We present a very rare case of chronic encapsulated intracerebral hematoma involving the septum pellucidum and the foramen of Monro that by location radiological appearance, and clinical history was mimicking a recurrent astrocytoma or a shunt-related foreign body granuloma.A young adult underwent the resection of a juvenile pilocytic astrocytoma as a child, and with a mass encasing the tip of an old non-functioning ventricular catheter, the differential diagnosis of shunt-related foreign body granuloma versus recurrent low-grade glioma was raised. Although chronic encapsulated intracerebral hematomas have been reported in the literature, the anatomical location of the lesion in the presented case was unique, with radiological and history findings also posing a peculiar diagnostic challenge. Chronic encapsulated intracerebral hematomas are benign entities that may also be found to involve deep and midline supra-tentorial structures usually not prone to spontaneous intraparenchymal hemorrhages. When symptomatic, surgical resection of the hematoma can be both diagnostic and curative. Chronic encapsulated intracerebral hematoma (CEIH) is a well-known complication of spontaneous intraparenchymal hemorrhage (ICH) characterized by the slow enlargement of the hematoma due to recurrent micro-hemorrhages within its capsule . The freA young adult presented to our evaluation after an accidental fall with head injury and brief loss of consciousness. He had a history of cognitive disability with short-term memory deficit since early childhood when he was operated for a resection of a hemispheric frontal juvenile pilocytic astrocytoma (JPA), as per family report. As a child, he also sustained a severe head injury in a motor vehicle accident (MVA) that led to a posttraumatic hydrocephalus (HCP) that was treated with the placement of a right frontal ventriculoperitoneal (VP) shunt. After a few years, the patient underwent a shunt revision for recurrent HCP where the extracranial portion of the old shunt was tied and disconnected and a new right parietal shunt was placed. The patient had no further follow-ups with the neurosurgery service, and his cognitive deficits remained stable, with stable mild gait ataxia/instability and occasional urinary urgency. At ER evaluation, a CT of the head and MRI of the brain revealed the presence of a heterogeneous solid mass involving the region of the right foramen of Monro and septum pellucidum with a large right frontal cystic component. The solid and deep mass had only minimal faint enhancement after gadolinium injection, and there were no peripheral enhancement or HCP. There was no restricted diffusion on DWI (diffusion-weighted imaging) and unenhanced T1-weighted images, but was some increased signal intensity consistent with small areas of hemorrhage. The mass was encasing the tip of a shunt catheter, whereas another ventricular catheter was ending within the right lateral ventricle Figures . These fThe patient had no history of recurrent headaches, loss of consciousness, and no progressive symptoms as per family members’ report. Aside from the MVA, no other recurrent head traumas were reported. In light of the clinical and radiological findings, a differential diagnosis comprehensive of foreign body granuloma and recurrent JPA was raised.The patient (with the support of his family) elected to undergo a right frontal craniotomy for resection of the mass, decompression, and diagnosis, which was uneventful. He recovered well, his gait improved, and he was able to resume some work activities a few weeks after the surgery.At the time of the surgery and after decompressing the frontal cyst, a solid mass consistent with an organizing hematoma was found and removed from the surrounding gliotic parenchyma. There were no feeders to the mass, and an old frontal flanged, spring reinforced, Portnoy ventricular catheter was found at the center of the organizing hematoma Figures , 4.Postoperative MRI confirmed the complete resection of the mass, and there were no new postoperative deficits Figure .Pathology examination revealed a mass tightly adherent to the Portnoy shunt catheter. The lesion wall had multiple calcified foci with central hemorrhagic necrotic friable material. Histological sections reveal a dense fibrous hyalinized capsule with osseous metaplasia. Various stages of organizing hematoma were present within the mass. There were no foreign body giant cells or granulomas to suggest a foreign body granuloma. Surrounding this encapsulated hematoma, there was non-neoplastic brain tissue with reactive