebrile, pale, not cyanotic, tachycardic with pulse rate ranging between 100 and 115 beats per minute and a blood pressure on the lower limit at 95/63 which improved to 105/69 with initial fluid bolus. Per abdominal examination revealed a normal contour, without surgical nor therapeutic scars. She had significant tenderness noted at the right flank without discoloration of overlying skin and positive right renal angle tenderness. Rest of abdomen was soft without palpable organomegaly, tympanic percussion note and normal bowel sounds.Initial blood work up revealed leukocytosis predominantly neutrophilia with a hemoglobin level of 7.4 g/dL, elevated creatinine level of 102.13 umol/L, negative serum Beta HCG test, and urine analysis significant for 10–25 red blood cells/hpf. A contrasted Computed Tomography scan  of the aA midline incision made with dissection into the abdominal cavity and duodenum kocherized to expose retroperitoneal contents. A retroperitoneal hematoma extending into the right paracolic gutter displacing overlying bowel to the left was seen which encased the right renal hilum as well as the inferior vena cava. Encased within the hematoma revealed a right kidney with fungating mass extending from the mid to the upper pole, suspicious of a ruptured AML . The hemPost-operative was sent to the intensive care unit for close observation to receive 3 more units of blood, having received 2 units with 6 units of fresh frozen plasma at the emergency department, and fared well with no complications and vitals had normalised. Was transferred out by day 3 and by day 5 discharged home while tolerating regular feeds, ambulating and pain controlled with oral analgesia and a hemoglobin level of 11 g/dL. Follow up in the outpatient department was uneventful.Histopathology showed benign renal parenchyma with tumor composed of mature adipose tissue, thick-walled dilated blood vessels which are congested and spindle (rhabdoid like) to round to oval cells with some pleomorphism, others with vesicular chromatin and prominent nucleoli. Few scattered mitoses were seen. Hemorrhage and necrosis were present with free ureter and renal hilar vessels. Hence confirming diagnosis of right ruptured renal AML.3Wunderlich in 1856 first described the clinical picture of spontaneous renal bleeding confined to subcapsular or perinephric space in patients with no known underlying cause [Treatment of AMLs includes active surveillance, surgery , selective angioembolization, thermal ablation, or systemic therapy with mTOR  inhibitors . Once a Upon completion of diagnostic evaluation, if indications for surgical resection are not present, active surveillance should be used to monitor progression in size and to identify development of new ones . NephrecSelective Arterial Embolization  of renalManagement of patients with spontaneous rupture is more individualized rather than the stepwise approach for an incidentally discovered AML. Factors based on hemodynamic stability and expertise availability dictates management hence due to the unstable nature of our patient we went in for an emergency laparotomy and nephrectomy so as to control the hemorrhage and facilitate adequate resuscitation with blood products in the ICU.4Renal AML occur as a rare benign phenomenon which when ruptured are associated with high mortality rate if not treated promptly in a setting with specialized treatment and intensive unit care. In our setting, there is under-reporting as well as missed diagnoses of renal AML, making our case report essential. We hope that through our experience of successful treatment approach to spontaneous rupture of AML, practitioners, particularly in resource limited settings, will be able to suspect individuals presenting with Lenk's triad so as to diagnose them early and manage them accordingly.AMLangiomyolipomaCTComputed TomographyHUHounsfield unitsLAMlymphangioleiomyomatosisSAEselective arterial embolisationTSCtuberous sclerosis complexI was very worried when I went to the hospital, everything was going so fast and being told I need an emergency operation was very stressful. However, looking back, I am very grateful to the team in charge of my care and can still not believe how having the tumor on my kidney made me so vulnerable.Written informed consent was obtained from the patient for publication 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.Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval is not required at our institution  for case reports if patient particulars are not disclosed.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.N.C: Study conception, production of initial manuscript, collection of data, proofreadingA.I: Revision of the manuscript, proofreadingS.P: Revision of the manuscript, proofreadingA.D: Revision of the manuscript, proofreadingH.U: Production of initial manuscript, collection of data.A.Z: Study conception, production of initial manuscript, collection of data.Dr. Aliakbar Zehri.1.Name of the registry: RESEARCH REGISTRY2.Unique identifying number or registration ID: researchregistry95893.https://www.researchregistry.com/register-now#userresearchregistry/registerresearchdetails/6524157f5a974c0028f90483/Hyperlink to your specific registration (must be publicly accessible and will be checked): No conflicts of interest.


Ultrasound is the modality of choice for detecting the causes of acute scrotal pain and diagnosing scrotal pathologies. Pyocele is a term used for describing the purulent fluid collection in the scrotal sac, which may present to the hospital as a complication of testicular abscess, epididymal-orchitis, or post-trauma. Ultrasound is the modality of choice for diagnosing such pathologies. The presented case is of a young male from rural India who developed a pyocele post-trauma and underwent an ultrasound examination, where it was found to be a ruptured pyocele with contents spreading into the hemi-scrotum. Rupture of the tunica is frequently associated with the hematocele; however, pyocele is less commonly associated with rupture. The case report discusses the causes of pyocele, imaging features, management, and complications of this pathology along with other possible differential diagnosis. Scrotal pyocele, a rare urological emergency, is defined as a purulent collection between the visceral and parietal tunica vaginalis layers surrounding the testicle. Pyocele may develop through sexually transmitted infections, intra-abdominal infections, or due to trauma -3. UltraA 28-year-old male came to the emergency department with complaints of pain in the left hemi-scrotum which was appearing red and swollen with a gradual increase in the swelling for three days. On inspection, the left hemi-scrotum appears red and swollen with loss of crease, giving a smooth and shiny appearance. On examination, the scrotum was hot and tender on touch with signs of inflammation. The patient was advised to undergo an ultrasound investigation to determine the cause of the pain and swelling.On ultrasound investigation, there was a heterogeneous collection between the scrotal sac and testes with multiple hyper-echogenic debris within, giving a falling snow sign. The collection measured approximately 6 x 5 x 3 cm and was causing a mass effect in the form of displacement of the left testes towards the right as shown in Figure The collection was noted adjacent to the left testicle, and there was a disruption in the continuity of the tunica layers with defect of size approximately 1 cm. The contents are noted to pass out of the ruptured membrane and visceral tunica vaginalis appears intact, as shown in Figure No calcification or air foci were noted within the collection. The size, shape, vascularity, and echotexture of the right testicle appear normal. The patient has a history of trauma to the scrotal sac seven days ago when a rod hit the scrotal sac while working in a field. No significant history of unprotected sexual intercourse, urinary tract infection or sexually transmitted infection.The patient underwent emergency surgical exploration with debridement and excision of the devitalized tissues. A tissue culture was sent to the microbiology department to find out the pathogen behind the formation of the pyocele. The patient was then discharged and advised to follow up after three weeks to check for the status of the post-operative scrotum.The purulent collection between the visceral and parietal tunica vaginalis layers surrounding the testes is called pyocele. There are various routes through which micro-organisms reach the scrotal sac, which may include transmission via the sexual route, intra-abdominal infections, or trauma -3.Epididymo-orchitis and epididymitis are the most common causes of acute presentation of scrotal pain, which, when left untreated, might lead to an abscess formation or infarction . NeisserHydrocele is an acquired or congenital serous fluid collection between the two layers of tunica vaginalis and is the most common cause of painless scrotal enlargement. Ultrasound shows simple fluid collection, which shows no vascularity on the color Doppler. Sometimes, the collection may be septated and may occasionally contain calcifications and cholesterol .Hematocele is a vital differential that develops as a sequel to trauma to the scrotum, occasionally after surgical intervention. Some authors report that varicocele is considered a significant risk factor for the development of hematocele. Ultrasound is the first-line imaging modality which shows collection with increased echogenicity and often septa within. In cases of fresh hematocele, the collection might appear anechoic, though some turbulence will occasionally be seen within it . The preTesticular trauma is the third most common cause of acute scrotal pain . VariousPyocele can be managed conservatively by fluid resuscitation, pain management, and empirical antibiotics . HoweverThe presented case had a history of trauma, following which the patient developed pyocele. He underwent an ultrasound investigation, which confirmed the presence of heterogenous collection between the two layers of tunica vaginalis with rupture of the tunica and leakage of contents outside. Immediate surgical exploration with debridement and excision of the devitalized tissues was performed.Complications may include Fournier gangrene, a necrotizing infection involving both the superficial and deep facial planes and can be fatal if not treated in time. Computed tomography is the modality of choice for diagnosing Fournier gangrene .Pyocele is an acute scrotal emergency that needs immediate management. Hematocele must be considered the first differential diagnosis in cases of ruptured membranes of the scrotal sac; however, pyocele should not be simply ruled out. Early detection of the cause of acute scrotal pain must be done with prompt, timely management to prevent any complications. Surgical management remains the gold standard treatment for the pyocele.


