Vascular lesions have a varied appearance and can commonly occur in the head and neck. A majority of these lesions are cutaneous and congenital; however, some may be acquired and malignant. The presentation and clinical history of patients presenting with head and neck lesions can be used to guide further imaging, which can provide important diagnostic and therapeutic considerations. This review discusses the revised International Society for the Study of Vascular Anomalies (ISSVA) classification system for vascular tumors and malformations, as well as explores the most common vascular anomalies including their clinical presentations and imaging findings. The ISSVA has recently updated its classification of vascular anomalies.Vascular anomalies of the head and neck present unique diagnostic and therapeutic challenges.Age and clinical history/presentation are important factors in diagnosis.Vascular malformations and tumors may require multiple imaging modalities to fully characterize.Vascular lesions within the head and neck have a broad pathological spectrum. These include a variety of tumors and malformations ranging from simple capillary irregularities to complex structures involving arteries, veins and lymphatics. There have been several classifications dating back to a histologically based version by Virchow in 1863. Since then, there have been many others based on the gross appearance, histological appearance, therapeutic treatment, and even flow rates. One of the most well-known is that of Mulliken and Glowacki, who published the first histology-based scheme, which described lesions in the pediatric population, dividing them into two major groups, tumors, and malformations .The most commonly used classification in use today comes from the International Society for the Study of Vascular Anomalies (ISSVA). It is a comprehensive scheme based on Mullikan and Glowacki’s seminal work. Overtime, advances in diagnostics, genetics, and treatments have led to several iterations of this classification, most recently in 2018. This updated version includes more lesions and reflects a more comprehensive understanding of underlying genetic causes. The ISSVA classification divides vascular lesions into two major categories: tumors (true proliferative neoplasms) and malformations (defects in morphogenesis).The basic categories have remained the same. Vascular tumors are separated into benign, locally aggressive/borderline, and malignant Table . The vasMany of these vascular lesions have characteristic presentations and a comprehensive patient history plays a key role in establishing the correct diagnosis. Additionally, the clinical history can help recommend the imaging modality of choice and guide the clinician to the next most appropriate step. Most commonly, initial evaluation of most vascular lesions is often performed with ultrasound. This is followed by magnetic resonance imaging (MRI) for further characterization and to evaluate extent and structural involvement.Hemangiomas come in two forms infantile or congenital. Infantile hemangiomas are glucose transporter protein-1 (GLUT1) positive while congenital hemangiomas are not. Interestingly, GLUT-1 expression has been linked to poor prognosis in many neoplastic processes –7. This In addition to this genetic difference, they have several unique features that can help differentiate them. Infantile hemangiomas are usually diagnosed in the first year of life. They follow a pattern of rapid growth in the first few months followed by slower growth and involution phases that are slower and more variable. These lesions can be contrasted with congenital hemangiomas, which by definition are present at birth, and become symptomatic as they increase in size or in response to hormonal changes, infection and trauma.Infantile hemangiomas can be hyper or hypoechoic on ultrasound but demonstrate hypervascularity on color flow Doppler. These are best imaged on T1, T2, and post-contrast sequences when using MRI. Proliferating hemangiomas are iso to intermediate T1 and relatively hyperintense on T2 , with enhancement after contrast administration. A serpiginous vessel with a prominent flow void denotes an arterial feeder, this along with lack of perilesional edema are important supporting findings. Dynamic contrast-enhanced imaging will demonstrate gradual, intense enhancement of the lesion, followed by gradual washout. In the involuting phase; these lesions demonstrate fibro-fatty infiltration with T1 hyper intense foci and decreasing contrast enhancement , multifocal , segmental (diffuse plaque like), and indeterminate . In addiIt is important to contrast these lesions to Kaposiform hemangioendothelioma (KHE), which can also have a rapidly expanding phase, but is more infiltrative often crossing multiple soft tissue planes and often involving of the overlying skin. Most hemangiomas are clinically observed, but treatment maybe indicated if there is involvement of the airway, visual system, permanent disfigurement, or large lesions that may result in cardiac symptomatology. The mainstay of treatment is beta-blockers, namely propranolol .Congenital hemangiomas are similar to infantile hemangiomas in regards to their US and MRI findings. They are diagnosed retrospectively by their natural progression into rapidly involuting congenital hemangiomas (RICH), partially involuting congenital hemangiomas (PICH) and non-involuting capillary hemangioma (NICH) subtypes. RICH involute during the first year of life, in contrast to PICH and NICH. These lesions are associated with GNAQ/GNA11 genetic changes , 12. SimTufted angioma is a rare vascular tumor that presents with red or violet plaques. Histologically, it is characterized by capillary vessels forming oval or rounded “tufts.” These develop usually within the first 5 years of life and can extend into many layers beyond the dermis. There is differing data on the location of these lesions but they tend to occur in the trunk and extremities in children. In adults, lesions are more likely to present in the head and neck, specifically the oral mucosa , 14. It Spindle cell hemangioma can present as a red–brown nodule ranging from a few millimeter to a few centimeter in diameter. They can present as a solitary lesion or cluster of several lesions. These lesions can be painful and have been associated with lymphedema, Mafucci syndrome, and Klippel–Trenaunay syndrome. These are mostly superficial lesions limited to the dermal and subcutaneous tissues. On MRI, they have low T1 signal and lobulated high T2 signal, often with phleboliths due to abnormal venous vessels. The most common treatment is surgical excision. While imaging is of limited utility, in select cases it can be helpful prior to treatment to characterize extent and when extensive reconstruction is expected , 18.Epithelioid hemangiomas, previously named angiolymphoid hyperplasia with eosinophilia, are slow growing vascular lesions that present as one or more nodules in the soft tissues. It can also occur within osseous structures. It is most common in patients in their third through sixth decade of life with a mean age of onset in the early 30s. These lesions most commonly occur in the head and neck, most commonly in the periauricular region , 20. TheBRAF, RAS, and GNA14 suggest that this is truly a benign neoplastic process. Sonographic evaluation usually demonstrates hypoechoic nodules in the region of interest with marked internal vascularity [Pyogenic granulomas, also known as lobular capillary hemangiomas, are relatively common and commonly present as a angiomatous pedunculated polyp or papule. These lesions commonly occur on the forehead and check, but can also occur on the mucosal surface including the conjunctiva and oral mucosa. These lesions most often occur secondary to prior trauma, infection, burns, and even pregnancy –28. Thescularity . On MRI,cularity . ImagingKaposiform hemangioendotheliomas are the most common aggressive vascular tumors, but still rare with a reported incidence between .07 and .091 per 100,000 children, presenting usually within the first year. It is an enlarging cutaneous lesion often associated with thrombocytopenia and pain. The majority of these lesions occur in the extremities, but about one-fifth occur in the head and neck region. On imaging, it is an ill-defined region of soft tissue thickening that crosses multiple planes. On T2-weighted imaging, the lesions demonstrate a hyperintense mass with an ill-defined margin that crosses multiple soft tissue planes. Additionally, there can be stranding of the subcutaneous fat, hemosiderin deposits, and destructive changes in the adjacent bone  Fig. 4)4). This In addition to these, there are several other less common hemangioendotheliomas. These mainly affect adults. Overall, these commonly present as a solitary or several nodules in the skin, but can be seen elsewhere. They generally have a low metastatic potential, but can and often recur locally. Retiform hemangioendothelioma is a rare tumor with few cases and only one noted on the face. It has been shown to present as a dermal or subcutaneous nodule with slow growth over the course of months to several years. It is most common among young and middle-aged adults , 37. ThePapillary intralymphatic angioendothelioma (PILA), also known as Dabska Tumor, is a rare locally aggressive tumor that involves the skin and subcutaneous tissues, with few case reports reporting lesions in the bone and other organs. It rarely metastasizes. On imaging, it has been shown to demonstrate aggressive features with isointense T1, heterogeneously increased T2 signal, and variable enhancement that can invade adjacent structures and demonstrate infiltrative characteristics , 41.Lastly, there is Kaposi sarcoma (KS), a mesenchymal tumor that arises from lymphatic endothelial cells first described in 1872 . KS garnKS is divided into four variants: classic, endemic, iatrogenic (most commonly post-transplant), and AIDs related. Classic and endemic KS have a more indolent course and typically do not require imaging evaluation. Iatrogenic and AIDS-related KS are much more aggressive and often present with disseminated disease . There hConversely, due to increase number of transplants, biologic treatment, and long-term immunosuppression, the iatrogenic variant has been increasing in incidence , 48. PatAngiosarcoma is a rare aggressive soft tissue malignancy arising from endothelial cells. Overall survival is approximately 6 to 16 months as these tumors have a propensity to recur and metastasize . AngiosaEpithelioid hemangioendothelioma (EHE) is a rare vascular tumor first described in 1975 as an aggressive bronchoalveolar cell carcinoma . Later nThe lesions discussed above are not inclusive of all vascular malignant vascular tumors; there are others, which are exceedingly rare and mostly differentiated on pathology.Vascular malformations make up the second set of anomalies and are broken up into four categories. Simple malformations include capillary, lymphatic, venous, arteriovenous malformations, and arteriovenous fistulas. These are usually described on imaging based on flow rates