gliosis and hemosiderin Figures -8. No evThe findings were consistent with the final diagnosis of CEIH with osseous metaplasia.CEIH is a rare type of intracerebral hematoma first described by Hirsh et al. and characterized by the presence of a fibrotic capsule surrounding an organizing hematoma . CEIH isCEIHs have been reported to involve the hemispheric convexity, the basal ganglia, and the cerebellum -9. AlthoThe case presented is original in that the chronic encapsulated hematoma developed years after a resection of a low-grade glioma , was strictly associated with a first-generation retained nonfunctioning ventricular catheter, and demonstrated osseous metaplasia of the capsule. The anatomical location of the pathology was also very uncommon and not previously reported. The presence of immature bone formation (osseous metaplasia) within the hematoma capsule has been previously described in subdural, and rarely interdural, hematomas ,17 and wThe differential clinical and radiological diagnosis included recurrent low-grade tumor and foreign body granuloma. Pilocytic astrocytomas are low-grade gliomas most commonly seen in childhood and can be cured with complete surgical resection. In adults, they can present as adult pilocytic astrocytomas or reflect a recurrent tumor after an incomplete surgical resection at an early age . PilocytIn our case, it is unclear if the initial ICH that led to the formation of the CEIH was related to an intraoperative bleeding in the region of the foramen of Monro/choroid plexus at the time of the shunt revision, was secondary to a minor trauma, or was possibly related to a rare hemorrhage within a residual JPA.CEIHs involving the septum pellucidum and the foramen of Monro are very rare, and, when associated with the presence of a ventricular shunt, may mimic the appearance of a shunt-related foreign body granuloma. Although radiological preoperative examinations can facilitate narrowing the differential diagnosis, surgical resection of the encapsulated hematoma is both diagnostic and curative.


Anorectal malignant melanoma (AMM) is a rare and aggressive malignance with poor prognosis, yet no consensus of treatment exists to date. Abdominoperineal resection surgery (APR) is the standard treatment of anorectal malignant melanoma, capable of controlling lymphatic spread and obtaining a large negative margin for local control but it can lead to complications. Wide local excision (WLE) allows for quicker recovery and has minimal impact on bowel function .A 66-year-old male patient presented with a 2-months history of painless rectal bleeding.The characteristic finding from colonoscopy and magnetic resonance imaging led to a diagnosis of colorectal cancer. Immunohistochemistry analyses confirmed malignant melanoma. The tumor was classified as: HMB-45(+), S-100(+), CD117(±), PCK(−), ki-67.The patient underwent abdominoperineal resection with no other adjuvant therapy.The patient is doing well at 24 month after the operation, with no signs of recurrence.AMM is a rare malignance, and is easy to misdiagnose. The therapy approach remains controversial. Every effort should be made to ensure prompt diagnosis and to define the optimally effective standard therapy approach. While the typical therapeutic approach remains surgical resection, it is controversial whether abdominoperineal resection (APR) of the anorectum or wide local excision (WLE) provides the better outcome.In this report, we present a patient who underwent APR for primary AMM and completed 24-months of follow-up.2A 66-year-old man with complaint of painless rectal bleeding for 2 months was referred to the General Surgery Department of our Hospital. The patient presented in good condition, with no weight loss and reporting no significant past medical history. Rectal examination revealed an irregular mass near the anal verge. Colonoscopy showed a 30-mm lesion on the posterior wall of the rectum, located within 2 cm of the anal verge, and with visual erosion and hemorrhage Fig. . BiopsieBlood tests showed no blood count or biochemical abnormalities. Carcinoembryonic antigen and carbohydrate antigen 19–9 levels were also within normal ranges. Magnetic resonance imaging (MRI) detected a well-defined mass in the anal region (17.4 mm × 20 mm × 24 mm) Fig. .The patient underwent APR. On intraoperative exploration, no distant organ metastasis was found. The mass is located in the posterior wall of the rectum, with the lower pole near the dentate line. The histologic examination of the operative specimen showed the tumor invaded through the muscularis