We report a 20‐year‐old man with neurofibromatosis type 1 presenting with frequent episodes of suprapubic pain. The episodes started 6 months ago, occurred 1 h a day, and were not related to urination. A prostate‐sparing cystectomy with orthotopic diversion was performed. Histopathological assessment of the specimen confirmed bladder plexiform neurofibromatosis.  The altered gene products play a role in the dysregulation of tumor suppression. Neurofibromatosis type 1 (NF1), neurofibromatosis type 2, and schwannomatosis are three types of the disease, which differ regarding the age of onset, clinical manifestations, and gene loci.NF1, also known as von Recklinghausen disease, is the peripheral type of the disease affecting several systems in the body. It manifests at birth or early childhood with classic symptoms of multiple hyperpigmented (café‐au‐lait) macules, intertriginous freckling, cutaneous neurofibromas, and varying levels of cognitive impairment. Although NF1 is mainly inherited as an autosomal dominant pattern, sporadic mutational change is also frequent.Regarding the very rare nature of bladder involvement in NF1 and the lack of sufficient data about its diagnostic and treatment approaches, formulating the diagnosis in the first place, and providing accordant management is of great importance. Therefore, this case report aims to lead the audience's mind toward bladder involvement as one of the rare but important complications of NF1, to be able to take timely relevant measures. Herein we report a case of NF1 with diffused bladder involvement in a 20‐year‐old man who presented with frequent episodes of suprapubic pain but did not complain of any urinary symptoms.2A 20‐year‐old man was referred to the department of Urology, affiliated with Isfahan University of Medical Sciences, complaining of frequent episodes of suprapubic pain. The pain episodes had started 6 months ago, occurred once a day, lasted approximately 1 h, were accompanied by nausea and constipation, and were not related to urination. He denied any lower urinary tract symptoms (LUTS), gross hematuria, or significant weight loss since the beginning of the symptoms.The patient had a past medical history of sporadic neurofibromatosis with no positive family history. He had previously undergone outpatient surgical removal of some of the cutaneous neurofibromatosis tumors on the forearm and back Figure , as wellA physical exam noted an overweight individual compatible with his age. All of the vital signs were within the normal range. There was mild tenderness in the suprapubic region and various café‐au‐lait lesions were observed on the abdomen, feet, shoulder, and forearms Figure . Other sA multi‐detector computed tomography (MDCT) of the abdomen and pelvis with contrast medium injection was performed to further investigate the cause of the chronic suprapubic pain. The results revealed diffused bladder wall thickening, as well as a high attenuated lobular marginated mass in size of 83*76 mm involving the superior and posterior parts of the bladder protruding into the lumen and causing a pressure effect Figure .Since the patient had previously experienced visceral neurofibroma, bladder neurofibroma was considered our first differential diagnosis; however, other bladder tumors could not be ruled out without histopathological confirmation.A pre‐operative biopsy for detecting the tumor type was not indicated since tumor excision was necessary due to the significant impact of chronic pain on the patient's quality of life. Given the tumor's large size, an open laparotomy approach was conducted in order to excise the tumor and investigate other adjacent structures. Under general anesthesia, in the supine position, the bladder was approached by a mid‐line sub‐periumbilical laparotomy. After resecting the adjacent fascia, a large mass with invasion to the dome, trigone, and posterior part of the bladder was detected. In addition, the bladder appeared deformed and tumorous with several adhesions to the rectum and peri‐vesical fat; therefore, resection of the primary tumor alone did not seem to be effective, and we intended to perform a prostate‐sparing cystectomy along with orthotopic urinary diversion, using approximately 60 cm of the ileum with proper vascular base.The resected specimen was sent to the pathology department. Macroscopic evaluation demonstrated a urinary bladder measuring 14*8*4.5 cm on the external surface containing serosal and muscular walls and multiple masses with the largest diameter of 2 cm Figure . HistopaThe postoperative course was uneventful and the patient was discharged 5 days later in good general condition. On an outpatient follow‐up visit after 6 months, the pain was completely resolved and he did not complain of any urinary symptoms.3Bladder involvement in NF1 is very rare and mostly affects the age group of 7 to 28 yearsClinical manifestations are often associated with the mass effect and include irritative LUTS, hematuria, and recurrent urinary tract infection.No definitive criteria have been established for diagnosing bladder neurofibromatosis; however, the diagnosis is initially formed based on clinical and radiological findings and later confirmed by histopathology. Both magnetic resonance imaging (MRI) and CT‐scan could be used to identify the tumor. Data regarding the representative radiological findings is scares. Castillo et al. described bladder wall thickening as the most distinctive radiological feature.MRI is believed to be the imaging of choice, especially in cases of abdomino‐pelvic involvement. It is superior to CT‐scan regarding its ability in distinguishing benign and malignant lesion as well as identifying small neurofibromas with rather atypical features.Histopathologically, bladder involvement usually exhibits diffuse proliferation of uniform neurofibromas containing multiple nests of medium‐sized spindle cells with elongated wavy nuclei and myxoid stroma. In addition, mast cells could be present in small numbers within the stroma.In general, there is a 30% chance that a neurofibroma would undergo malignant degenerationRegarding the variable clinical manifestations and the difference in severity and type of bladder involvement, every patient must be approached individually in terms of management modalities. Surgical excision of the tumor seems to be the most adopted method.In conclusion, contrary to the majority of the literature, the distinguishing feature of our case was the absence of any urinary symptoms despite the great occupation of the bladder. One should always rule out malignancy in cases of bladder involvement. This article emphasizes the importance of timely identification of bladder neurofibromatosis and having a holistic vision while choosing the appropriate management option.The presented figures have been created by the authors who confirm that they are original and not copied from elsewhere.Saina Paymannejad: Investigation; validation; visualization; writing – original draft; writing – review and editing. Pardis Rafei Dehkordi: Investigation; methodology; project administration; visualization; writing – original draft. Reza Kazemi: Conceptualization; methodology; project administration; resources; supervision.The authors would like to express their gratitude to the study patient who signed written consent for publishing this information.This report did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Desmoplastic fibroma (DF) is an aggressive benign tumor that commonly affects long tubular bones. Also, the skull, mandible, pelvis and spine involvement have been reported. However, its occurrence in the scapula is extremely rare. In this case report, we present the challenging diagnosis and successful treatment of DF in a 27-year-old woman who had been experiencing worsening pain in her right shoulder for 5 years. Plain radiographs and magnetic resonance imaging revealed a lucent, trabeculated and expansile infiltrative lesion, disrupting the posterior cortex and extended to the posterior soft tissue. After ruling out malignancy through a core needle biopsy, the patient underwent wide surgical resection of the tumor, which involved a hemi-scapulectomy. And histologic diagnosis consistent with DF, no postoperative radiation was administered. Remarkably, the patient became pain-free just 2 weeks after surgery. Follow-up examinations, X-rays and computed tomography scans conducted 6 weeks, 6 months and 18 months after surgery revealed no signs of recurrence. Desmoplastic fibroma (DF) is one of the primary benign-aggressive bone tumors, which includes 0.06% of bone tumors and 0.3% of all benign bone tumors , 2. SincThis study aimed to discuss the clinical, histological, immunohistochemical and radiographic characteristics of this rare neoplasm; a few case reports about DF have been published.A 27-year-old woman presented to the Orthopedic clinic at the Imam Khomeini Hospital, Sari, Iran, in December 2020 with a 5-year history of pain in the right shoulder without follow-up. The pain had initially been dull, activity-dependent and relieved by the occasional oral administration of an analgesic. The pain gradually progressed in intensity during the 6 months before the visit. The patient reported continuous consumption of analgesics. The patient was a housekeeper who had not engaged in any strenuous or specific physical activity. There was no family history of lesions or masses. During examination, there is no redness, warmth or nodules present upon palpation of the skin. There is no evidence of pigmentation.No deformity was found in the right shoulder; in palpation, a tender 2 × 2 cm mass was felt in the scapula area. The range of Motion was painful in all directions, but there was no limit to the passive Range of Motion. The neurologic exam was normal, and no hypoesthesia was detected.P = 3, Alkp = 117, PTH = 30.5, ESR = 5, CRP = 3.3).Plain radiographs revealed a trabeculated, lucent, expansile lesion with cortical destruction in the scapula, and a soft-tissue mass also was seen . ComputeAn expert intervention radiologist performed a CT-guided core needle biopsy, and no evidence of malignancy was seen, and the section demonstrated portions of tissue composed of degenerated bone.Wide surgical resection of the tumor (hemi-scapulectomy) was performed with the patient under general anesthesia. Through Judet Approach . The remHistological examination of the bone specimen following the tumor resection revealed mesenchymal neoplasm composed of whorled bundles of well-differentiated spindle-shaped cells with rare mitotic activity and foci of myxoid stromal changes and some bony trabeculae also noted; the appearance was in accordance with a fibroblastic desmoid tumor of the bone a (desmoid type fibromatosis) . The immNo postoperative radiation of the lesion was performed. The patient became pain-free after 2 weeks. Postoperative follow-up examinations and X-rays, and CT-scan 6 weeks and 6 and 18 months after surgery showed no signs of recurrence.DF of bone is an extremely rare, locally aggressive benign bone tumor. The WHO described the microscopic appearance of DF as being composed of slender, spindle-to-stellate cells with minimal cytological atypia, few mitoses and an abundant collagenous matrix , 6, so tDF has been reported in all age groups but is more common in the second and third decades  as our pet al. [The long tubular bones are often involved, but the involvement of the skull, mandible, pelvis and spine has been reported , 7. Veryet al.  reportedet al.  as our cet al. [On plain radiography, the tumor appears to be a well-circumscribed lytic lobulated lesion with a narrow transition zone and, frequently, a thin rim of reactive bone with or without cortical destruction , 10. On Metastasis and malignant transformation have not been reported in patients with DF, but local recurrence is common after simple curettage, between 37% and 72% , 10, so Through this case report, we highlight the importance of early detection, careful evaluation and multidisciplinary management of DF, particularly when it occurs in rare sites such as the scapula.