through the lesion, slow or fast. Combined malformations include lesions with more than one type of malformation, such as capillary-venous, lymphatic-venous, etc. Malformations of major vessels and those associated with other anomalies make up the last two categories Fig. .Capillary malformations are cutaneous lesions that often follow a dermal pattern. The diagnosis is usually clinical as a “port wine stain” is usually noted on routine physical exam. On ultrasound, these lesions are isoechoic and confined to the dermis; Doppler flow can be seen occasionally. The main utility of imaging is in the setting of associated findings . The mainstay of treatment is laser therapy, but surgical excision with reconstruction can also be considered .Venous malformations make up most slow flow lesions. These lesions initially present during mid to late childhood. They are continuous, soft, and compressible lesions that involve several layers. They tend to align with muscle groups or track along nerves or major vessels. They are responsive to changes in venous flow such as Valsalva or sometimes compression of the ipsilateral jugular vein when the lesion is in the head and neck. On ultrasound, these lesions appear as multiple tubules and may or may not have detectible flow due to low velocities. MRI is the mainstay for evaluating venous malformations. These lesions are markedly T2 hyperintense with serpiginous tubules. One of the most common and highly specific differentiating features is the presence of phleboliths. These lesions can thrombose , 61. CT Lymphatic malformations are overall very rare, but the majority, approximately three-fourth, occur in the head and neck region. One review found the bulk of these occur in the cheek, around the mandible and parotid gland. They are soft and compressible cystic structures, which usually present within the first two years of life. These cystic structures can be macrocytic (greater than 2 cm) or microcystic (less than 2 cm). Mixed lesions with macro- and microcystic components can also occur. On ultrasound, they appear as cystic structures without flow. On MRI, they usually have high T2 signal with minimal peripheral enhancement. The T1 signal is variable. These lesions have a tendency to hemorrhage, and therefore fluid-fluid levels are key to the correct diagnosis Fig. . An impoArteriovenous malformations and fistulae are high flow anomalies. These malformations lack the normal capillary bed between vessels. They can be congenital or occur secondary to surgery, trauma, and pregnancy. They may present with a skin deformity, pulsatile mass, bleeding, ulceration, or secondary symptoms including arterial steal, venous congestion, and high output cardiac failure. These lesions demonstrate high flow on ultrasound; it can be difficult to identify the arterial origin or venous drainage of these lesions. CT is employed to evaluate bony involvement. MRI can be used to evaluate soft tissue involvement. Key to diagnosis is that these lesions show flow voids on both T1W and T2W sequences. Conventional arteriography can be both diagnostic and therapeutic if there is embolization of the lesion Figs.  and 12. These lesions are complex and include more than one type of malformation. These lesions are highly variable and can present unique challenges in both diagnosis and treatment. It is important to determine if the lesion is high or slow flow or a combination. These lesions can be evaluated by MRI and magnetic resonance venography, which can help delineate between venous and lymphatic components Fig. . AdditioThere are numerous malformations associated with syndromes. In this review, we have included multiple related to the head and neck. The most commonly seen is Sturge-Weber. These patients have facial capillary malformations with variable involvement of the leptomeninges and orbits . This anCongenital, lipomatous overgrowth, vascular malformations, epidermal nevi, and skeletal/spinal abnormalities (CLAPO) syndrome is characterized by capillary malformations of the lower lip often with lymphatic and venous malformations of the head and neck. Additionally, these patients have variable degrees of asymmetric overgrowth. It is important to look for venous and lymphatic malformations in patients with suspected CLAPO syndrome. Other common findings include facial infiltrating lipomatosis. Interestingly, these patients do not have neurological findings seen in other similar syndromes, likely due to the embryonic origin of the involved tissues , 68.Congenital, lipomatous, overgrowth, vascular malformations, epidermal nevi and spinal/skeletal anomalies and/or scoliosis (CLOVES) syndrome is associated with several kinds of malformations, including lymphatic, venous, capillary, and even arteriovenous malformations, along with lipomatous overgrowth. Patients with CLOVES syndrome often have cranial abnormalities including megalocephaly, Chiari malformation, and cortical dysplasia, among others. These findings should be considered when evaluating CLOVES syndrome patients , 70. SevIt is important to remember that vascular anomalies of the head and neck can be divided into vascular tumors and vascular malformations; the former representing true proliferative neoplasms and the latter defects of vascular morphogenesis. These lesions can present in a variety of locations in the head and neck. Imaging plays a role for many of these lesions, and therefore, knowledge of the classification of these lesions based on the updated 2018 International Society for the Study of Vascular Anomalies, as well as characteristic imaging findings are key to diagnosis and subsequent appropriate treatment.


Double primary cancers have a low incidence rate, and synchronous hepatocellular carcinoma and gallbladder adenocarcinoma are rarely reported. Here, we report such a case— the 12th case of synchronous double primary cancers featuring HCC and GC, but the first case of neuroendocrine differentiation in the gallbladder.A 77-year-old female was admitted to the hospital complaining of weakness and inappetence for six months. Contrast-enhanced computed tomography (CT) of the abdomen indicated an 11 cm space-occupying lesion in the right lobe of the liver. Later, magnetic resonance imaging showed a high possibility of a massive hepatoma, and multiple gallstones were also seen. After transhepatic arterial chemoembolization, a repeat abdominal CT showed obvious local nodular thickening in the gallbladder wall. Finally, resection of the right lobe of the liver and cholecystectomy were performed. During an approximately 2-year follow-up, the patient recovered uneventfully without recurrence or metastasis.The disease in this case is rare and lacked typical radiological features. More precise and advanced diagnostic techniques are needed to obtain a clear diagnosis and refine treatment strategies. The management strategy should always be curative, even in the presence of multiple malignancies. Multiple primary cancers (MPCs) refer to two or more kinds of malignancies occurring in the same or different organs, with unknown pathogeneses. MPC involving both the liver and gallbladder is rarely reported, and only 15 cases have been recorded, with 11 cases histologically proven as hepatocellular carcinoma (HCC) and gallbladder adenocarcinoma (GC). Here, we present the 12th case of synchronous double primary cancers featuring HCC and GC, but the first case of neuroendocrine differentiation in the gallbladder.In 2017, a 77-year-old retired female patient was admitted to our hospital, which serves as an outpatient hospital, with only complaints of weakness and inappetence for 6 months. A contrast-enhanced CT indicated an 11 cm space-occupying lesion in the right lobe of the liver. There was no particular family history or infectious medical history. She did not receive any medical intervention before admission, and her vital signs, such as blood pressure, heart rate, respiration rate and body temperature, were normal. Physical examination showed the appearance of mild cachexia, no significant abdominal symptoms such as tenderness, rebound tenderness or muscular tension were noticed, and the abdomen was soft. Palpation revealed a normal liver and spleen, and normal borborygmus existed. The blood routine was normal, other blood chemistries showed a serum albumin of 29.3 (40–55 g/L), ALT of 21 (< 15U/L), AST of 98 (13-35U/L), T-Bil of 17.7 (5.1–20.5 µmol/L), CEA of 3.02 (< 4.7 ng/mL), CA19-9 of 7.49 (< 39U/mL) and CA12-5 of 20.35 (< 35U/mL), but a unusually high level of AFP (more than 1210 ng/mL). Serological tests for hepatitis viruses B and C were negative, as were other infectious indications. Then, the patient underwent an MRI examination that revealed a suspicion of a massive hepatoma (8.9 × 12.3 × 9.9 cm) and multiple gallstones. In fact, there was slight local nodular thickening in the gallbladder wall that was easily ignored  each tumor must present definite features of malignancy, (2) each tumor must be distinct, and (3) the chance of one being a metastasis of the other must be excluded . Based o each tumThe pathogenesis of MPC has not been exactly clarified, although the etiological factors can be roughly grouped into host-related factors, lifestyle factors and environmental influences  as well The preoperative diagnosis of MPC can be difficult, and gallbladder cancer with hepatic metastasis or liver cancer with gallbladder invasion can be mistakenly diagnosed. In this case, except for weakness and inappetence, no other discomfort was observed. A sharp rise in the serum level of AFP is usually linked with liver cancer, while CEA, CA19-9 and CA125 are linked with gallbladder adenocarcinoma, but these levels were normal in this patient. The giant tumor in the right lobe of the liver was noticed first so the tiny lesions in the gallbladder wall were nearly neglected. Six weeks after TACE was performed, an enhanced CT scan clearly demonstrated nodular thickness of the gallbladder wall up to 0.5 cm. To some extent, unobvious symptoms, insensitive serum examinations and atypical radiological manifestations made the diagnosis delayed and vague. Even though these assessments may mislead us to consider the possibility a primary HCC with satellite nodules in the gallbladder may exist, we finally denied this possibility because the two specimens showed totally different histopathological morphologies; moreover, the immunohistochemical markers revealed AFP(+) in liver specimens and AFP(−) in gallbladder specimens.For all types of cancer, it is necessary to obtain as specific of a diagnosis as early as possible because different kinds of malignancies require various therapeutic methods. Few studies in the literature evaluate the different aspects that MPC involve and are also inconsistent , yet it In conclusion, synchronous primary double cancers in the liver and gallbladder display are rare and lack apparent radiological features. More precise and advanced diagnostic techniques are needed to obtain a clear diagnosis and refine treatment strategies. The management strategy should always be curative, even in the presence of multiple malignancies.