propria. The 2 regional lymph nodes examined were free of tumor. Postoperative paraffin pathology of the resected tissues confirmed the diagnosis of stage 1 AMM. Postoperative adjuvant chemotherapy and radiotherapy was not performed because of the patient refused. Currently, at 2-year postsurgery, the patient is relapse-free and attends follow-up every 3 months on an out-patient basis.3–3,5–8AMM is a rare type of melanoma, with a poor prognosis. The incidence of AMM increases with advanced age in both sexes and at all tumor sites. In general, the 5-year survival rate is low, being only 6% to 22% reportedly with a median survival period of 12.2 to 22 months. Weinstock reported that 41% of anorectal melanoma cases had regional spread and 22% had distant metastasis, while 37% had confined disease. The major sites of distant metastases are lung, liver, brain, bone, and breast.–13 The patient presented herein did not experience any bleeding and had no distant or regional metastasis.AMM lacks subjective symptoms in the early stage. The most common symptom is bleeding, with 53% to 89% of patients reporting this as the predominant complaint. The other symptoms include altered bowel habits, constipation, decreased stool caliber, unintentional weight loss, and palpable inguinal mass. Unfortunately, quite a few patients are diagnosed with AMM when they have already developed distant or regional metastasis.Histopathologically, AMM show considerable variability regarding the size and type of cells. They can be misdiagnosed as malignant lymphoma, small round cell sarcoma, spindle cell sarcoma, gastrointestinal stromal tumour, and epidermoid carcinoma. Thus, immunohistochemical analysis plays a pivotal role in the diagnosis of AMM. The most commonly used IHC stain in the diagnosis of AMM is Anti-S-100 protein and it is highly sensitive for melanocytic differentiation. Also, human melanoma black (HMB-45), Vimentin, and Melan A antibody are the melanocyte specific stains used for diagnosis of malignant melanoma.,15 However, APR can lead to complications such as urinary and sexual dysfunctions. Some investigators have recommended the WLE, instead, as it allows for quicker recovery and has minimal impact on bowel function .,16 Evidence in the literature has suggested no significant statistical difference in 5-year survival rates and patterns of relapse between APR with a sufficient safety margin and WLE. Although, it is important to consider that WLE has no benefits when the tumor is invading the sphincter complex or causing chronic bleeding or obstruction. As such, many authors continue to advocate for APR to be performed when margins of the local excision are positive or in the event of recurrence.The treatment of anorectal melanoma is controversial. While the typical therapeutic approach remains surgical resection, there is no consensus on which surgical approach –WLE or APR – is preferred. APR is regarded as the standard surgery for treatment of AMM because it can control lymphatic spread and obtain a larger negative margin for local control. Locoregional recurrence of AMM occurs more frequently at the inguinal lymph nodes than at the pelvic lymph nodes. Neither APR nor WLE affect any of the inguinal lymph nodes, so they do not offer an advantage in controlling locoregional recurrence.Bullard et al reported that AMM recurrence is unrelated to the initial surgical procedure. It is also relevant to the decision as to whether a patient will undergo surgical resection or not. Positron emission tomography/computed tomography is the most widely adopted modality for detecting perirectal lymph nodes and screening for distant metastasis to assess patient status for the options of curative surgery. The patient in the present study underwent APR without adjuvant therapy. To date, he has been attending follow-up every 3 months and no considerable changes in his condition have presented.The prognosis of AMM is closely connected with the tumor biology, presence of perineural invasion, and lymphovascular involvement.In summary, AMM is a rare malignancy with extremely low 5-year survival rate. Due to low incidence, the treatment for AMM has not been well studied. The typical therapeutic approach remains surgical resection, but the surgical approaches are still controversial. Large-scale prospective clinical trials are needed to establish effective therapeutic approaches for AMM treatment.On behalf of all the authors, I acknowledge the contribution of Dr. Shenghua Cao to this article.Data curation: Xingdong Xu, Ting Ge.Writing – review & editing: Gang Wang.