Although vulvar lesions are mostly malignant, polyps represent one of the most frequent benign tumors of the vulva, typically measuring less than 5 cm in size. Larger lesions are uncommon and are likely the result of mesenchymal cell growth in the hormonally responsive subepithelial stromal layer of the lower genital tract. Typically, vulvar polyps are asymptomatic in their initial stages, and patients often delay seeking medical attention due to sociocultural factors. In this report, we present a case of a giant vulvar polyp and examine the underlying etiology and symptoms of this condition, highlighting the life stages of women that are most frequently affected. Additionally, we emphasize the rare but potential occurrence of malignant forms. Fibroepithelial stromal polyps (FEPs) are commonly observed in women of reproductive age and typically manifest in the vagina, although they may also occur in the vulva and cervix with a lower frequency . Soft tiUpon presentation at our clinic, a 21-year-old female patient with a BMI of 22 presented with a mass located on the right vulva, which has been present for a duration of two years and exhibited recent growth over the past six months. In accordance with ethical guidelines governing the use of data and images, informed consent was obtained from the patient. The patient has refrained from engaging in sexual intercourse for a duration of two years, citing discomfort arising from the presence of a mass. Recently, the patient has reported a significant increase in the size of the aforementioned mass, further exacerbating the associated discomfort and cosmetic concerns. Physical examination revealed a painless mass of approximately 4 cm, originating from the inferior-posterior aspect of the right labium majus, extending to the thigh region, and measuring 10 cm in size. The mass was slightly firm to the touch and covered with normal skin, as depicted in Figure During the internal genital examination, no pathological findings were detected. Similarly, transvaginal ultrasonography revealed no abnormalities. The radiology department reported that the superficial ultrasonography results showed soft tissue elements. Given the location of the mass, both visual examination and superficial ultrasonography were used to rule out herniation. The patient was prepared for surgery, and under spinal anesthesia, excision of the mass and vulvar reconstruction were performed. The excision material exhibited a slightly firm consistency, measured 9 x 6 x 3 cm in size, and weighed approximately 100 g, as depicted in Figure Upon pathological examination, a macroscopic observation revealed an ulcerated polypoid, a soft-consistent lesion on the surface. In the histopathological evaluation, a tissue covered with keratinized stratified squamous epithelium was observed on the surface, along with ulceration and granulation tissue in one area, and a hypocellular stroma lacking skin appendages. Immunohistochemical examination revealed desmin positivity for estrogen receptor (ER) Figure .Based on these findings, the lesion was diagnosed as a fibroepithelial polyp, with stromal cells exhibiting sensitivity to hormones, as evidenced by ER staining Figure .Fibroepithelial polyps are benign lesions and may be an indicator of a hyperplastic process involving the subepithelial myxoid stroma, commonly mistaken for a malignant tumor. They are mostly small in size, the same color as the skin, and do not produce any symptoms . They teThese lesions are sensitive to hormones and frequently appear during pregnancy and at reproductive age. In about 15% of the cases identified, these polyps occur in pregnant women and are more often multiple. Upon delivery, they may regress spontaneously . MoreoveEven though it is uncommon, fibroepithelial polyps can reappear especially when not completely excised. There are several cases of such recurrence described in the literature .In this report, we illustrate the case of a non-pregnant woman with a single FEP. The pathogenesis of FEP is not yet identified; however, some theories have been put forward. An important cause seems to be frequent irritation, particularly in women with obesity . HormoneFEPs are benign mesenchymal lesions that typically occur in women of reproductive age, although they can also be seen in prepubertal and postmenopausal individuals, albeit rarely. Hormonal changes during pregnancy can result in an increased incidence of multiple FEPs. Similarly, postmenopausal women receiving hormone replacement therapy may also have an elevated incidence of this condition. Although atypia can occur, it is important to be cautious in the differential diagnosis of malignancies. Microscopic evaluation of the polyp is critical for excluding malignancy.


Mesenteric desmoid-type fibromatosis (DTF) is a rare benign yet aggressive neoplasm that has an unpredictable biological behavior ranging from spontaneous regression to extensive local infiltration and has a high tendency for recurrence. The presenting symptoms are usually nonspecific and mostly related to the large size of the tumor compressing adjacent organs. Imaging studies can be suggestive of the diagnosis, but confirmation is based on histopathological and immunohistochemical examination. The lack of knowledge on the etiology and pathogenetic behavior of this tumor leads to therapeutic and prognostic challenges. Future genetic studies may help in advancing our understanding of this neoplasm and in formulating the proper management and follow-up plan. Here we present a case of a 14-year-old female who presented to the emergency room complaining of diffuse abdominal pain and distention. A computed tomography (CT) scan showed a large mass occupying most of the abdominal cavity and compressing adjacent organs. Exploratory laparotomy with resection and anastomosis was performed, and the histopathological and immunohistochemical examination of the resected mass was consistent with mesenteric DTF. Mesenteric desmoid-type fibromatosis (DTF) is an infrequent benign yet invasive tumor, known for its potential to infiltrate locally and recur, even following surgical removal . It reprA 14-year-old female patient, previously healthy, presented to the emergency room (ER) complaining of diffuse abdominal pain for two days. The pain was gradual in onset and colicky in nature, progressive in severity over time, associated with vomiting five times a day, containing ingested food and gastric juice, with no blood, no coffee ground vomitus, and no bile. It was also associated with a fever of 38°C, in a background of chronic constipation and abdominal distention for a few months. The patient stated that the abdominal distention started a couple of months earlier when she simply assumed she was getting obese and decided to follow a very strict diet to lose weight. Consequently, she developed symptoms of dizziness and palpitation, in addition to irregularity in her menstrual cycle, which could be related to anemia. Her past medical history was free, with no previous diagnosis of colon polyps or any other colon disease. She had no previous surgeries, including abdominal, and no history of trauma. She was not on any medications and had no allergies. Her family history was free, especially of colon polyps, FAP, or Gardner’s syndrome.On physical examination, the patient was conscious, alert, and oriented, and her Glasgow Coma Score (GCS) was 15/15. She looked pale, in pain, with tachycardia of 133 beats per minute (bpm) but normal blood pressure was 134/74 mm Hg. Her temperature was 38.4°C orally, and her oxygen saturation was 98% in room air.The abdomen was diffusely distended and tender all over. It was dull to percussion with no fluid thrill. Bowel sounds were audible and her digital rectal examination (DRE) was normal with soft stool present in the rectum and no palpable abnormalities.Her lab workup was consistent with anemia with mild elevation of liver enzymes Table .The patient underwent computed tomography (CT) scan with IV contrast; the CT report stated that there is a large lobulated soft tissue mass with an internal cystic component occupying the abdominal and pelvic cavities, measuring approximately 30x20x10 cm, causing compression of adjacent organs and blood vessels with lateral displacement of these structures  was initiated in addition to prophylactic IV antibiotics (cefuroxime and metronidazole) and analgesic (IV paracetamol). Blood group and cross-match were tested and preparation of blood components including packed red blood cells (pRBCs) and plasma was requested. Two units of cross-matched pRBCs were given preoperatively.Due to the large size of the mass and the symptoms caused by mass pressure on adjacent organs, a decision was made with the patient and her family to perform surgical exploration with resection.The patient underwent exploratory laparotomy. After the incision was made, and layers opened down to the peritoneum; a large mass was immediately appreciable, occupying most of the abdominal cavity, from the pelvic region to the epigastric area. The mass is contained within the mesentery of the small bowel, specifically the mesentery supplying the right side of the bowel, causing mass effects on both the small and large bowel and other abdominal organs. The involved mesentery was found extending from the mid ilium to the midpoint of the ascending colon, with the mass abutting the margins of the bowel along these areas. A decision was made to resect the mass with the attached bowel Figure .After resecting the mass, a primary end-to-end ileocolic anastomosis was performed with the closure of the mesenteric defect. After securing hemostasis and confirming the correct count of towels and instruments, a pelvic drain was inserted and the incision was closed layer by layer.On histopathological examination of the mass, the mass grossly measured 30x21x11 cm with 66 cm of attached bowel. The cut surface was pink with the site of cystic formation and hemorrhage. The sample also included the resected bowel with an attached appendix measuring 6.5x1x1 cm. The sample contained two large lymph nodes.Microscopically, the mass was found to contain mesenteric large spindle cell neoplasm with bland-looking nuclei. The lesion had pushing growth for the most part, but focally tumor cells intersect with the muscle part of the bowel wall Figure .On immunohistochemical examination, the lesion cells had nuclear immunoactivity for beta-catenin immunostain but were negative for S100, CD34, Desmin, and DOG1 Figure .The diagnosis was consistent with mesenteric deep fibromatosis (desmoid-type) with unremarkable overlying epithelium and unremarkable appendix. The total lymph nodes harvested within the sample were five and found to be reactive lymph nodes.The patient had a prolonged recovery. She had recurrent attacks of abdominal pain despite receiving regular analgesics. Her follow-up evaluation, lab workup, and imaging did not identify any possible intra-abdominal surgical complication. After the post-operative day 5, there was a minimal discharge from the distal end of the incision, which was