A 1-year-old male Spinone Italiano dog was treated for an amyloid-producing odontogenic tumor on the right maxilla with a cytoreductive surgery followed by a definitive radiation protocol. Six years later, the dog presented for a new mass on the rostral mandible as well as a lung nodule without recurrence of the original maxillary tumor. Both the mandibular mass and the lung nodule were histologically confirmed to be amyloid-producing odontogenic tumor based on the appearance of sheets and cords of the odontogenic epithelium disrupted by amorphous extracellular amyloid. This case illustrates the metastatic potential for amyloid-producing odontogenic tumor in dogs and asynchronous occurrence of multiple APOTs in the oral cavity. The amyloid-producing odontogenic tumor (APOT) is an uncommon odontogenic neoplasm in dogs and cats. Based on previous case reports, it occurs most commonly in older dogs with a predilection for small breeds, but large clinicopathologic studies are lacking –6. APOT Histologically, APOTs are characterized by the presence of the odontogenic epithelium with extracellular deposition of amyloid-like material –6. PreviSimilar to ameloblastoma, this tumor is generally regarded as benign yet locally invasive into surrounding bone and teeth –6. It isInitial presentation of the APOT was in a 1-year-old castrated male Spinone Italiano dog. There was a firm, nonpainful mass over his right rostral maxilla measuring 7 cm craniocaudal × 4 cm mediolateral × 2.5 cm dorsoventral that had been noted for approximately 1 month prior to presentation. A CT scan of the skull was performed using a 64-slice helical CT scanner . Pre- and post-contrast transverse images were acquired at 0.5-mm slice thickness and 0.3-mm slice interval and subsequently reconstructed into 2-mm slice thickness by 2-mm slice interval. Ioversol  was administered intravenously at a 2-mL/kg body weight for contrast images. Imaging revealed an expansile, multiloculated lesion with cortical lysis as well as irregular periosteal reaction affecting the right maxilla from the canine tooth to the fourth premolar (104–108) . The rig2), although nuclear atypia was mild to moderate , and nuclear atypia was mild. Because the abundance of amyloid so disrupted architecture of the neoplasm, immunohistochemistry with pancytokeratin AE1/AE3  was administered intravenously at a 2-mL/kg body weight for contrast images. Post-contrast sequences were obtained in the arterial, venous, and delayed phase. CT lymphangiography was performed with 1 ml of ioversol combined with 1 ml of sterile saline for sentinel lymph-node mapping. It was elected to perform sentinel lymph-node mapping and include the thorax and abdomen in the preoperative imaging due to age of the dog and history of multiple previous therapies performed for treatment of the initial oral mass.Images of the head and neck revealed a predominantly soft tissue-attenuating, heterogeneously contrast-enhancing mass containing amorphous mineralization and several internal non- to minimally enhancing cavitations at the most rostral aspect of the right mandible measuring approximately 19 mm (H) × 22.7 mm (W) × 25 mm (L) . CT scanImages of the thorax, however, revealed a soft tissue attenuating, mildly heterogeneously contrast-enhancing mass, surrounding the distal aspect of the lobar bronchus at the most cranioventral aspect of the right cranial lung lobe. The mass appeared rounded, measuring 25.6 mm (H) × 21.4 mm (W) × 19.1 mm (L), partially bordered by the lobar vessels and a rim of enhancement. A small mineral-attenuating focus was present at the dorsomedial aspect of the mass . At the The right cranial pulmonary mass was concerning for a primary pulmonary neoplasm. The left cranial pulmonary nodule was more consistent with a granuloma given the degree of mineralization and was not considered consistent with a metastatic nodule. Aspirates of the right and left cranial lung lobe masses were non-diagnostic due to poor cellularity.2)  . A Congo2) . Larger 2) . Areas oThree weeks after treatment for the lung lesion, a bilateral rostral mandibulectomy was performed from the mesial aspect of the mandibular second premolars  to treat the mandibular APOT with 1-cm gross surgical margins. Histopathology findings were identical to the aforementioned biopsy, and the rostral mandibulectomy margins were complete. The medial retropharyngeal lymph nodes and mandibular lymph nodes were also removed bilaterally, and histological evaluation found no evidence of metastasis.All pathologic samples, including the initial specimen from 6 years prior, were sent to a single pathologist for review (CB). A pathologic review confirmed all specimens to be consistent with APOT with the primary difference being a higher mitotic rate in the initial oral tumor  and metastatic lung tumor (40 per 10 hpf) vs. the second oral tumor (0 per 10 hpf). The dog is doing well with good oral function 9 months after mandibulectomy.To the authors' knowledge, this is the first case report of a metastatic APOT in a canine. What is especially unusual in this case is that the dog had APOT in two separate locations in the oral cavity that presented 6 years apart. It is not possible to know which of these was the primary tumor that metastasized to the lungs. While the two oral tumors had similar histological features, the first had a higher mitotic rate and was larger. In retrospect, this tumor may have represented an APOT-like carcinoma as recently described in a dog . AlthougAlthough rare, histologically benign epithelial odontogenic tumors are known to carry a metastatic potential in humans. Ameloblastoma has a biological subset referred to as the metastasizing ameloblastoma, which is new to the 2017 WHO classification of odontogenic tumors . This biNew evidence on oncogenesis of canine ameloblastoma supports that ameloblastoma in dogs develops similarly to its human counterpart via mutations in the MAPK pathway . Thus, gAdditional studies are necessary to better characterize the tumor (or group of tumors) that are currently known as APOT in animals. Since first described in animals, tumors of odontogenic epithelium that produce amyloid have fit poorly into the nomenclature for odontogenic tumors of both humans and animals. The term APOT was proposed to address this problem . For oveUntil this work can be performed, it is recommended that clinicians discuss the potential, albeit low, for distant metastasis in patients with APOT, especially if there are histological features of potential malignancy . There is also justification for long-term follow-up and monitoring since this patient was initially treated as a juvenile with metastasis becoming apparent 6 years later. A protracted time course of metastasis is similar to that reported in humans with metastatic ameloblastoma .The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Ethical review and approval was not required for the animal study because this case report was a clinical case and not a part of a research study. Written informed consent was obtained from the owners for the participation of their animals in this study.CBW contributed to the clinical and surgical case management and completed the first manuscript draft. CMB provided the processing and interpretation for all histological samples. SG contributed to clinical and surgical case management and manuscript preparation. All authors assisted in writing and editing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Barium sulfate is widely used for gastroenterology imaging. Retention of barium in the appendix, where it acts as an appendicolith, thereby leading to obstruction and inflammation. Barium-associated appendicitis is a very rare complication of upper gastrointestinal imaging (UGI), especially in children. We present a case involving an 8-year-old girl who was diagnosed with acute appendicitis due to a barolith and required a laparoscopic appendectomy 6 weeks after UGI. After UGI, patients should be informed regarding possible retention of barium in the appendix, which can cause acute appendicitis. Then, a laparoscopic appendectomy was performed successfully. We should be cautious of this potential risk to prevent complications with early intervention in children. Acute appendicitis of children is one of the most common surgical problems encountered by pediatric surgeons. An obstruction of the appendiceal lumen can result in the development of acute appendicitis , 2. UppeAn 8-year-old girl was admitted to our clinic complaining of abdominal pain for 3 days. She denied any other gastrointestinal or genitourinary symptoms. The abdominal pain originally was periumbilical in nature, but later spread to the right lower quadrant. She had undergone an UGI study of her stomach 6 weeks earlier as a routine evaluation for gastric volvulus.9/L with 78% neutrophils and a C-reactive protein concentration of 30 mg/L. Other laboratory study results were normal. A plain abdominal radiograph revealed a radiopaque tubular structure in the right lower quadrant , and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.GS and KS: conceptualization and data curation. ZF: investigation, validation, and writing of the original draft. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Lipomatous tumors of the adrenal glands are a diverse group of tumors characterized by the composition of adipose tissue. This group of tumors include myelolipomas, angiomyolipomas (AML), lipomas, and teratomas. They are usually benign, non-functioning tumors, and they account for 5% of all primary adrenal tumors. This study aimed to elucidate the management of the initial size of the adrenal mass and symptoms of presentation. We provide a succinct literature review regarding angiomyolipomas tumors of the adrenal glands.Here, we report 5 cases of lipomatous tumors of the adrenal glands. All 5 tumors were non-functioning. Four of them were myelolipoma, and one was AML. Two cases of myelolipoma presented with flank pain, while the rest of the 3 cases presented with hypochondrium pain. Three cases of myelolipoma were managed with laparoscopic adrenalectomy, one case of myelolipoma was converted from laparoscopic to open adrenalectomy because of abdominal adhesions, and the last case was AML and was managed with open adrenalectomy. All patients had an uneventful recovery with regular follow-up.Myelolipoma, the most common lipomatous tumor of the adrenal gland, consists of a mixture of bone morrow element and adipose tissue. AML consists of a mixture of a thick-walled blood vessel, smooth muscle, and adipose tissue. They mimic many different benign and malignant tumors on radiography, and the histopathological examination is still needed to confirm the diagnosis. There is still controversy in the management of these tumors. Usually, the management is individualized on each case. Reporting of these tumors are increasing due the wide-spread use of modern imaging modalities.Adrenal lipomatous tumors are uncommon but with the increase use of imaging modalities their detection has increased. Further studies are needed to establish guidelines in the management of these tumors, especially that they can mimic malignant conditions. This gr22.19/L, haematocrit: 30.3%, and platelet count: 359 × 109/L. The liver function test, renal function test, and the coagulation profile were all within normal ranges. Hormonal profiles were all within normal ranges, including the investigations of serum cortisol, aldosterone, metanephrine, normetanephrine, 5 hydroxyindoleacetic acid, adrenocorticotropic hormone, and renin. Computed tomography (CT) scan of abdomen and pelvis revealed right adrenal mass measuring approximately 6 × 4 × 6 cm with predominant fat with patchy areas of heterogeneous attenuation with no evidence of enlarged lymph nodes or invasion to the surrounding organs and vessels. No other mases were found. The mass was circumscribed with well-defined borders which was suggestive of adrenal myelolipoma  of abdomen was done in the referral hospital at that time and showed a large oval-shaped hypoechoic focal lesion superior to the right kidney. On physical examination, the patient was well-nourished, in moderate pain, and had no pallor or jaundice. Abdominal examination revealed mild tenderness in the right hypochondrium area with no palpable masses. Laboratory examination revealed the following: haemoglobin: 9.6 g/dl, leucocyte count: 6.06 × 10lolipoma A. Thereflolipoma B. The po2.29/L, haematocrit: 31.2%, and platelet count: 249 × 109/L. The liver function test, renal function test, and the coagulation profile were all within normal ranges. Hormonal profiles were all within normal ranges, including the investigations of serum cortisol, aldosterone, metanephrine, normetanephrine, 5 hydroxyindoleacetic acid, adrenocorticotropic hormone, and renin. CT scan of the abdomen and pelvis revealed right adrenal mass measuring approximately 6 × 5 cm oval-shaped soft tissue mass lesion in the right adrenal gland. It showed fatty contents with thin internal septations. No definite invasion of adjacent organs was detected. No other masses were found. The findings were suggestive for Adrenal Myelolipoma . The patient denied any history of anorexia and weight loss. Upon arrival at our hospital, the patient was well-nourished, in moderate pain, and had no pallor or jaundice. Abdominal examination revealed moderate tenderness in the right flank area with no palpable masses. Laboratory examination revealed the following: haemoglobin: 9.2 g/dl, leucocyte count: 6.24 × 10lolipoma A. Thereflolipoma B. The po2.39/L, hematocrit: 35.7%, and platelet count: 189 × 109/L. The liver function test, renal function test, and the coagulation profile were all within normal ranges. Hormonal profiles were all within normal ranges, including the investigations of serum cortisol, aldosterone, metanephrine, normetanephrine, 5 hydroxyindoleacetic acid, adrenocorticotropic hormone, and renin. CT scan of the abdomen and pelvis revealed a horseshoe kidney with few small sub-centimeter cortical cysts on the right-side kidney, along with a 9 × 7 × 6.6 cm well-defined right adrenal mass of mixed density containing soft tissue enhancement and fatty component. No other masses were found  of abdomen and pelvis was done in the referral hospital with no clear explanation of using this imaging modality. The MRI revealed a well-defined mass measuring 7 × 6 