Epiploic appendagitis is an unusual and very commonly overlooked source of acute abdominal pain. Its incidence is highest in middle-aged obese males. It presents clinically as a focal lower quadrant abdominal pain, usually in the absence of pyrexia, nausea, vomiting or change in bowel habit, and unremarkable laboratory markers. Due to its vague presentation, epiploic appendagitis may be mistaken for other more severe causes of acute abdominal pain like diverticulitis and appendicitis, thereby causing patients to undergo unwarranted management interventions and hospital stay. Epiploic appendagitis is usually diagnosed through imaging, most commonly computed tomography (CT). This condition is largely self-resolving and can be managed conservatively with nonsteroidal anti-inflammatory drugs (NSAIDs). Operative intervention is usually employed when symptoms persist or when complications arise. We present a case of epiploic appendagitis in a patient who presented with right lower quadrant pain initially misdiagnosed as acute appendicitis. Epiploic appendagitis is a rare, benign inflammatory process  arising Epiploic appendagitis has shown increased prevalence in the male and obese population. Other factors associated with this condition are strenuous exercise and the presence of an abdominal hernia .Diagnosis is made through imaging, with classic computed tomography (CT) findings of hyperaenuating ring sign, central dot sign, and mild thickening of the bowel wall. Treatment is usually conservative with nonsteroidal anti-inflammatory drugs (NSAIDs) and symptoms resolving within few days .This article was previously presented as a poster at the 2021 Craiova International Medical Students’ Conference on November 20, 2020.A 57-year-old man with no significant past medical or surgical history presented to the emergency department complaining of pain in the right lower quadrant that started a day prior to presentation. He described the pain as sharp and sudden in onset, and was initially felt in the mid-abdomen but worsened and migrated to the right lower quadrant on the day of presentation. He denied any associated fever, chills, vomiting, diarrhea, dysuria, hematuria, or other gastrointestinal symptoms.Vital signs and laboratory analysis were unremarkable. On physical examination, the patient was not in acute distress, and abdominal exam showed tenderness in the right iliac fossa along with guarding.Ultrasonography of the abdomen revealed fluid in the ileocecal fossa, a 10 mm appendiceal diameter with periappendiceal inflammation, which was suggestive of acute appendicitis (Figure Consequently, laparoscopic appendectomy was scheduled. Intraoperatively, a moderate amount of serous fluid in the right iliac fossa and Douglas pouch was found and aspirated. The appendix did not appear to be inflamed Figure . A necroEpiploic appendages, also referred to as omental appendages, first described anatomically by Vesalius in 1543 ,6. Its vIn prior literature, the reported incidence rate of epiploic appendagitis was about 8.8 cases/10 million population/year ,5, accouEpiploic appendagitis most commonly presents as an insidious non-migratory lower abdominal pain that is exacerbated by coughing and abdominal stretching. Pyrexia, nausea, vomiting, or change in bowel habits are very rarely seen with epiploic appendagitis ,2,5. TheA diagnostic hypothesis based solely on clinical findings often does not permit the recognition of this condition . ConsideHistorically, epiploic appendagitis was most commonly diagnosed during exploratory laparotomy/laparoscopy, but in 1986 the imaging features for the condition were identified and described . The mosUntreated, a variety of complications may result. Adhesions may develop due to inflammation in the surrounding tissue, thereby causing even more severe symptoms. Other possible complications are peritonitis, intestinal obstruction, local abscess formation, and intussusception .Common differentials of epiploic appendagitis include acute diverticulitis, omental infarction, acute appendicitis, sclerosing mesenteritis, and less commonly, acute cholecystitis, salpingitis, ectopic pregnancy, ovarian cyst rupture, and ovarian torsion .Epiploic appendagitis is typically regarded as a self-resolving condition and can be managed conservatively with NSAIDs ,13,14. AEpiploic appendagitis is an underdiagnosed condition in patients presenting with acute abdominal pain. The increased use of CT and ultrasound for diagnosis has caused a reduction in its misdiagnosis. Conservative management is preferred, with surgical intervention reserved for cases of recurrence or complications. This case report highlights the importance of its inclusion as a differential for acute abdominal pain.