treated with drainage and dressing, but further delayed the recovery progress.The patient was discharged on post-operative day 13 with stable vital signs, cessation of abdominal pain, toleration of oral intake including solid food, normal bowel motion, and clean operative wound. After discharge, she was referred to the oncology clinic to continue the proper medical management of her condition. As she underwent complete resection, her oncologist decided to follow her up and perform yearly imaging surveillance without using any medical treatment. Over a year of follow-up, no recurrence or complications have been reported so far, and her surveillance CT scan was normal.DTF within the abdominal region is a rare yet assertive benign tumor, accounting for a scant 0.03% of all tumors, predominantly occurring in the bowel's mesentery . TypicalEtiologyThe etiological factors predisposing to this tumor are not well known yet ,6. MultiThe patient we present herein was a young female who had no personal or family history of FAP or Gardner syndrome, no history of trauma or abdominal surgeries and was not on any hormonal treatment.PresentationMost of the symptoms caused by mesenteric DTF are nonspecific and commonly related to mass effect, as these tumors increase in size unnoticeably before becoming problematic causing pressure on adjacent organs including the bowel, solid organs, or vascular structures . As highPatients with this tumor may complain of abdominal pain of a variable course, the subacute or chronic, abdominal mass that could be felt by the patient, fever, symptoms of bowel obstruction, bowel ischemia, gastrointestinal bleeding, or hydronephrosis among others ,5,8.Our patient presented with subacute abdominal pain and distention that increased in severity over a few months and was associated with constipation and fever.DiagnosisImaging modalities including ultrasonography (US), CT, and magnetic resonance imaging (MRI) scans can help in making the diagnosis, determining the resectability of the tumor, and planning the proper surgical procedure if the tumor is found to be resectable.US scan is frequently the first imaging modality to use, due to its low cost and availability. It can detect a soft tissue mass, with or without cystic components, yet it does not show specific radiological features of abdominal DTF .Of the imaging modalities available, a CT scan with contrast is the scan of choice for DTF. Masses can appear solitary or multiple, they may be homogenous or heterogenous, solid or cystic or both, they can be well-defined or ill-defined with infiltration to adjacent organs, and the radiological signs related to the mass effect or infiltration to adjacent organs will be evident, including signs of bowel obstruction or ischemia, vascular obstruction, hydronephrosis or solid organ compression and displacement .MRI scan defines the soft tissue characteristics and morphology in better quality compared to CT scan, providing more data regarding the degree of cellularity and presence of necrosis within the mass, but due to cost and availability issues, in addition to the relatively longer time needed to conduct the scan, it is the not the standard scan for imaging, especially in emergency cases .Despite having some specific features on imaging, abdominal DTF can radiologically mimic other tumors including GIST. So, the diagnosis is confirmed with histopathological examination and immunohistochemical staining of the biopsy samples or the resected mass .Histologically, DTF is composed of spindle or stellate fibroblasts within a collagen stroma. Examination of the periphery might give clues to the presence of infiltration or the lack thereof . On immuGenetic studies have a promising role in diagnosing DTF through the detection of specific mutations in the tumor and help guide the choice of therapeutic intervention. It has been reported that using next-generation mutation analysis sequencing for detecting CTNNB1 mutation in sporadic DTF can reach a sensitivity of 92% and a specificity of 100%. Consequently, this can guide treatment with COX 2 selective inhibitors [Differential diagnoses include GIST, carcinoid tumors, intestinal tumors including carcinoma, mesothelioma, lymphoma, large hematoma, and fibrosarcoma ,5-6.ManagementTreatment of mesenteric DTF is controversial. A period of watchful observation with active surveillance is advised initially for some cases when the presentation is non-fatal, and the patient’s status and the tumor’s characteristics permit a period of “watchful waiting.” This is based on the observation that some tumors regress spontaneously without any treatment, while complete resection of the tumor is widely considered the standard treatment for resectable tumors, especially when symptomatic, as we performed in the case we present herein ,11-13. RThe fact that there are reported cases of recurrence after complete resection signifies the aggressiveness of this tumor and the dilemma in the management of this condition and necessitates a better understanding of the tumor and its pathological course .Other treatment modalities are explored, particularly in cases where tumors are inoperable, demonstrate aggressive characteristics, or recur. The effectiveness of these treatments can vary and encompass a range of medical options such as nonsteroidal anti-inflammatory drugs (NSAIDs), tamoxifen, radiation therapy, chemotherapy involving cytotoxic agents, and sorafenib, a type of tyrosine kinase inhibitor ,14,16. TThe variability associated with mesenteric DTF’s presentation, location, and size and our limited understanding of the possible etiological causes and course of progression of DTF have led to therapeutic and prognostic challenges in treating this condition . Future Mesenteric DTF is a rare benign tumor that is notorious for being aggressive and recurrent. It usually presents with symptoms related to the mass effect caused by the large size of the tumor, and it should be considered in the differential diagnosis of a large abdominal mass. Data is still lacking regarding the etiological factors leading to DTF, which limits our knowledge of the prognosis and risk of recurrence, as well as the appropriate treatment plan to implement. Therefore, management should be individualized based on the clinical, radiological, and pathological findings.Future genetic investigations are needed to further understand the biological course of this tumor, which would eventually help clinicians better manage this condition in both the short and long terms.


Vulvar hematomas are more common in the obstetric population, and usually present within 24 h of delivery. Small, nonexpanding vulvar hematomas will often resolve with conservative management. In a rural setting in the USA, a 35-year-old woman, G3P3, presented to clinic 26 days after a home vaginal delivery attended by a midwife, which was complicated by postpartum hemorrhage secondary to retained placenta. Ten days after her delivery she developed intense pressure in her inferior right vulva. On examination a 4–5 cm well defined right vulvar mass was observed. Incision and drainage were performed and the mass was determined to be a hematoma that had not resorbed. Four days later, the patient returned to clinic as the mass had reformed. Computerized tomography did not show extravasation of contrast. As examination showed the mass was now 1 cm smaller, no intervention was undertaken and after one month the hematoma had completely resolved. This case provides a rare example of the delayed development of a vulvar hematoma. In the literature, the vast majority are reported to present within 24 h of delivery. Smaller hematomas, such as this one, which was 4-5 cm, are treated conservatively, as they typically absorb. This hematoma was present for approximately two weeks without resorbing. •A 35-year-old parous woman developed a 4–5 cm vulvar hematoma 10 days after a home vaginal delivery attended by a midwife.•She presented approximately two weeks later as the hematoma had not resorbed.•In the literature, the vast majority of vulvar hematomas are reported to develop within 24 h of delivery. In the 2A 35-year-old woman, G3P3, presented to clinic as a referral from her midwife with concern for a Bartholin's gland cyst. She had had a vaginal delivery 26 days earlier, which had been complicated by postpartum hemorrhage secondary to retained placenta. Ten days after her delivery she developed intense pressure in her lower right vulvar area. It was not provoked and the patient denied any sexual intercourse, objects in the vagina, or any strenuous activity. She also denied any issues or complications after delivery. Since its development, she had felt it growing slowly until about a week prior to presentation, when believed it had stopped. It had not been draining any material. Prior to cessation of growth, she was beginning to feel pain in her rectum radiating towards her lower back.On physical exam, there was a 4–5 cm well circumscribed mass of moderate firmness at about 7–8 o'clock (using the vagina for reference) inside the tissue of the right vulva going inferiorly towards the right gluteal cleft. The mass was tender to palpation with no erythema to the surrounding area or discharge expressible from the mass. The mass felt mildly fluctuant. Palpation inward from the vagina indicated that the mass was limited to this area and did not track up the vagina or further into the perirectal space see . As the The area was prepped with iodine solution and then anesthetized with 5 cc of 1% lidocaine with epinephrine. Using an 11-blade scalpel, a stab incision was made on the medial aspect of the mass. Instantly, dark, old-appearing blood came forth from the incision see . Old bloFour days after this drainage, the mass had reformed so the patient underwent computerized tomography with contrast, which did not show any extravasation.Three days later, the patient returned to clinic to report that she still had pressure in the area but it was less than before. On physical exam, the hematoma was smaller than before by about 1 cm in all dimensions, with no signs of infection. Due to the hematoma being smaller, it was decided that did not need to be explored surgically. One month later, the patient returned for a second follow-up. On physical exam, the hematoma had completely resolved and patient had no additional concerns.3A hematoma is defined as a collection of blood beneath an intact epidermis that presents as a swollen fluctuant lump which can be tender on palpation . A vulvaThe median time to detect formation of a hematoma is 6 h postpartum ,3. One rThere is limited data on the optimal management of vulvar hematoma . Small, 4This case provided a rare example of a vulvar hematoma that presented over a week postpartum. As seen through the literature search, the vast majority of postpartum hematomas present within 24 h of delivery, with a median time of 6 h. Smaller hematomas, such as this one, which was 4–5 cm, are treated conservatively, as they typically resorb. This hematoma was present for approximately two weeks without resorbing.