cm arising from the lateral limb of left adrenal gland. It demonstrated heterogeneous low to intermediate signal intensity on T1, low peripheral solid component on T2 with central high signal intensity representing necrosis/hemorrhage. There was another well-defined nodule arising from the medial limb of the left adrenal gland as well measuring 1.5 × 2.5 cm, it showed drop in signal intensity on in/out of phase in keeping with adenoma. There were no other masses detected , glucose-6-phosphate dehydrogenase deficiency, and cholelithiasis which was managed with cholecystectomy. The patient was found to have an incidental left adrenal mass during workup of moderate left flank pain for 4 years. The patient denied any history of anorexia and weight loss. Also, the patient denied any history of gastrointestinal and urinary symptoms. On physical examination, the patient was thin, in mild pain, and had no pallor. Abdominal examination revealed mild tenderness in the left flank area, and there were no palpable masses. Laboratory examination revealed the following: normocytic normochromic anemia, low calcium: 2.05 mmol/L, and high C-reactive protein: 11.6 mg/L, which is consistent with her sickle cell disease. Complete blood count revealed: hemoglobin: 9.6 g/dl, leucocyte count: 11.48 × 10detected A. An extdetected B and C. The postoperative recovery was uneventful, and the patient was discharged home at post-operative day 2 with regular follow-up in our outpatient department clinic.2.59/L, haematocrit: 43.7%, and platelet count: 221 × 109/L. The liver function test, renal function test, and the coagulation profile were all within normal ranges. Hormonal profiles were all within normal ranges, including the investigations of serum cortisol, aldosterone, metanephrine, normetanephrine, 5 hydroxyindoleacetic acid, adrenocorticotropic hormone, and renin. CT scan of the abdomen and pelvis revealed a large fatty mass measuring 16 × 11 × 10 cm on the left upper abdomen. It was displacing the left kidney inferiorly, laterally and partially encasing the medial aspect and the upper pole of left kidney reaching to the level of the left renal vessels inferiorly and abutting the diaphragm superiorly. It was also displacing the limbs of the left adrenal gland and abutting the posterior surface of the spleen and the inferior surface of the pancreatic tail. Small interspersed vascular branches from the left renal vessels noted along the margin and within the mass  Dated 22/10/2019.Written informed consent was obtained from the patients for publication of this case series and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Study concept or design – MYD, ASQ, OHS.Participation in the pre/post-operative management of the patients – NA, JYA, AMA, MA.Data collection – MYD, AMK, MS, FQ.Data interpretation – MYD, AMK, ASQ, AJA, FQ.Literature review – AMK, ASQ, AJA.Drafting of the paper – MYD, AMK, AJA, ASQ.Editing of the paper – MYD, ASQ, OHS.Researchregistry5168.Mohammed Yousef Aldossary.Not commissioned, externally peer-reviewed.The authors declare no conflict of interest


The embryonic root groove is an anatomical abnormality that starts in the cingulum and extends longitudinally down the long axis root towards the apex. This developmental anomaly is more frequently reported in maxillary lateral incisors. Gu YC in 2011 established three types of radicular grooves depending on its severity. According to this classification, type III presents a greater diagnostic and therapeutic complexity. The prevalence of palatogingival grooves in maxillary lateral incisors ranges from 1.9 to 14%. This case report provides valuable information about the diagnosis and treatment plan of palatogingival grooves with Cone-beam computed tomography (CBCT) scan. The patient was referred to the University Dental Clinic of European University of Valencia, with recurrent abscesses at the upper right lateral incisor region for the last two years. Palpation and percussion tests were positive for tooth 1.2. There was no clinical history of caries or previous trauma. Periapical radiography showed periapical radiolucent lesions located, not only in the apical area of tooth 1.2, but also in tooth 1.3. Both teeth had previously been endodontically treated. Periodontal probing showed normal values. CBCT scan was perfomed in order to establish a definitive diagnosis and appropriate treatment plan. The complex anatomy of the palatal root groove requires detailed knowledge of the internal root morphology for endodontic treatment success. This complementary tool allows a more accurate image of hard tissue structures, such as palatal grooves and/or accessory roots, in comparison to conventional periapical radiography. The treatment plan of this primary periodontal lesion with secondary endodontic involvement was as follows: periapical surgery combined with root amputation and sealing with MTA, and guided bone regeneration. Key words:Palatal radicular groove, palatogingival groove, maxillary lateral incisor, cone-beam computed tomography, endodontic-periodontal lesion, guided bone regeneration. Furthermore, this primary periodontal lesion may affect the dental pulp and cause endodontic-periodontal lesions or retrograde pulpitis. ,7.Intraoral periapical radiographs are useful complementary diagnostic tests, but their bidimensionality makes these embryonic root grooves difficult to diagnose. Therefore, more precise diagnostic tools, as the CBCT scan, are required to obtain reconstructed three-dimensional images of teeth and surrounding tissues ,9.The treatment choice will depend on the severity of these endo-periodontal lesions, but the root canal treatment on its own will generally not be effective . The proThis case report provides valuable information about the diagnosis and treatment plan of palatogingival grooves with Cone-beam computed tomography (CBCT) scan.A 25-year old healthy Spanish female attended to the University Dental Clinic of European University of Valencia with recurrent abscesses at the upper right lateral incisor region for the last two years. The patient did not report any previous traumatism and clinically, no caries was observed. Nevertheless, adhesive restorations were found on the palatal side of the teeth 1.2 and 1.3. These teeth were not mobile but were sensitive to percussion and palpation, especially tooth 1.2. Furthermore, thermal and electrical pulp vitality tests were negative. Periodontal probing was performed after local anesthesia, and no periodontal pockets were found.Periapical radiographs were taken from different projection angles. A large radiolucent area >1cm) was observed around the apex of the endodontically treated teeth 1.2 and 1.3  was performed to establish a more accurate diagnosis and treatment plan. CBCT images revealed, in the middle third of tooth 1.2, the presence of a non-endodontically treated accessory root Fig. .Based on clinical and radiological findings, an endo-periodontal lesion associated to a palatogingival groove (type III according to Gu Y-Ch (5)) found in the upper right lateral incisor was considered the definitive diagnosis. The treatment plan of this primary periodontal lesion with secondary endodontic involvement was as follows: periapical surgery combined with root amputation and sealing with MTA, and guided bone regeneration for reconstruction of bone defect.This article describes, with the help of CBCT scan, the diagnosis and treatment planning of a class III embryonic root groove with an accessory root in an endodontically-treated upper right lateral incisor. This tooth presented a severe endo-periodontal complication that encompassed the apex of teeth 1.2 and 1.3.Palatogingival grooves can cause pulpal and periodontal pathologies, but they may be difficult to be identified as an etiological factor. The identification of these lesions can be clinically and radiologically challenging in early stages, especially if an acute abscess does not occur. Furthermore, root grooves or accessory roots can sometimes be mistaken for vertical root fractures . In addiThe patient came to our department with a complaint of recurrent abscesses. After performing percussion and palpation tests, clinical examination revealed slight pain on both teeth 1.2 and 1.3. In addition, despite the vast majority of authors relate the presence of a deep and narrow pocket to palatogingival grooves ,12,14,15Radiographic examination is vital to detect embryionic grooves. Nevertheless, sometimes two-dimensional x-rays may not be sufficient to observe and understand the complex root system of these teeth. Some authors ,11,12 afet al. (2015)   confirm . (2015) . Tan X.  (et al.  conclude  confirmThere are different treatment options available for endo-periodontal lesions, non-surgical and surgical procedures . In thisDentists should consider the possible anatomical variations of upper lateral incisors, carefully examine the preoperative radiographs, and make use of the CBCT as an additional diagnostic tool. Thus, the CBCT shows us more precisely the possible existence of the palatogingival groove and/or accessory root. An early diagnosis can increase the treatment success rate, however, the long-term prognosis of these lesions remains uncertain.


Extraskeletal chondroma (ESC) is a benign, slow-growing cartilaginous tumor arising from tenosynovial sheaths. The aim of this article is to report and discuss a case of ESC affecting upper thigh.A 41-year-old male presented with a swelling in the medial aspect of the left thigh. On clinical examination, there was a 10 × 15 cm non-tender, hard, ill-defined mass in the medial aspect of the left upper thigh. Ultrasound showed a large well defined thick wall mass, located inside gracillis or adductor muscles. Magnetic resonance imaging showed a large well defined mass involving the adductor compartment of the upper thigh. The patient underwent wide local excision under spinal anesthesia. The histopathological examination of the specimen revealed binucleated chondrocytes with dots of calcification confirming ESC.There are many theories trying to explain the origin of ESC, as some authors think that it originates from the pluripotent cells of the tenosynovium, while others state that it may be derived from metaplasia of the tendon sheath. In this case, the lesion was completely surrounded by muscle fibers away from the nearby tendons.Extraskeletal chondroma is a rare benign lesion, although mostly affect the upper extremities, it can be found anywhere in the body, histopathological examination of the specimen is the diagnostic method of choice. They can be found in any part of the body with cartilaginous bones, but often occur in short tubular bones, especially metacarpals and phalanges . A benigThe aim of this article is to report and discuss a case of ESC affecting upper thigh in line with SCARE guidelines with brief literature review .1.1A 41-year-old male presented with a swelling in the medial aspect of the left thigh. His past medical and surgical history was clear. He was neither smoker nor alcoholic. There was no family history of the current situation.1.2There was a 10 × 15 cm non-tender, hard, ill-defined mass in the medial aspect of the left upper thigh extending to the inguinal region. No skin changes, no neurovascular abnormality.1.3Hematological tests were normal. Ultrasound showed that the mascular layers of the upper medial compartment of the left thigh contained a large well defined thick wall mass, 10 × 7.5 cm in size, located inside gracillis or adductor muscles, the features were suspicious for hemangioma. Magnetic resonance imaging (MRI) showed a large well defined mass involving the adductor compartment of the upper thigh extending to the lower part of the gluteal region. The lesion was hyperintense to the surrounding muscles on T2-weighted image  and isoi1.4Under the supervision of the first author with spinal anesthesia, in supine position, the patient underwent wide local excision through a longitudinal incision in the medial aspect of the left upper thigh . The his1.5The postoperative course was uneventful. The patient remained overnight in hospital. He was discharged on simple oral analgesic. Three months later, he was found to be healthy.2Although chondroma is a common tumor, ESC is an exceptionally rare benign lesion that arises from soft tissue, without continuity to the bone or periosteum . The comThere are many theories trying to explain the origin of ESC, as some authors think that it originates from the pluripotent cell of the tenosynovium, while others state that it may be derived from metaplasia of the tendon sheath . In thisIn the literature, the lesion has been described as a well demarcated one, sometimes lobulated and one to two centimeters in size . It is aUltrasound examination is usually the starting point in work up of swelling, however MRI is the method of choice for evaluation of ESC. It defines the contour, the extent, the shape, calcification and the relation of the tumor to the surrounding structures. Sometime FNAC or core needle biopsy is required to determine the exact diagnosis preoperatively, especially when the physician worried about malignancy . RegardiAs the current case revealed, the histopathological findings show cartilaginous cells with centralized zones of cellular polymorphism and proliferation of giant cells on the tumor margin. Occasionally, this tumor may present atypical morphologic characteristics, which makes the differential diagnosis with malignant lesions difficult .Complete excision is a preferred mode of therapy . However3ESC is a rare benign lesion, although mostly affects the upper extremities, it can be found anywhere in the body, histopathological examination of the specimen is the diagnostic method of choice.There is no conflict to be declared.No source to be stated.Approval is not necessary for case report in our locality.Consent has been taken from the patient and the family of the patient.Fahmi Hussein Kakamd: Surgeon performing the operation, writing and final approval of the manuscript and follow up.Marwan N.hassan, Karukh K.Mohammed, Dlshad R.Ahmmad, Dahat A.Hussen: Writing the manuscript, final approval of the manuscript.Imad J Habibullah, Shvan H.Mohammed, Hiwa O. Abdulla, Diyar A.Mohammed, Abdulwahid M.Salih: literature review, final approval of the manuscript.Not applicable.Fahmi Hussein kakamad.Not commissioned, externally peer-reviewed.


Sarcoidosis is a chronic granulomatous disease that is characterized by the formation of non-caseating granulomas, predominantly involving the lung and lymph nodes. Over the years, sarcoidosis has been associated with a high risk of malignancy. Solid pseudopapillary tumor of the pancreas is an uncommon pancreatic tumor with a 15% malignant potential. Ours is an interesting case of a 34-year-old patient who was found to have a pancreatic mass and incidental mediastinal lymphadenopathy on imaging, initially raising concern for metastatic pancreatic cancer. However, she was later diagnosed to have an isolated solid pseudopapillary tumor of the pancreas in association with concurrent sarcoidosis. Sarcoidosis, historically known as Besnier-Boeck-Schaumann disease, is a systemic disorder of an unclear etiology. Histologically, it is characterized by the presence of a mononuclear cellular infiltrate leading to the formation of non-caseating granulomas, mostly affecting the lungs and intra-thoracic lymph nodes in 90% to 95% of cases . Almost A 34-year-old Caucasian woman with no significant medical history presented with right flank pain, low-grade fever, nausea, anorexia, and unintentional weight loss (~5 kg) for a period of two months. She denied any history of recent travel or exposure to sick contacts. On physical examination, she was afebrile with stable hemodynamics. Abdominal examination revealed tenderness to palpation in the right upper quadrant and epigastric regions. There was no costovertebral tenderness. Cardiopulmonary examination was within normal limits.Laboratory studies including a complete blood count, markers of liver, kidney, and thyroid function, and urinalysis were within normal limits. HIV antibody test was negative. An ultrasound of the abdomen showed a well-defined complex solid-cystic mass in the neck of the pancreas. Tumor markers  were within normal limits. Additionally, a routine chest X-ray revealed suspicious mediastinal lymphadenopathy  for microorganisms were found to be negative. On further investigation, the patient was also found to have elevated angiotensin-converting enzyme level. These findings eventually led to the diagnosis of sarcoidosis in this patient. CT-guided biopsy of the pancreatic mass revealed polygonal epithelial cells with characteristic pseudopapillary changes, leading to the diagnosis of pseudopapillary tumor (Frantz tumor) of the pancreas. Special stains including vimentin and beta-catenin were positive, thus confirming our diagnosis. Over the next few days, the patient underwent a Whipple pancreaticoduodenectomy for her pancreatic mass Figure . She recSarcoidosis is a multisystem chronic granulomatous disease of unclear etiology that is prevalent in more than 0.05% of the overall population. It is almost three times more common in African Americans as compared with the White population, with a female predominance among all racial groups ,3. ExtraSolid pseudopapillary tumors of the pancreas, first described by Frantz in 1959, are rare pancreatic tumors predominantly involving the tail of the pancreas . Owing tIn conclusion, sarcoidosis is associated with a high risk of malignancy and should prompt a comprehensive workup in suspicious cases. Interestingly, this is the second case in the literature of pseudopapillary pancreatic tumor presenting in association with sarcoidosis. Further studies aimed at establishing a causal relationship between sarcoidosis and malignancy are necessitated to provide more robust data.


A lymphatic mesenteric cyst (LMC) is a rare clinical entity, of unclear etiopathogenesis, which can arise in the abdominal cavity or retroperitoneum without a clear origin.We describe a case of a 74-year-old male presenting with abdominal pain that was non-specific and non-responsive to medical therapy. Laboratory tests clinical examination were inconclusive while the abdominal computed tomography (CT) scan showed a cystic lesion of the ileal mesentery. We performed an open surgical excision of the lesion with the resolution of clinical symptoms. The lesion resulted to be an LMC at the histological examination. At the five-year CT scan follow-up, we did not record any recurrences.LMCs present without specific symptoms and imaging diagnostic techniques, such as ultrasound (US) or CT scan may define its features, location, or size. The preoperative diagnosis remains difficult, which is why the complete surgical excision is the gold standard treatment, aiming to prevent malignant transformation, complications, and recurrences. The term “mesenteric cyst” (MC) refers to a heterogeneous group of cystic lesions with different etiopathogenetic roots, which appear in the abdominal cavity or in the retroperitoneum without knowledge of its abdominal organ of origin. The MC is a rare entity and its reported incidence ranges from one per 100.000 to one per 250.000 hospital admissions [Several classifications for this kind of lesion have been proposed. In 2000, de Perrot et al. .We present the case of a lymphatic mesenteric cyst (LMC) in a 74-year-old male patient coming under our observation.A 74-year-old male patient presented with the appearance of diffuse abdominal pain for about two months without association with any other gastrointestinal (GI) or general symptoms. He has a personal history of essential hypertension without any other relevant fact. The physical examination showed only non-specific abdominal tenderness without signs of peritonitis and the laboratory blood tests were negative. We performed a complete abdominal ultrasound, which showed a cystic neoformation in the left lower abdominal quadrant with liquid content and did not detect any septae in it. A contrast-enhanced computed tomography (CT) scan of the abdomen was carried out Figure . It showWe performed a complete open surgical excision of the lesion, which was located in the mesentery of the ileal loop. We did not have to perform an intestinal resection. The definitive histological examination pleads in favor of an LMC Figure . In the LMC is defined as any cyst located in the mesentery with the possibility of being extended to the retroperitoneum. Usually, MC has a recognizable lining of endothelial or mesothelial cells  and can Usually, MCs are unique lesions; in rare cases, they can be found as multiple ones. The male gender is more frequently involved. Their dimension of the MC may range from a few centimeters to 20 cm .Histopathological examination of the surgical specimen may result in a unilocular or multilocular cyst containing serous or viscous fluid with chylomicrons, cholesterol crystals, and triglycerides surrounded by a single layer of flattened mesothelial immunoreactivity cells with cytokeratins and a fibrous wall with lymphocytes ,7-9.LMC etiology remains unknown but several mechanisms have been suggested to account for its development. The most commonly accepted theory is the benign proliferation of ectopic lymphatics in the mesentery that lack communication with the remainder of the lymphatic system. Another theory advocates the gradual enlargement of embryonic lymphatic channels, given the failure of venous system joining.The clinical manifestation can be varied and non-specific. LMCs are often asymptomatic and occasionally diagnosed during diagnostic assessment for different diseases; they can cause non-specific abdominal pain or present themselves as a surgical emergency, determining complications such as bleeding, bowel infarction, or volvulus ,10-11.There must be a high diagnostic suspicion; although in most cases, the diagnosis is performed as an image finding. Ultrasound features may be various, but an MC should be considered in the presence of an avascular oval mesenteric mass; moreover, this diagnostic tool is superior to the CT in determining the nature of the cyst. A CT scan could be useful to exclude a super-infection, rupture, or internal bleeding by visualizing signs such as a thickened enhancing wall with perifocal fatty stranding. Also, ultrasound may detect this kind of complication underlining echogenic content, thickened capsule, or septations .Magnetic resonance imaging can help the diagnosis by characterizing the origin and content of the MC, as well as pre-operative laparoscopy exploration.The treatment of choice is their surgical excision in order to prevent a malignant transformation as well as the development of complications or recurrences. The preferred surgical technique should be laparoscopy and if the enucleation of the lesion cannot be performed safely, an intestinal loop resection “en bloc” may be necessary .Even if good results have been achieved with percutaneous drainage and sclerosis of the abdominal wall, this management should be avoided for its high rate of recurrence -14.MCs are an extremely rare entity, given the lack of pathognomonic clinical, laboratory, and imaging features. Surgical excision is advisable in order to prevent the risk of complications, malignant transformation, and recurrences; moreover, the laparoscopic approach should be preferred.