Testicular rupture is a surgical emergency necessitating prompt diagnosis and intervention to prevent irreversible damage. Blunt trauma, including motorcycle collisions, is a common cause of testicular rupture. In the case of multi-trauma, the diagnosis of testicular rupture may be missed in the rush to surgical intervention of more grossly obvious injuries. We present a case of a 24-year-old male who suffered a motorcycle accident and subsequently presented with diffuse abdominal and hip pain. Physical exam and imaging at the emergency department showed multiple pelvic bone fractures, along with a small scrotal injury which was triaged below his pelvic injuries. His pelvic fractures were immediately operated on. Nearly 18 hours after his initial presentation, the patient received a scrotal ultrasound which demonstrated a rupture of the right testicle. Due to this long delay in diagnosis, his urological team opted for non-surgical management and instead employed a more conservative treatment regimen involving pain control, scrotal support, rest, and serial scrotal ultrasounds. This case highlights the importance of timely ultrasound examination for testicular pathology in the setting of multi-trauma and known scrotal injury. Another highlight of this case is the showcase of an uncommon treatment regimen utilizing conservative tactics as opposed to opting for surgical intervention. While an uncommon sequela of trauma, testicular rupture is a surgical emergency that requires prompt diagnosis and management to prevent irreversible damage. Most causes of testicular rupture are associated with blunt trauma such as athletics and motor vehicle accidents . MotorcyA 24-year-old male presented to the emergency department with diffuse abdominal and right hip pain after a motorcycle accident. Physical examination showed an alert male with stable vitals. His hips were unstable to palpation, so a pelvic binder was placed. A small, 1-inch wide laceration was also noted on the right hemiscrotum. Computer tomography (CT) and x-ray evaluation demonstrated multiple fractures including acute, comminuted pelvic fractures which were treated with immediate surgery. After undergoing surgical management of these multiple fractures, attention was turned to the scrotal injury, and a scrotal ultrasound examination was performed. This showed discontinuity of the right tunica albuginea with eccentric echogenicity of the right testicular body and a heterogenous, avascular collection, compatible with right testicular rupture and an associated hematoma Figure . The uroThis case highlights the importance of prompt ultrasound evaluation of testicular pathology in the setting of multi-trauma and scrotal injury as well as ultrasound monitoring after a treatment plan is made and implemented. Testicular infarction occurs approximately six hours after the onset of ischemia, thus the single most important prognostic factor for testicular salvage is time to surgical intervention ,7. UltraTesticular rupture is primarily managed surgically with debridement and repair of the tunica albuginea ,7,9-11. This treatment regimen has been shown in one case series to lead to a better outcome profile as compared to surgical intervention. In that case series, the testicular salvage rate was 100% as there were no cases where patients needed to have an orchidectomy or a surgical exploration . InteresUltrasound evaluation is a valuable tool for the diagnosis of testicular injuries, such as rupture of the testis. Timely diagnosis is needed for surgical intervention, which is still considered to be the standard of care. However, a conservative approach to care may be employed safely in select cases, which is a key highlight of this report.


Nephrogenic adenoma (NA) is a rare, benign lesion of the urinary tract that is induced by chronic irritation or injury to the urinary tract. Ureteral nephrogenic adenoma arising from both ureters is an exceptionally rare condition. We report an unusual case of a 73-year-old male who presented with a several-month history of recurrent UTI-like symptoms. Subsequent imaging showed bilateral hydronephrosis and ureteral wall thickening. A retrograde ureteroscopy revealed several papillary masses filling the lumens of both ureters. Ureteroscopic biopsies revealed NA in both ureters. Nephrogenic adenoma (NA) is an uncommon benign neoplasm. The condition was first identified in 1949 and was initially referred to as "hamartoma" of the bladder. Later, the term “nephrogenic adenoma” was introduced by Friedman and Kuhlenbeck because of their histologic resemblance to renal tubules . DiagnosA 73-year-old male patient with a history of hypertension presented to the urology department with an 18-month history of recurrent dysuria and dark strong-smelling urine. He had no history of haematuria or lower urinary tract symptoms. Surgical history was unremarkable with no previous history of urological intervention. Renal ultrasonography showed hydronephrosis in both kidneys despite having an empty bladder. Computerized tomography urogram (CTU) revealed significant hydroureteronephrosis in bilateral kidneys along with perifocal fat stranding over the entire upper urinary tract , also known as nephrogenic metaplasia, is a rare benign lesion of the urinary tract that can occur in various locations. These lesions are often associated with chronic conditions of the urinary tract, such as recurrent infections, calculi, congenital abnormalities, and previous trauma or surgeries . It can The exact pathogenesis of NA is still unclear, and various theories have been proposed. One prevalent theory suggests that NA may arise from metaplastic changes in the urothelium, possibly as a result of chronic inflammation or previous urothelial injury ,6. AnothNA is typically found incidentally and detected during imaging studies or cystoscopy. In some cases, patients may present with lower urinary tract symptoms such as haematuria, frequency, dysuria and recurrent urinary tract infections. NA in the ureter may mimic malignancy clinically and radiologically with obstructive symptoms resulting from mass lesion effect, and filling defect on radiological evaluation . The endThe characteristic microscopic features of NA include the presence of small tubules and microcysts in the lamina propria, papillary projections on the surface, and a single layer of flat, cuboid, or low columnar cells with uniform nuclei . ImmunohThe treatment approach for ureteral NA depends on various factors, including the size and location of the lesion, as well as the presence of symptoms. In many cases, conservative management is sufficient, and the lesion may regress or remain stable over time . HoweverNA is not considered malignant, but it has a relatively high recurrence rate. Follow-up studies have indicated that NAs can recur after resection . There aWe have presented a rare case of NA arising from both ureters. NA is a rare benign lesion of the urinary tract that can be misdiagnosed due to its nonspecific symptoms and endoscopic features. It is essential for urologists and pathologists to be aware of this rare tumour to avoid misdiagnosis and over-treatment of this benign tumour.


A 54-year-old man experienced abdominal pain, nausea, and vomiting for 3 days after abdominal acupuncture 15 days before. The lab results were unremarkable. Upon computed tomography (CT), a high-density intraluminal mass consistent with hemorrhage was revealed to completely obstruct the colon . ColonoThe treatment plan prioritized endoscopic treatment of an intramural hematoma over surgical intervention. The top of the hematoma was carefully punctured with an electroacupuncture knife, followed by an incision. A large amount of liquefied, pale-yellow substance was observed emanating from the hematoma upon puncture. When the endoscope was inserted into the incision, the intestinal tissue was found to have a honeycomb-like adhesion. This procedure was repeated at multiple points on the hematoma. The hematoma was then accessed through a larger incision; an attempt was made to release the adhering tissue. A portion of the tissue was removed using electrocautery, and the hematoma’s interior was flushed to ensure that there were no bleeding perforations in the bowel wall. The hematoma was successfully decompressed using this procedure .Video 1 Endoscopic incision and drainage for the treatment of obstruction caused by colonic hematomas.The patientʼs symptoms improved following conservative treatment. A CT taken 7 days later revealed partial improvement in the colonic obstruction and decreased density in the colon proper . A CT sIntramural hematomas are a rare condition caused by various etiologiesEndoscopy_UCTN_Code_TTT_1AQ_2AJ


Nasal osteoblastoma (OB) is a rare and locally aggressive osteogenic tumor that has rarely been reported, and there is a lack of effective evidence data for its diagnosis and treatment. In this study, we report a 31-year-old female patient who presented with nasal congestion and associated progressive painless swelling of the left maxillofacial region. A preoperative computed tomography (CT) examination of the paranasal sinuses was performed, and based on the imaging presentation, the surgeon was unable to differentiate between OB, osteoid osteoma (OO), fibrous dysplasia of bone (FDB) and osteoblastic fibroma (OF). After excluding contraindications to surgery, the patient underwent nasal endoscopic excision of the left nasal mass, which was found to be gravel-like and difficult to remove cleanly during the operation. The mass was brittle and bled easily, resulting in inadequate exposure of the operative field, prolonged operation time, and substantial intraoperative blood loss. This indicates that definite preoperative diagnosis (biopsy of deeper parts of the mass is recommended) and appropriate preoperative preparations  are very important. The intraoperative frozen and postoperative pathological results clearly identified the tumor as OB. No local recurrence of the tumor was observed at the 11-month postoperative follow-up. Osteoblastoma (OB) is a locally aggressive osteogenic tumor that is of intermediate malignancy between benign and malignant . OB is aThis case report presents a 31-year-old woman who was admitted to the hospital with “recurrent nasal congestion for 3 years, aggravated with left maxillofacial swelling for 1 year”. The patient had recurrent nasal congestion for the past 3 years, especially in the left nasal cavity. Unfortunately, she exhibited painless progressive swelling of the left maxillofacial region for the past 1 year, and the symptoms of nasal congestion on the left side continued to worsen without other symptoms, such as nasal itching, sneezing or runny nose. The patient had a history of chronic rhinitis and had undergone bilateral inferior turbinate plasma ablation for “nasal congestion” in the hospital. At admission, the main symptoms and signs of the patient were obvious nasal congestion on the left side and progressive swelling of the left maxillofacial region without pain.After admission to the hospital, the patient underwent relevant examinations. Electronic nasal endoscopy was not performed because the swelling was found to completely block the left nasal cavity during anterior rhinoscopy. Subsequently, a CT scan of the paranasal sinuses was performed see Figure 1Sequential CT imaging showed that the mass was growing outward and compressing the medial wall of the left maxillary sinus, the nasal septum, and the superior alveolus. Since the border between the left inferior turbinate bone and the high-density shadow of the mass was unclear, we speculated that the mass might originate from