Mycotic pseudoaneurysm of the carotid artery is a severe and rare disease. When it ruptures, it can produce severe morbidity and high mortality. It presents clinically as a pulsatile mass, usually diagnosable by computed tomography angiography with definitive confirmation achieved by establishing the presence of the pathogen in the tissue sample.We present the case of a 68-year-old male patient with a history of total laryngectomy. He presented with painful and pulsatile mass in his neck and, after precise evaluation, a ruptured carotid mycotic pseudoaneurysm was promptly detected and treated. After a surgical intervention and an adequate course of antibiotics, the patient successfully recovered.Mycotic pseudoaneurysms of the extracranial carotid artery are uncommon and should always be surgically treated. Due to the high risk of potential complications, restoration of the arterial flow should be attempted in all occasions. High clinical awareness is imperative when approaching a mycotic pseudoaneurysm due to its wide spectrum of clinical symptoms, and must always be considered when diagnosing tumors of the neck. Despite its rarity, early detection and prompt treatment are critical to minimize the possibility of a fatal outcome. Generally speaking, mycotic pseudoaneurysms are localized, irreversible arterial destruction of the vessel by an infection. The term was described by Osler in 1885, and is employed to highlight false aneurysms that appear on a vessel associated to an infection. Clinically, they present as a growing, pulsatile cervical mass associated with pain, tenderness, fever, dysphonia, and dysphagia . PreoperThis work has been reported in line with the SCARE criteria .2The patient is a 68-year-old male with a past medical history of larynx carcinoma and a radical laryngectomy with bilateral neck dissection. The surgery was performed more than 6 years ago and he never presented complications attributable to the intervention. He arrived at the emergency room (ER) with a high fever and a painful left neck mass. 15 days before arriving at the ER, he developed a general feeling of unwellness, along with high fever and the aforementioned pulsating mass in the neck which had been increasing in size ever since. During the previous 24 h, he developed severe pain around the mass and progressive shortness of breath. There was no history of neck trauma, infection or stroke.On physical examination, a tachycardic, febrile, and dehydrated patient was encountered. Along with a 15 × 5 × 2 cm beating and painful mass in the left region of his neck, general swelling was observed and the patient reported severe pain on touch. Also, a carotid murmur was audible on auscultation. The rest of his physical examination was unremarkable. After adequate resuscitation, complementary exams revealed leukocytosis with neutrophilia, along with anaemia. Due to the size of the mass, and to aid in the preoperative planning, a computed tomography angiography (CTA) was requested. The results revealed a 10 × 5 × 2 cm hyper-enhanced lobulated lesion involving the left common carotid artery (CCA) and carotid bulb A, B, andBroad-spectrum antibiotics were initiated and a left neck cervicotomy was achieved with exposure of the left common carotid artery. The circumference of the mass was dissected, and the proximal and distal CCA regions were identified and clamped. The aneurysmal sac was opened and we discovered a ruptured wall of the CCA with inflammation, necrosis and 150 cc of pus. After exhaustive washing of the wound, and since the left carotid artery had some ischemic patches, a saphenous vein graft bypass A was useStaphylococcus aureus). The bacteriologic profile of the tissue sample showed that the identified S. aureus presented sensitivity to the vancomycin, and therefore the patient received a 10-day cycle of intravenous vancomycin. He was discharged without any complications and, on follow-up controls up to one year after surgery, the patient is doing well.The postoperative course was unremarkable. A histologic examination of the arterial wall identified the presence of a mycotic pseudoaneurysm with evidence of organisms (3Mycotic pseudoaneurysms fall within one of two categories: actual mycotic pseudoaneurysms arise following infection of a previously normal arterial wall, whereas an infected traumatic pseudoaneurysm is an infection of a pre-existing aneurysm ,14. In tStaphylococcus aureus, Salmonella spp. and different Streptococci [The nonspecific symptomatology of mycotic pseudoaneurysms includes cervical pain, tenderness, dysphonia, dysphagia, and a growing and pulsatile cervical mass . Auscultptococci  (as it wManagement of mycotic pseudoaneurysms includes the administration of systemic antibiotics and surgical resection. Vascular reconstruction due to the high risk of thrombosis, embolization, and rupture is also key, as these complications have been reported in up to 10% of the cases ,8. SurgiA particular emphasis should be placed on the ligation of the CCA. This procedure should be performed only when there is evidence of an intact Circle of Willis, as this intervention carries a mortality risk of 25%–60% and a high incidence of stroke . EndovasMycotic pseudoaneurysms of the extracranial carotid artery are uncommon and should always be surgically treated, with an emphasis on the restoration of the arterial flow due to the high risk of complications ,2,8. DueThe authors declares that there is no conflict of interest regarding the publication of this article.The authors have no funding to report.The authors declare that = we obtained permission from the ethics committee in our institution.The authors declare that written consent was obtained from the patient before publication of this case.The authors declare that the patient gave his consent to publish this case, and as this is a case report not human participants were involved in a study.Patricio Gálvez MD, Docente Carrera de Medicina, facultad de ciencias médicas, Universidad de las Américas, Quito-Ecuador.Not commissioned, externally peer-reviewed.Gabriel Molina: Conceptualization. Carolina Mesías: Conceptualization, Data curation, Formal analysis. Juan Calispa: Data curation. Kevin Arroyo: Data curation. Katherine Jaramillo: Data curation. Ligia Lluglla: Conceptualization, Data curation, Formal analysis. Bernardo Gutierrez: Data curation. Patricio Gálvez: Conceptualization, Data curation, Formal analysis.


Solitary fibrous tumors (SFTs) are mesenchymal fibroblastic tumors, and forms of SFTs that originate from the abdominal wall are extremely rare. Here we report a case of a nonpalpable SFT along the abdominal wall. Abdominal magnetic resonance (MR) imaging showed a well-circumscribed mass measuring 5 cm in diameter with heterogeneous signal intensity on T2-weighted MR images; this mass was diagnosed as a benign abdominal tumor of unknown origin. Successful laparoscopic excision of the tumor was performed. Histological examination revealed a benign extrapleural SFT. No tumor recurrence was observed after 20-month follow-up. This is the first case of laparoscopic excision of an SFT originating from the abdominal wall. Our report highlights the safety and usefulness of laparoscopic excision of abdominal wall tumors such as SFTs. This approach is an underutilized surgical treatment that can be applied to select cases of SFT in the abdominal cavity. Solitary fibrous tumors (SFTs) are rare slow-growing fibrous tumors of mesenchymal origin that usually arise from the pleura . RecentlA 70-year-old woman underwent right thyroidectomy for thyroid cancer 7 years ago. An abdominal tumor was incidentally detected on computed tomography (CT) during a follow-up visit, and the patient was referred to our hospital for further evaluation. On physical examination, the mass was nonpalpable and nontender. Laboratory test results were nonspecific. Abdominal contrast-enhanced CT revealed a well-circumscribed soft tissue mass measuring 5.1 × 3.2 × 2.6 cm at the left anterolateral abdominal wall . There wThe mass was excised using a five-trocar approach. We separated the omentum from the left upper abdominal wall andfound a pedunculated mass on the anterior abdominal wall that had a stalk and bulged into the abdominal cavity, with its peritoneal surface covered with hard nodules . The tumHematoxylin and eosin staining revealed spindle-shaped tumor cells with elongated nuclei . ImmunohThe patient was discharged without complications on postoperative Day 4. No tumor recurrence was confirmed after 20 months of postsurgical follow-up.SFTs originating from the abdominal wall are extremely rare, and only 16 cases have been reported in English literatures .The clinical presentation of extrapleural SFTs depends on both tumor localization and size, mostly caused by the compression of adjacent structures.Radiological diagnosis of SFTs is usually very difficult because SFTs do not have typical imaging features; hence, histopathological examination is required. SFTs are composed of spindle cells with varying amounts of hyalinized collagen, usually arranged in a ‘pattern-less pattern’ and with heterogeneous distribution of cellular density. This is why fine-needle aspiration biopsies rarely provide sufficient tissue for a definitive diagnosis. Immunohistochemical staining may be used to accurately diagnose the tumor; immunohistochemical markers, such as CD34, CD99, BCL-2, are commonly used to characterize SFTs. SFTs are positive for CD34 and BCL-2 in 78%–100% and 96% of cases, respectively [The most effective treatment for SFTs is surgical excision with a sufficient surgical margin. Malignant lesions are distinguished from benign lesions based on high cellularity of >4 mitotic figures per 10 high-power fields, pleomorphism, hemorrhage and the presence of necrosis . SFTs arIt is generally technically difficult to excise large abdominopelvic tumors because poor visualization of the operative field may cause massive intraoperative bleeding.In the present case, the tumor was incidentally detected before the onset of any symptoms. We selected a laparoscopic approach because of the tumor location at the anterior abdominal wall, which could provide us good surgical visualization. Indeed, we confirmed the stalk of the tumor and excised it safely and easily with a sufficient surgical margin via laparoscopic surgery. This is the first case of laparoscopic excision of SFT originating from the abdominal wall. The laparoscopic approach prevented abdominal wall trauma associated with open surgery in addition to providing the well-known benefits of faster recovery and better cosmesis. It also prevented excision of the oblique abdominal wall muscle, thus averting abdominal wall reconstruction using a prosthetic mesh.In summary, our report highlights the safety and usefulness of laparoscopic excision of abdominal wall tumors, particularly pedunculated tumors, such as SFTs, bulging into the abdominal cavity. This is an underutilized surgical treatment that can be applied to select cases of SFTs in the abdominal cavity.None declared.Informed consent was obtained from the patient for whom identifying information is included in this article.


Somatostatinomas are rare neuroendocrine tumors (NET) that arise in the gastrointestinal (GI) tract. Because of their insidious growth, they are usually asymptomatic until late stages, presenting as malignant disease. We report the case of a 50-year-old woman who presented with epigastric abdominal pain, diarrhea and significant weight loss in the last two years. On clinical examination the patient met the criteria for neurofibromatosis type 1 (NF1). Abdominal CT and MRI revealed an infiltrative duodenal mass, with pancreatic invasion, locoregional enlarged lymph nodes and disseminated hepatic nodules. Microscopy and immunohistochemistry uncovered a neuroendocrine tumor, staining positive for chromogranin A (CgA), synaptophysin and somatostatin, with a Ki67 = 1%. Somatostatin receptors (SSTRs) type 2 were negative and SSTRs type 5 were positive in less than 50% of tumoral cells. Our patient was classified as a T3N1M1 stage IV metastatic duodenal grade 1 somatostatinoma and treatment with somatostatin analogues and chemotherapy with capecitabine and temozolomide was started, with so far abdominal imaging follow-up showing stable disease. When a patient is diagnosed with a rare NET, such as a somatostatinoma, it is of utmost importance to determine if it is a sporadic tumor or just a feature of a genetic disorder. Somatostatinomas are neuroendocrine tumors of D-cell origin that contain and sometimes secrete somatostatine . The estNF1 is the most common hereditary multitumor syndrome with an incidence at birth of approximately 1:3000 and it is caused by mutations in the NF1 gene. NF1 is localized on chromosome band 17q11.2 and it acts as a tumor suppressor gene. Biallelic NF1 inactivation results in complete loss of functional neurofibromin activity. Neurofibromin acts as a negative regulator of the RAS-MAPK pathway, and it has a GTPase activating domain that interacts with RAS and converts active RAS-GTP to its inactive form. Apart from NF1 promotor hypermethylation, other somatic inactivation events occur in tumors associated with NF1, such as intragenic mutations and loss of heterozygosity . The freSomatostatin is a tetradecapeptide that inhibits numerous endocrine hormones, including insulin; pancreatic polypeptide; cholecystokinin; gastrin; glucagon; gastric inhibitory polypeptide; secretin; motilin; and exocrine functions such as gastrointestinal transit time, intestinal motility and absorption of nutrients from the small intestine. The classic somatostatinoma syndrome is described as an association of weight loss; abdominal pain; and less often diabetes mellitus, cholelithiasis and diarrhea/ steatorrhea. This syndrome occurs more often in tumors that are localized in the pancreas than those in the duodenum . Most tuSomatostatinomas are usually found during exploratory laparotomy, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound or gastrointestinal endoscopy studies that are performed due to various symptoms and signs associated with somatostatinoma syndrome. The diagnosis can also be established by the presence of a fasting plasma somatostatin level exceeding 30 pg/ml ,11. ImagUsually, at diagnosis, patients present with metastatic disease, but survival rate is high, especially in those with metastatic duodenal somatostatinoma . In caseThere are not enough data on somatostatinomas to give accurate estimates of survival, but the prognosis with any therapy is poor in patients with metastatic disease. The follow-up extends to a maximum of 10 years post-resection, and it should consist of history and physical examination, a check of the fasting plasma somatostatin level and imaging studies every 6 to 12 months or more often in the first year .We report the case of a 50 years old woman, without any significant personal or family history, who presented with epigastric abdominal pain, diarrhea and 30 kg weight loss in the last 2 years. The patient signed a written informed consent and the ethics committee of Elias Hospital approved the publication of this case report (no 5316/2020). The clinical examination revealed elevated blood pressure (160/100 mmHg) and the presence of a few café au lait spots located on the upper limbs; large, poorly circumscribed areas of hyperpigmentation on the trunk; bilateral axillary freckling ; and mulThe mucous membranes did not show any pathologic changes and Lisch nodules were absent. Based upon the presence of three out of seven characteristic clinical features, our patient met diagnostic criteria developed by the United States National Institutes of Health (NIH) Consensus Conference in 1987 and updated in 1997 and was clinically diagnosed with neurofibromatosis type 1 (NF1) . BiologiUpper digestive endoscopy revealed a gastric mucosa with prepyloric, circumferential linear and round-oval ulcerations, the largest of 6 mm, with the base covered with fibrin debris and an infiltrated area of 7 mm that could be seen between the first and second portion of the duodenum, on the medial wall, with rigidity and exaggerated friability upon biopsy. The normal papilla was visualized distally to the infiltrated area. A multiphasic contrast-enhanced CT diagnosed a 32 × 37 × 47 mm infiltrative duodenal mass, with heterogenous contrast enhancement, which narrowed the duodenal lumen and compressed the pancreatic head, and multiple low-density hepatic nodules strongly suggestive of metastatic disease. On MRI, the tumor displayed irregular borders with high contrast subtraction and heterogenous texture; it was located near the ampulla, in the second segment of the duodenum, with pancreatic invasion, associated locoregional enlarged lymph nodes and multiple disseminated hepatic nodules, with maximum diameters of 12 × 10 mm, suggestive of miliary metastatic disease .lamina propria, with an infiltrative aspect, focal foveolar metaplasia of the villous epithelia  and late (4 h after injection) whole body scans with a two-headed, large field-of-view gamma camera equipped with low energy high resolution (LEHR) collimator and SPECT-CT acquisition 2 h after injection, on the region of interest (abdomen). On somatostatin receptor scintigraphy (SRS), SPECT-CT acquisition, we noticed the duodenal tumor compressing the pancreatic head and the particular aspect of very small disseminated nodules in both hepatic lobes, but without any uptake of the specific radiopharmaceutical; the aspect correlates with the immunohistochemistry results .In this context we performed an endocrinological screening for MEN1 and pheochromocytoma which were negative. Plasma chromogranin A and 24 h urinary 5-hydroxyindoleacetic acid (5- HIAA) were in normal ranges. Unfortunately, plasma levels of somatostatin could not be measured at diagnosis.According to the American Joint Committee on Cancer TNM staging system for neuroendocrine tumors of the duodenum and ampulla of Vater , our patThere was a very good tolerability of both SSAs and chemotherapy. The patient presented grade 2 thrombocytopenia at cycles 3 and 4 and grade 2 palmar-plantar erythrodysesthesia at cycles 3, 4 and 5. Diarheea disappearead after the first two months of therapy.NF1 is an autosomal dominant disorder with complete penetrance and variable expression, associated with an increased risk of developing benign and malignant tumors of the skin, central and peripheral nervous system, adrenals and gastrointestinal tract, including pancreatic tumors ,24. The Somatostatinoma is a rare NET  that oriDuodenal neuroendocrine tumors account for about 20% of gastrointestinal tract neuroendocrine tumors and may show G-cell differentiation (gastrinomas) or D-cell differentiation expressing somatostatin, termed somatostatinomas, if they are functional. Acinar and psammomatous somatostatinomas are commonly found in the periampullary region in patients with NF1 and represent one third of somatostatin expressing tumors. Sometimes patients with NF1 may present other mesenchymal lesions: neurofibromas and gastrointestinal stromal tumors. Biopsy was performed and light microscopy revealed the presence of psammoma bodies, which had been previously identified in 68% of duodenal somatostatinomas . ImmunohConventional and functional imaging revealed in our case, on diagnosis, a stage IV duodenal somatostatinoma  with pancreatic invasion, locoregional lymph nodes enlargement and multiple disseminated hepatic nodules described as miliary metastases. Although it seems unreasonable to include SSAs in the therapeutic approach of a mostly SSTR negative somatostatinoma, in patients with symptomatic disease, clinically significant tumor burden or progressive disease, there is evidence in favor of SSA therapy (octreotide LAR or lanreotide) that can improve the related symptoms by reducing somatostatin secretion and potentially control tumor growth ,41. The Cytotoxic chemotherapy with 5-fluorouracil, capecitabine, dacarbazine, oxaliplatin, streptozocin and temozolomide can be used, in association with SSAs, in patients with progressive metastatic disease . ESMO guCAPTEM regimen is rarely associated with serious toxicities (grade 3 or 4 stratified by Common Terminology Criteria for Adverse Events (CTCAE) v5.0 Grade) and has low discontinuation rates, even in patients who follow the treatment for more than a year . The ENERADIANT-4, a phase 3 study, found that treatment with everolimus is associated with significant improvement in PFS vs. placebo, in patients with advanced, progressive, well-differentiated, non-functional neuroendocrine tumors of lung or gastrointestinal origin . The appAblative methods, including radiofrequency ablation and cryoablation, and hepatic artery chemoembolization with doxorubicin, cisplatin and mitomycin C, can result in tumor regression and control of the symptoms. Additionally, surgery is recommended for symptoms palliation . PRRT isIn conclusion, the lesson to be learned from this case resides in the fact that somatostatinomas are rare NETs, seldom associated with somatostatinoma syndrome, which can sometimes occur in the settings of a genetic syndrome such as NF1. Despite the progress achieved in the management of metastatic, progressive, unresectable NETs, in general, and for somatostatinoma, in particular, prognosis is poor, and the optimal treatment of choice still remains a challenge for the multidisciplinary team involved.


Intestinal malrotation is a congenital anatomical anomaly resulting from abnormal midgut rotation. Many cases occur during childhood and present with intestinal obstruction and midgut volvulus. Intestinal malrotation rarely occurs in adults and is found incidentally because it is asymptomatic. We herein report a case of intestinal malrotation, and colorectal cancer operated laparoscopically.A 78-year-old man presented to our Department of Surgical Gastroenterology with fecal occult blood. There were no abnormal findings in the physical examination. Colonoscopy revealed a type 3 tumor in the cecum. Contrast-enhanced computed tomography revealed that the tumor was located in the appendix along the midline of the abdomen. The small intestine and colon occupied the right and left sides of the abdominal cavity, respectively. The diagnosis was appendiceal cancer with nonrotation-type intestinal malrotation. A laparoscopy-assisted ileocecal resection was performed. During surgery, the right-side colon was not fixed to the retroperitoneum, and the right-side colon could be extracted out of the abdominal cavity through the umbilical wound with only adhesive dissection, and mesenteric and lymph node dissection can be performed outside the body. The postoperative course was uneventful.Appendiceal cancer with intestinal malrotation is managed with laparoscopic surgery because this method is safe and minimally invasive.The laparoscopic approach may be safer and less invasive than laparotomy, and extracorporeal lymph node dissection is safe and reliable for patients with intestinal malrotation. It may often present in childhood with intestinal obstruction and midgut volvulus . In adulWe herein report a patient with intestinal malrotation and colorectal cancer who had undergone laparoscopic surgery. This work has been reported in line with the SCARE criteria .2A 78-year-old man presented to our Department of Surgical Gastroenterology, unassisted, with fecal occult blood. He had a past medical history of hypertension and diabetes mellitus, having been prescribed antihypertensive and antidiabetic medicines, and there was no relevant family history. He has never had any abdominal related surgery before. There were no abnormal findings in the physical examination. Colonoscopy revealed a type 3 tumor in the cecum, which was confirmed as an adenocarcinoma. His serum carcinoembryonic antigen level was 3.5 ng/mL, and his carbohydrate antigen 19-9 level was 4.6 ng/mL. Other laboratory data showed no abnormalities. Contrast-enhanced computed tomography (CT) revealed the thickness of the appendiceal wall, which was located along the midline of the abdomen, without lymph node swelling or metastatic lesions. The small intestine and colon occupied the right and left sides of the abdominal cavity, respectively . Three-d3Intestinal malrotation is a congenital abnormal rotation in the midgut. During embryologic development, the midgut rotates 270° counterclockwise around the SMA and fixes to the retroperitoneum . DependiIntestinal malrotation is found in 0.01–0.02% of infants, and 80% of cases present with midgut volvulus or intestinal obstruction in the first few weeks of life .Intestinal malrotation diagnosed in adulthood is rare, and the recent method of diagnosis is CT . IntestiReports have indicated that in complications of right-side colon cancer, chronic intestinal obstruction caused by anatomical disorders of the colon leads to inflammation and carcinogenesis . LiteratWith respect to the surgical approach for intestinal malrotation with right-sided colon cancer, 31 cases of laparotomy and 16 cases of laparoscopic surgery have been performed . In the The learning point in this case is that laparoscopic surgery should be considered as the first choice for patients with intestinal malrotation because it is minimally invasive and allows for a variety of approaches. In addition, extracorporeal mesenteric and lymph node dissection should be performed because of the ease of adhesion dissection.4We believe that the laparoscopic approach is safer and less invasive than laparotomy. We also believe that extracorporeal lymph node dissection is a safe and reliable method for patients with intestinal malrotation.The authors report no declarations of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This report was reviewed and approved by the Institutional Review Board of JA GIFU Kouseiren Ibi Kosei Hospital.Informed consent was obtained from the patient for publication of this case report.Hirokatsu Hayashi: Data Acquisition, Data Interpret and writing of the manuscript.Mamoru Matsuhisa: management of case.Yusuke Murase: management of case.Hitoya Sano: management of case.Kimitosi Nishio: Supervision, review and editing.Iwao Kumazawa: Supervision, review, editing, and final approval of the version to be submitted.N/A.The Guarantor is Hirokatsu Hayashi.Not commissioned, externally peer-reviewed.