the inferior turbinate bone. Combined with the patient’s clinical symptoms and signs, we preoperatively considered that the patient’s left nasal mass might be OB or OF. Therefore, the patient was scheduled for elective resection of the left nasal mass.During the operation, we found that the mass Figure 2OB must be distinguished from FDB, OF and OO, as they have very similar imaging presentations , especiaFDB: Patients often present with a painless bony bulge; it is only when the mass enlarges and compresses the surrounding tissues that it causes the corresponding clinical symptoms, such as nasal congestion when the nasal sinuses are involved , 9. FDB OF: OF is also called cemento-ossifying fibroma. The disease tends to occur in adolescents. Based on the imaging features, OF occurring in childhood or adolescence can be subdivided into juvenile trabecular OF and juvenile psammomatoid OF . ClinicaOO: OO and OB are both benign bone-forming tumors, but OO is not locally aggressive and generally has a low probability of malignancy , 16. In The clinical presentation of OB is nonspecific. Its preoperative diagnosis mainly relies on imaging and pathological examinations, with the main imaging examination methods including CT and MRI. CT imaging of OB has shown that bone shells of uneven thickness can form around the tumor, and calcification of different shapes can be seen inside the tumor. The MRI findings of osteoblastoma are not specific compared to those of other bone tumors. On T1-weighted imaging, osteoblastoma lesions show low- to moderate-intensity signals. The presentation on T2-weighted imaging is more varied, with low-, medium-, or high-intensity signals in different cases. Calcification shadows inside the lesion may show different degrees of hypointensity on T2-weighted imaging, and osteosclerosis around the lesion is characterized by annular low-intensity shadows on T2 imaging , 21. ComHowever, the paranasal sinus CT results of this patient showed that the mass had a mixed-density appearance, with mainly high-density shadows, which did not distinguish it from OO, OF, or FDB, as previously described. Although the most effective treatment for these diseases is complete surgical excision of the mass , 13, 15,Nasal OB is a rare disease with few clinical reports, and there is a lack of evidence and consensus on effective treatment. According to the available literature, surgery remains the most effective treatment for OB . Since tIn this case report, the patient’s preoperative diagnosis was a left-sided nasal OO. Since it was a localized, isolated lesion with clear borders and a well-defined hard border surrounding it, the operator believed that complete resection of the lesion would be possible along the bony border during surgical excision and thus performed only routine preoperative preparation. However, during surgical resection, the mass, although of bony origin, was found to be soft, gravel-like, brittle, and prone to bleeding. Intraoperative bleeding caused an unclear field, which made the operation more difficult and significantly lengthened the operation, further increasing intraoperative bleeding and other potential risks, such as those due to surgical anesthesia. Postoperative blood analysis revealed that the patient’s hemoglobin volume was reduced by more than half compared to the preoperative volume, further confirming the high intraoperative blood loss of this patient.In summary, this case suggests that OB tumors may have abundant blood flow. Preoperative blood preparation and intraoperative bleeding control are important. As a consequence, preoperative prophylactic angiography and embolization as well as adequate blood preparation should be comprehensively considered when dealing with patients of the same type. During the operation, autologous blood transfusion can be performed to effectively control the patient’s blood pressure to further reduce the risk of intraoperative bleeding.Based on this case review, we can draw the following conclusions. First, for progressive nasal congestion for which conventional treatment in the clinic is ineffective, it is necessary to improve in-depth examinations, such as CT scans of the paranasal sinuses, to avoid missing a diagnosis of related tumor-like diseases. Second, for nasal bone tumor diseases with an unclear diagnosis after preoperative CT examination, it is recommended to improve pathological examinations before surgery and try to collect deeper tissue samples during biopsy to clarify the diagnosis. Finally, if the preoperative diagnosis of nasal OB is definitive, preoperative angiography and embolization and adequate blood preparation should be considered sufficiently. During the operation, autologous blood transfusion and active blood pressure control can be performed to further reduce the risk of intraoperative bleeding.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Ethics Committee of The First Affiliated Hospital of Guangzhou University of Chinese Medicine (File No. ZYYECK [2022]041). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.CL and CF participated in the clinical diagnosis and treatment of this reported case. CF and RW wrote the manuscript, and QZ helped check the text for grammatical errors. MZ and TC collected the clinical data. YR provided funding support. All authors contributed to the article and approved the submitted version.


An arteriovenous malformation (AVM) is an abnormal tangle of blood vessels that connects the arteries and the veins. Because normal capillary bed is partially or completely absented in the AVM, the blood passes quickly from the arteries to the veins, which disrupts normal blood flow and oxygen supply to the surrounding tissues. This is called “steal phenomenon,” and in the inferior mesenteric artery (IMA) territory, this may lead to abdominal pain, gastrointestinal bleeding, portal hypertension, and even ischemic colitis.A 67-year-old man presented to our emergency department because of left side abdominal pain.The abdominal computed tomography with contrast enhancement revealed a cluster of abnormal vascular lesions abutting the IMA with early opacification of the left colonic marginal vein. In addition, poor enhancement of segmental colonic wall was found from proximal descending colon to middle rectum. The diagnosis of AVM of the IMA and ischemic colitis was made.The patient underwent left hemicolectomy as well as the AVM resection.He was discharged uneventfully after the surgery without complications.IMA AVM carries the risk of ischemic colitis. computed tomography scan is helpful not only to the diagnosis of AVMs but also to exclude other lesions as well. Treatment options include endovascular embolization, surgical intervention, and a combination of both. Due to the complexity of this disease, treatment requires a case-specific multidisciplinary approach and a coordination of medical, radiological, and surgical staffs. Due to the complexity of this disease, treatment requires a case-specific multidisciplinary approach and a coordination of medical, radiological, and surgical staffs.An arteriovenous malformation (AVM) is an abnormal tangle of blood vessels that connects the arteries and the veins. It can be either primary or secondary due to previous surgery or trauma. Because normal capillary bed is partially or completely absented in the AVM, the blood passes quickly from the arteries to the veins, which disrupts normal blood flow and oxygen supply to the surrounding tissues. This is called “steal phenomenon,” and in the inferior mesenteric artery (IMA) territory, this may lead to abdominal pain, gastrointestinal bleeding, portal hypertension, and even ischemic colitis.A 67-year-old man presented to our emergency department because of left side abdominal pain for several days. There was no fever, vomiting, diarrhea, or specific past medical history.On arrival, his vital signs were stable. The physical examination revealed let side abdominal tenderness. Laboratory data showed white blood cell count 8.0 (1000/uL), hemoglobin 11.4 (g/dL), and high C-reactive protein 151.8 (mg/L). The renal function, hepatic enzyme, pancreatic enzyme, and blood sugar were all within normal range.Because intra-abdominal infection was highly suspected, the computed tomography (CT) was arranged. The abdominal CT with contrast enhancement revealed a cluster of abnormal vascular lesions abutting the inferior mesenteric artery with early opacification of the left colonic marginal vein (shown in Fig. AVMs are aberrant vascular connections between the arteries and veins. The etiology of AVMs can be either primary due to developmental vascular defects or secondary due to previous surgery or trauma. AVMs can affect any organs, but they are mostly seen in the brain. Less frequently, the AVMs can involve the extremities, trunk, and viscera of the chest and abdomen. AVMs in the IMA territory are extremely rare.,6Because normal capillary bed is partially or completely absented in the AVM, the blood passes quickly from the arteries to the veins, which disrupts normal blood flow and oxygen supply to the surrounding tissues. This is called “steal phenomenon” and the clinical presentations are usually flow dependent. When it comes to the IMA territory, reduced arterial blood flow and venous congestion may lead to abdominal pain, gastrointestinal bleeding, portal hypertension, and even ischemic colitis.Vascular imaging is usually required to confirm the diagnosis and to identify the extent of the lesion. The catheter-based angiography is helpful to determine the extent and severity of the AVMs. However, the catheter-based angiography lacks the ability to exclude other potential life-threatening diseases. As a result, the CT scan may be the modality of choice because it is helpful not only to the diagnosis of AVMs but also to exclude other intra-abdominal lesions as well. In this case, we also applied the curved planar reconstruction imaging technique to evaluate the gastrointestinal tract. The affected colon demonstrated edematous change, pericolic stranding, poor contrast enhancement, and venous congestion. These findings are suggestive of ischemic colitis caused by the AVMs and are also useful to guide the subsequent treatment of the disease.,7–10 Embolization can be the definitive treatment alone or as a bridge prior to the operation. However, embolization carries the risk of bowel ischemia and recurrence of the AVMs had been reported if inadequate embolization was performed. Surgery is a potential curative treatment but bleeding is a major concern given the nature of the AVMs. Our patient underwent left hemicolectomy as well as the AVM resection without endovascular embolization because of lacking the experience of such endovascular intervention at our institution. Although we did not perform the endovascular embolization in advance, the surgery was done smoothly without complications and he was discharged uneventfully.The treatment of IMA AVMs requires a case-specific multidisciplinary approach because of its complexity. Treatment options include endovascular embolization, surgical intervention, and a combination of both.IMA AVM carries the risk of ischemic colitis. CT scan is helpful not only to the diagnosis of AVMs but also to exclude other lesions as well. Treatment options include endovascular embolization, surgical intervention, and a combination of both. Due to the complexity of this disease, treatment requires a case-specific multidisciplinary approach and a coordination of medical, radiological, and surgical staffs.Writing – original draft: Ching Tang Chang.Writing – review & editing: Wei-Xiong Lim, Ting-Ting Liu, Yueh-Ming Lin, Ching-Di Chang.