Dermoid cysts are well-known lesions that manifest as subcutaneous tumors around the lateral sides of the eyebrows in young patients. Computed tomography or magnetic resonance imaging (MRI) is often performed to confirm the diagnosis. On the other hand, a lipoma is usually a circular lesion, which is sometimes observed in the upper part of the face. The signals of both T1-weighted and T2-weighted images of MRI of a lipoma are, in general, relatively highly homogenous, and the signals decrease in fat-suppressed images. Therefore, differential diagnosis between a dermoid cyst and a lipoma is usually made with MRI, especially based on fat-suppressed images. Here, we present a case of misdiagnosis of a dermoid cyst as a lipoma because of atypical magnetic resonance images.We report a case of a 24-year-old Japanese woman with a dermoid cyst around the lateral edge of the eyebrow. The cyst had been gradually increasing in size for the past 2 years. On MRI, it showed high internal signals on T1- and T2-weighted images. However, the signal intensity decreased homogeneously in the fat-suppressed T2-weighted images. The observed tumor had a yellowish appearance under the endoscope. On the basis of these findings, the lesion was considered a lipoma until it ruptured intraoperatively. The pathological diagnosis confirmed it to be a dermoid cyst.Some dermoid cysts contain lipid-rich liquid, and these may be misdiagnosed as lipomas by MRI. When a tumor is located at a common site for a dermoid cyst, the MRI images should be validated carefully if it appears like a lipoma, and the differential diagnosis should be considered carefully. Dermoid or epidermoid cysts are congenital lesions that manifest as subcutaneous tumors around the lateral sides of the eyebrows . They leA lipoma is a space-occupying lesion. Its T1- and T2-weighted MRI images show high signal intensity. The signal intensity of the T2-weighted images usually decreases on fat-suppressed T2-weighted images uniformly. On the basis of this imaging characteristic, misdiagnosis of a dermoid cyst is considered to be rare.This is a case report of a patient whose preoperative diagnosis was a lipoma based on the MRI images; however, the pathological findings revealed a dermoid cyst.A 24-year-old Japanese woman had a tumor located just above her right eyebrow. She had been aware of the lesion since she was 22 years old, and the tumor had been increasing in size without any subjective symptoms. She consulted a doctor at a clinic, as suggested by her family and friends. She had no past history of illness.The skin above the right eyebrow was slightly distended, and the diameter of the dome was about 2.5 cm. The tumor was palpable beneath the skin. There was no adhesion between the tumor and the skin; the tumor appeared to be attached to a deeper tissue layer such as the bone. The surface of the lesion was smooth, elastic, and soft without fluctuation. The protrusion became remarkable with a strong bite movement. There was no sign of facial palsy Fig. .Fig. 1.POne month after her initial consultation, she underwent MRI without any other imaging studies. The mass showed a homogenous, relatively high signal intensity compared to that of the muscle on both T1- and T2-weighted images. The actual diameter of the tumor was approximately 2.0 cm and was located between the superficial and deep temporal fascia. The signal intensity decreased homogeneously on fat-suppressed T2-weighted images; therefore, the tumor was diagnosed as a lipoma or an angiolipoma (Fig. Endoscopic surgery with an incision near the front hairline was thought to be most appropriate to preserve the esthetics; also, the tumor was quite close to the facial bone , 3, 6. AAn incision was created at her front hairline followed by dissection with the assistance of an endoscope Fig. a, b. BluThe tumor was dark yellow and capsulated by thin fibrous tissue, making its identification easy in the surrounding fatty tissue Fig. c. While The clinical course after surgery was uneventful. The function of the right frontalis muscle recovered completely the day after the operation as expected. The pathological diagnosis was a dermoid cyst Fig. : Data S1This case report has two important “takeaway” lessons. Firstly, a tumor found just above the eyebrow should have a dermoid cyst in the differential diagnosis, as this area is a common site. The second one is that few cases of dermoid cysts show lipoma-like images on MRI. Therefore, details of the images such as the tumor capsule and the internal signals should have been considered . Tumors Histopathological findings revealed many sebaceous glands in the subepithelial layers of the specimens. From these findings, it was inferred that these glands secreted the liquid found in the tumor, which was thought to be lipid rich. In retrospect, the preoperative MRI images of this case revealed that the tumor was surrounded by a thin capsule, and some T1-weighted images showed a heterogeneous internal signal that was not a typical pattern of a lipoma Fig. a, b, d.Dermoid cysts are observed in intracranial and intraperitoneal spaces except around the orbit , 7–10. TIn conclusion, we report a case of a dermoid cyst around the lateral eyebrow that was misdiagnosed as a lipoma based on the preoperative MRI findings. Imaging diagnosis should be examined closely not only regarding the major part of the lesion but also regarding the details such as the capsule and the irregular findings in the smaller areas. Common sites for some lesions should be considered in the differential diagnosis, because some cases have atypical images that do not correspond with their pathological findings. In such cases, other imaging modalities and diagnoses should be considered to avoid misdiagnosis or misinterpretation of the MRI findings.Additional file 1: Data S1. Microscopic findings of the tumor in the high-power field in other parts of the specimens. a. Magnified findings of the left inlet. Most of the lumen has lost the stratified inner layer. The blue arrowhead shows the keratins that may have reflected the irregular images seen on the MRI before surgery as seen in Fig. Additional file 2: Data S2a. A cine movie of T2-weighted images around the right orbit 1 year after surgery. The exact position of the tumor was marked on the skin. There is no sign of recurrence.Additional file 3: Data S2b. A cine movie of T1-weighted images around the right orbit 1 year after surgery. This movie also shows no signs of recurrence.Additional file 4: Data S3. Frontal views of the patient before and after the surgery. The image on the top is the same image as Fig.


Although osteoblastoma is an uncommon benign bone tumor, it sometimes behaves in a locally aggressive fashion. We herein report a case of recurrent lumbar spine osteoblastoma that was treated by repeated surgery and carbon ion radiotherapy.A 13-year-old Japanese girl presented with left side lumbar pain. Computed tomography and magnetic resonance imaging of the lumbar spine demonstrated a tumorous lesion in the left side pedicle of L4. Although gross total resection of the mass, including the nidus, was performed in the initial surgery, recurrence was observed repeatedly in the short term and the pathological diagnosis of all of the resected tumors was conventional osteoblastoma. We finally performed carbon ion radiotherapy after the patient’s 3rd palliative operation, and achieved a good outcome. No further recurrence has been observed in 10 years of follow-up.We performed carbon ion radiotherapy for a case of recurrent spinal osteoblastoma and achieved a good outcome without recurrence at 10 years after carbon ion radiotherapy treatment. To the best of our knowledge, this is the first case of osteoblastoma that was treated with carbon ion radiotherapy after multiple surgeries. Osteoblastoma (OB) is an uncommon benign bone tumor that accounts for 1% of all primary bone tumors, and approximately 30–40% of all OBs occur on the spine . It is wAdjuvant chemotherapy and radiotherapy can be considered if OB exhibits an aggressive nature, such as recurrence or malignant change. Furthermore, it has been reported that carbon ion radiotherapy (CIRT) has a cell-killing effect that is 2–3 times greater than X-ray radiotherapy, and also has curative potential in cases involving X-ray-resistant tumors , 5. HoweThe patient was a 13-year-old Japanese girl who presented with left side lumbar pain that had persisted for 7 months. She also complained of pain and torpor of the left lower limb for 2 weeks prior to admission for the initial surgery. A neurological examination revealed that the muscle strength of the left side iliopsoas, quadriceps femoris, and tibial anterior muscles was 4/5, 4/5, and 5/5, respectively.An X-ray examination revealed no remarkable space occupying lesions. Computed tomography (CT) showed an osteolytic lesion on the left side of the L4 pedicle Fig. a. MagnetWe performed left side facetectomy and gross total resection of the tumor Fig. a, and paAlthough her symptoms showed transient improvement, she complained of left side lumbar pain again at 4 months after surgery. CT and MRI showed local recurrence of the tumor Fig. . Based oAt 3 months after the second surgery, the lumbar pain and pain of the left lower limb recurred. CT and MRI showed a recurrent tumor extending from the epidural space to the paravertebral area Fig. a, b. We In the 2013 World Health Organization Classification of Tumor of Soft tissue and Bone, OB was classified as an intermediate  osteogenic tumor . At firsRecurrent tumors, especially those located near the spine, are very difficult to treat surgically , 14. ThuThe precise irradiation margin remains controversial, especially in the case of spinal tumors. According to previous studies, a margin of 5-mm is considered to provide safety from positioning errors and potential microscopic invasion, irrespective of the histology, and the potential area of spread , 19. HowThe subtypes and transformation of OB are still controversial , 21. In In conclusion, the possibility of clinically aggressive behavior of OB should be taken into account, even when the histology is not consistent with malignancy or “epithelioid” OB. CIRT can be a treatment option for spinal OBs with a clinically aggressive nature, such as OB in cases with repeated recurrences soon after surgery.