Adhesion is a leading cause of small bowel obstruction. Adhesive small bowel obstruction has significant challenges in diagnosis, treatment and prevention with considerable impact on morbidity and socioeconomic burden. Small bowel obstruction caused by adhesion or any other aetiology is clinically indistinguishable due to similar clinical presentation. Computed Tomography scans and water-soluble contrast studies are more specific in diagnosis and possess value in predicting the need for surgery. Surgical management is indicated only in complicated cases or failed conservative treatments with the majority resolving with non-operative management. However, there is no clear-cut consensus about the timing of operative intervention. Meticulous surgical practice is the keystone in preventing adhesion formation despite the availability of numerous pharmacological and surgical strategies. This review aims to update the current knowledge of the pathophysiology of adhesion formation, treatment options and various prevention modalities of adhesive small bowel obstruction. Although various pharmacological agents and surgical strategies have been developed, none have shown impressive effects to prevent it. The objective of this review is to update the present knowledge of the pathophysiology of adhesion formation, treatment options and various prevention modalities of Adhesive small bowel obstruction (ASBO).Adhesion may be defined as abnormal inflammatory attachment between tissue surfaces.3 The median time of first operation for ASBO is 0.9 to 1.4 years after colorectal surgery, 1.8 years after hepatobiliary surgery, 2 years after an appendectomy, 4 years after gastric surgery and 7 years after gynaecological surgery.4 The incidence of ASBO has beenis open cholecystectomies vs 0.2% in laparoscopic; 15.6% in open total abdominal hysterectomies vs 0.0% in laparoscopic; and 23.9% in open adnexal operations vs 0.0% in laparoscopic with no statistical difference following laparoscopic or open appendectomies (1.4% vs 1.3%).5 The timing of the first presentation varies according to studies but in general 20% present within one month of surgery, 30% within one year, 25% in subsequent one to five years and the final 25% occur in five to twenty-five years.6 The relative risk of recurrence of ASBO increases with subsequent abdominal operations which are 1.6, 1.8 and 3.2 after one, two and three or more abdominal operations respectively.7The most important risk factor for abdominal adhesion formation is the type of surgery and the extent of peritoneal damage. Lower abdomen and pelvic surgeries have a higher risk of adhesion formation than upper abdominal surgeries.8 Despite general improvements in healthcare, it still carries significant challenges regarding prevention, diagnosis and treatment with a huge influence on morbidity and socioeconomic burden. Most often there is confusion between small bowel obstructions (SBO) caused by adhesion and other etiologies with further causes a dilemma in proceeding with conservative management or surgical management. Although various pharmacological agents and surgical strategies have been developed to prevent the formation of adhesion, none have shown impressive effects. The lifetime risk of requiring hospital admission for adhesive small bowel obstruction (ASBO) following abdominal surgery is around four percent while requiring laparotomy is around two percent.9ASBO is a frequently encountered problem in general surgical practice and accounts for 20% of all surgical emergencies.10 Peritoneal healing  differs from healing in skin, where reepithelialization occurs from the periphery inward. In the peritoneum, operative or traumatic defects are reperitonealized by the implantation of mesothelial cells in multiple areas of the defect.11 On peritoneal injury, the detached mesothelial cells express cell adhesion molecules and various chemotactic factors which cause a large influx of inflammatory cells, predominantly macrophages. Macrophages produce inflammatory cytokines like IL-1, IL-6 & TNF and antiinflammatory cytokines like IL-10 and Interferon-γ (INF-γ). IL-6 is a potent adhesiogenic whereas IL-1 and Tumor Necrosis Factor (TNF) are potent inducers of IL-6.12 A higher ratio of inflammatory cytokines to antiinflammatory cytokines promotes the formation of adhesion.13 These inflammatory responses are directly proportional to the extent of peritoneal damage.14The visceral peritoneum is lined by a single layer of mesothelial cells which are loosely anchored to the basement membrane and are easily detachable on the slightest of trauma.15During peritoneal healing, there is a collection of fibrin-rich exudates in the injured area with simultaneous lysis. The fibrinolytic system degrades fibrin into fibrin degradation products by plasmin. The plasmin is activated from plasminogen by plasminogen activators (PA) such as tissue plasminogen activators (tPA) and Uroplasmin-like plasminogen activators (UPA) which can be inhibited by plasminogen activator inhibitors (PAI) such as PAI-1 and PAI-2. During injury to mesothelium, there is the deletion of the source of PA (tPA), as a result, the ratio of PAI to PA increases which leads to decreased fibrinolysis and stabilization of the fibrin matrix. Subsequently, fibroblasts proliferate and deposit extracellular matrix (ECM) including collagen which leads to the formation of adhesion.12 Latent TGF-β is found in platelet, macrophages and wound fluid which is a potent stimulator of fibroblasts that promotes the synthesis of ECM. The over-expression of TGF and VEGF causes fibrosis and subsequent adhesion formation.10Tissue injury and hypoxia promote the expression of vascular endothelial growth factor (VEGF) that boosts the proliferation of endothelial cells which initiate angiogenesis.16Adhesion is categorized mainly into fibrinous or fibrous. Fibrinous adhesion occurs during an early postoperative period which is avascular, flimsy and usually gets resolved completely. Fibrous adhesion is dense vascular adhesion in which the bowel gets attached to the peritoneum, omentum or other parts of the bowel that tends to persist and precipitate intestinal obstruction.17 A study has classified ASBO into Type I adhesions which are formed at sites that did not have previous adhesion and Type II adhesions which are reformed adhesions at the sites that had previous adhesion. Type 1 is further classified into Type 1A which has previous operative procedures and Type 1B, in which there is no previous operative procedure at the site of adhesion. Type 2 is also classified into Type 2A which has no operative procedure other than adhesiolysis and Type 2B, in which other operative procedures are performed at the site of adhesion.12ASBO can be classified into complete or partial according to the degree of obstruction and early (<30 days after surgery) or late according to the timing of presentation.18 Abdominal pain is the initial and most prominent symptom which occurs in paroxysms at four to five-minute intervals. Gilroy Bevan's triad of adhesive pain consists of (1) pain gets aggravated or relieved on change of posture, (2) pain in the region of the old abdominal scar and (3) tenderness elicited by pressure over the scar.19 Nausea and vomiting are more prominent with a higher obstruction while abdominal distention is prominent with distal obstruction. Obstipation is a later development.The patient of ASBO, like any other SBO, presents with complaints of abdominal pain, nausea, vomiting, abdominal distention and obstipation.20 Severe tenderness, guarding and rigidity along with fever, tachycardia and leukocytosis are observed in the settings of strangulations and peritonitis.21 Hernias and intra-rectal masses can be excluded with groin and rectal examinations respectively.On clinical examination, the patient may demonstrate severe signs of dehydration. The abdomen shows distention and scars from previous surgery may be noted if present. Early in the course of bowel obstruction, peristaltic waves may be visible particularly in thin patients along with hyperactive bowel sounds which later gradually disappear. Mild abdominal tenderness may be present.22 The triad of dilated bowel loops (>3 cm in diameter), multiple air-fluid levels in upright film and paucity of air in the colon is suggestive of SBO.23 The inability to differentiate obstruction caused by adhesion from other aetiology and false negative findings in closed-loop obstruction are the major limitations of plain radiographs.Usually, plain radiographs of the abdomen are the first investigation of choice because of widespread availability and low cost. They have sensitivity, specificity, and accuracy from 79% to 83%, from 67% to 83%, and 64% to 82%, respectively to diagnose ASBO.19 Discrete transition zone with dilatation of bowel proximally and decompression distally, intraluminal contrast not passing beyond the transitional zone and little gas or fluid in the colon are suggestive features of small bowel obstruction in CT scan.24 Clustered bowel loops, beak sign, fat notch sign and small-bowel faeces sign are some of the specific findings observed in adhesive small bowel obstruction.25CT scan is not routinely performed because of their cost and availability. It is usually done when clinical history, physical examination, and plain film are not conclusive. It is 90% to 94% sensitive, 96% specific and 95% accurate in diagnosing ASBO.11USG has limited value in diagnosing ASBO. It is highly operator-dependent, air may obscure the underlying findings and be difficult to perform in obese patients. But maybe particularly important in pregnancy and to rule out other diagnoses.26 This study can be performed immediately at the time of admission or after an attempt at initial traditional conservative treatment. It can rule out complete ASBO and predict the need for surgery. Those who fail to show contrast in the colon within 24 hours usually need surgical intervention.27A hyperosmolar water-soluble contrast medium, meglumine amidotrizoate (gastrografin) is valuable in patients undergoing initial non-operative management. It has both diagnostic and therapeutic value. It activates the movement of water into the small bowel lumen, decreases oedema of the bowel wall and enhances smooth muscle contractile activity which can generate effective peristalsis and overcome the obstruction.28 It can provide valuable information regarding the site, extent, severity and possible cause of obstruction.29 Disadvantages are slow transit of contrast material in the fluid-filled hypotonic small bowel, the need for gastroenteric intubation and the expertise to perform.Small bowel enteroclysis is useful for the diagnosis of low-grade partial intermittent SBO. About 200 ml to 250 ml of barium followed by one to two litres of a solution of methylcellulose in water is instilled into the proximal jejunum via a long nasoenteric catheter and the movement is followed fluoroscopically.30Laboratory tests are not helpful in the actual diagnosis of ASBO but are important to assess the general condition of the patient. Serum electrolytes and hematocrit denote the degree of dehydration and adequacy of fluid resuscitation. Leucocyte counts, serum amylase, alkaline phosphatase, D-lactate, urea and creatinine level may be elevated in the settings of strangulation and ischemia.31 Conservative treatment involves nasogastric decompression, fluid and electrolyte correction and clinical observation. Urinary Catheterization with urine output monitoring, serial electrolyte measurement, hematocrit and WBC count is done. The use of broad-spectrum antibiotics is advocated by some with concerns about bacterial translocation.32 The non-operative management can be prolonged for up to 72 hours in absence of signs of strangulation or peritonitis.27 The onset of fever and tachycardia, leukocytosis >15000/mm3, elevated lactate level, metabolic acidosis, continuous severe abdominal pain (VAS>4) and abdominal guarding along with abdominal CT findings of pneumatosis intestinalis, portal venous gas, lack of small bowel faeces sign, devascularized bowel indicate strangulation and mandate immediate surgical intervention.33 Absence of contrast in the colon after 24 hours of gastrografin study and failure of conservative management for 72 hours also dictates the need for operative management.34Partial ASBO and without signs of strangulation or peritonitis can safely undergo the initial trial of non-operative management with success in about 60% to 85% of patients.35 The open approach is generally preferred for strangulating ASBO. However, inadvertent enterotomy is noted in about 20% with open approach vs 1% to 100% with laparoscopic.36The presence of complications and failure of NOM mandates surgical intervention. The surgery itself can cause new adhesion formation with approximately 10% to 30% requiring another laparotomy for recurrent bowel obstruction.37 The factors associated with successful laparoscopic management are hemodynamically stability, absence of peritonitis or severe intra abdominal sepsis, proximal SBO, the first episode, absence of severe abdominal distension, low peritoneal Adhesion Index score in <3 abdominal quadrants, single band adhesion, experience and skills of the surgeon.27 Laparoscopic lysis of adhesion has potential advantages of less postoperative pain, faster return of intestinal function, shorter hospital stay and reduced recovery time, and decreased wound complications.39Laparoscopic lysis of adhesion is feasible only in uncomplicated ASBOs and in selected patients.AThe goal of adhesion prevention is to abolish or reduce the incidence, severity, extent and complications of adhesion while preserving normal healing. Various agents and strategies have been proposed in preventing postoperative adhesion formation.27 Strict adherence to meticulous surgical technique has been advocated for many years as a means to reduce adhesion formation. Minimization of peritoneal foreign body exposure , careful and gentle tissue handling, limited use of cautery and retractors and sharp dissections whenever feasible, ensuring meticulous hemostasis while avoiding desiccation and ischemia, administering prophylaxis against infection, copious irrigation with 8 to 10 litres of saline to remove clots, prevention of spillage of contents like bile, faeces and covering anastomosis and raw peritoneal surfaces are some of the measures described and advocated.13Opting for a minimally invasive approach whenever feasible reduces peritoneal damage thereby minimising adhesion formation.Numerous pharmacological agents have been studied extensively in an attempt to prevent post-operative adhesion formation. The majority of the agents are limited to animal models but some noteworthy agents with promising results are:13 Halofuginone, an inhibitor type I collagen prevent the formation of permanent fibrous adhesion by decreasing collagen deposition in the fibrin matrix.40 These agents are effective in reducing post-operative adhesion in animal studies only.Agents like citrate, heparin and dicumoral decrease the deposition of fibrin, which is necessary for adhesion formation.41 Their effectiveness is equivocal or even deleterious with abdominal wounds failing to heal.42The effects of non-selective cyclooxygenase inhibitors like indomethacin, and nimesulide and selective cyclooxygenase inhibitors like celecoxib and rofecoxib have been studied in murine models. These agents interfere with prostaglandin synthesis and decrease the initial inflammatory response, vascular permeability and inflammatory cytokines.10 Their use is limited because of the significant cost and the risk of haemorrhage.These agents promote fibrinolysis by enzymatic degradation of fibrin once fibrin is formed. Examples are streptokinase, urokinase and synthetic tissue plasminogen activators.43 Human studies are yet to be done. Dilute hyaluronic acid solutions can be used to precoat the serosal surface during surgery and thereby decreasing post-surgical damage and adhesion formation.44Lubricin is a glycoprotein found in articular cartilage with antiadhesive properties. The use of recombinant human lubricin in rat models reduced both macroscopic and microscopic intra-abdominal adhesions with minimal side effects.45 Modified oxidised regenerated cellulose (Interceed) is the first barrier to demonstrate efficacy in humans which forms a gel and physically separates tissue layers during tissue healing. Hyaluronan and carboxymethyl cellulose-based bioresorbable membrane (Seprafilm) are used as a barrier to keep the intestines separated until the mesothelial lining is restored.46 It has shown only moderate efficacy because of short life in the peritoneal cavity with increased anastomotic leaks when wrapped around the newly created anastomosis and suture lines.47Barrier agents separate injured peritoneal surfaces mechanically during the time of the post-operative healing period. They can be considered promising groups of agents in decreasing surgically induced adhesion. They exist in the form of a solution, membrane or gel. Icodextrin 4% solution, acts as an osmotic agent that retains fuid within the peritoneal cavity for 3 to 4 days and prevents contact between organs using hydro floatation.48 In Childs-Phillips mesenteric plication technique, the small intestinal mesentery is plicated to prevent crumpling of the bowel and adhesion formation.49 A procedure of intraluminal splinting with Baker's tube was developed as an alternative to extraluminal methods of Noble's plication and Child Philips mesenteric plication. A long stiff tube is inserted through jejunostomy or through the nasogastric route up to the entry into the large bowel, which acts as an intraluminal splint.50 Most of the proposed surgical methods are rarely performed these days and are only of historical importance.Numerous surgical methods have been attempted to prevent adhesion formation. A simple procedure developed by T.B. Noble in 1937 known as Noble's plication, wherein adjacent coils of the small bowel are sutured together to create controlled and predictable adhesion to prevent recurrent adhesive intestinal obstruction.All abdominal surgery possesses a risk for postoperative adhesion formation which increases with subsequent operations. The severity of peritoneal damage and the imbalance between fibrin deposition and degradation during healing are the major inciting factors for intra-abdominal adhesion formation. Plain abdominal X-rays can sufficiently diagnose small bowel obstruction but CT scans and water-soluble contrast studies are more specific for ASBO. In absence of signs of peritonitis or strangulation, the patients can safely undergo a trial of NOM for 48 to 72 hours. Open surgery is preferred for complicated cases while laparoscopic management is feasible in selected patients only. There are no consistent satisfactory results with various proposed adhesion-preventing agents and strategies and are limited to animal models only. There is a need for more advanced studies and human trials to develop effective agents and strategies that prevent adhesion without impairing the normal healing process. Meticulous surgical practice and the use of barrier agents are the only strategies currently competent to prevent adhesion formation and its subsequent complications.


Sixteen years ago, a then 35-year-old male patient presented with a right-sided flickering scotoma, diffuse vertigo, a tendency to fall to the left, and nausea. The patient had a history of recurrent headaches with retrobulbar accentuation. Magnetic resonance imaging (MRI) and computed tomography (CT) showed an osteolytic process in the left petrous apex Fig. . OsteoplBoth clinically and with regular MRI checks, the situation was stable for 10 years. In the twelfth year after irradiation, MRI showed changes suggestive of local recurrence Figs.  and 3. BMagnetic resonance (MR) and computed tomography (CT) scans performed at the time of initial presentation 16 years ago showed a lesion in the apex of the left petrous bone, adjacent to the clivus (Fig. Magnetic resonance and CT images obtained after tumor progression and increasing symptoms over the past 2 years showed an extensive osteodestructive mass lesion of the skull base Figs. . On T2-wChondrosarcoma of the skull base is a rare malignant tumor, arising from chondroid cells and accounting for approximately 0.15% of all intracranial neoplasms . LocatioIn the present case, because of the location of the tumor as well as the imaging characteristics with high T2‑w imaging signal and contrast enhancement, the initial imaging findings made chondrosarcoma the most probable diagnosis.Chordomas and the abovedescribed chondrosarcomas of the skull base share many similarities. While chordomas are in comparison a more frequent tumor entity, they still account for less than 1% of all intracranial tumors only , 7. The In our patient, the tumor was not located exactly in the midline; however, because of the matching MR characteristics we considered chordoma a valid differential diagnosis.Skull base metastases account for approximately 1–5% of all brain metastases . The incThe absence of a known malignancy and the singularity of the lesion made skull base metastasis more unlikely in our patient. Initial imaging could not rule out this differential diagnosis completely, however.The most common tumors of the skull base are meningiomas, accounting for approximately 20–25% of all intracranial tumors , 20. PatThe high T2 signal in the present case, as well as the absence of a dural attachment on imaging made this diagnosis unlikely in our patient.3 and exhibited bone fragments, connective tissue, and blood cells. No indication of inflammation or neoplasm was evident.The first specimen obtained from the patient in February 2007 from the petrous apex measured 1 mmThe patient’s second histopathologic specimen in August 2007 showed features characteristic of grade I chondrosarcoma, including minimally increased cellularity and nodular growth Fig. a. No mitIn December 2022, a tumor from the sphenoid sinus was surgically removed and examined. The histopathological analysis revealed numerous spindle-shaped cells with mitotic figures Fig. a. ImmunoRadiation-induced sarcomas, particularly undifferentiated pleomorphic sarcomas, may occur as a long-term complication of radiotherapy . In cancOn the other hand, numerous chondrosarcoma cases have been described that have dedifferentiated to a tumor resembling a high-grade sarcoma, including undifferentiated pleomorphic sarcomas . Dediffe