Orbital schwannoma is a relatively rare orbital tumor, and calcification of the lesion is rarely found in the orbit. We report a case of orbital schwannoma which was characterized by calcification in the orbital muscle cone, and was cured by intracapsular excision.A 54-year-old female with a complaint of a mass in the left orbit during a magnetic resonance imaging examination and symptom of dizziness 6 months before, presented with painless exophthalmos and vision decline in the left eye.According to clinical manifestations, imaging examinations and postoperative immunohistochemical examinations, the diagnosis was orbital schwannoma, with calcification in the muscle cone.The patient was treated by intracapsular excision of the left orbit. We removed the intracapsular mass and most part of the cyst wall in order to prevent orbital apex syndrome.The diagnosis of schwannoma with calcification was confirmed finally through histological and immunohistochemical exam. The patient was followed up for 28 months and the orbital CT scan showed that there were no significant lesions found in the orbital muscle cone.Understanding clinical, imaging diagnostic, and histopathological features of rare orbital schwannoma with calcification will facilitate timely diagnosis and treatment of this condition. The intracapsular excision can help in avoiding complications. But calcification of the lesion is rarely found in the orbit. We report a case of orbital schwannoma which was characterized by calcification in the orbital muscle cone that was cured after intracapsular excision.Orbital schwannoma is a relatively rare orbital tumor, accounting for 1% to 6% of all orbital tumors.2A 54-year-old east Asian female patient was found with a mass in the left orbit during a magnetic resonance examination performed 6 months ago for a complaint of dizziness. She was diagnosed with hypertension and cerebral infarction in the general hospital 6 months ago, and received systemic drug therapy. No special treatment was performed on her left orbit, and there was no significant change in ocular symptoms. Her systemic evaluation was unremarkable at the time of admission to our hospital. The patient presented with painless exophthalmos and vision decline in the left eye. There was no significant personal or familial medical history. Neurological signs were not found during physical examination. On ocular examination, the best-corrected visual acuity was 20/20 in the right eye and 20/200 in the left eye. The eye examination was unremarkable for eyelid, conjunctival, corneal, lenticular abnormalities, and fundus examination. Hertel exophthalmometry measured 12 mm in the right eye and 16 mm in the left eye. Intraocular pressure was 16 mmHg in the right eye and 18 mmHg in the left eye.1-weighted images (T1WI) showed moderate signals, T2-weighted images (T2WI) were mixed signals, and most of them showed moderately high signals. Both T1WI and T2WI contained low-signal regions. Most part of lesion was significantly enhanced, while local lesions without enhancement , while negative staining for NSE, Actin, and NF Fig. .The patient was followed up for 28 months. On ocular examination, the best-corrected visual acuity was 20/40 in the left eye; no abnormalities were observed in any direction of ocular movement. Hertel exophthalmometry measured 12 mm in the right eye and 11 mm in the left eye. The orbital CT scan showed that there were no significant lesions found in the orbital muscle cone Fig. .3 and it is mostly manifested as painless progressive lesions; its clinical manifestations are related to the location and size of the tumor. The common manifestations include exophthalmos and eyeball dislocation, and some patients may have the symptom of vision decline, diplopia, periorbital spontaneous pain, or tenderness.Orbital schwannoma is usually a kind of benign neuroectodermal tumor, but occasionally malignant cases are encountered. Most of the tumors originate from branches of the oculomotor, trochlear, trigeminal, and abducens nerves, as well as from sympathetic and parasympathetic fibers. As a result, it is very difficult to identify the originating nerve clinically. Orbital schwannoma is usually asymptomatic during its initial stages, Secondary degenerative changes of the tumor, such as cyst formation, hyalinization, hemorrhage, are relatively common.,7 However, calcification is extremely rare. Calcification results from the deposition of calcium salts in the body. From the pathological perspective, it can be divided into dystrophic calcification and metastatic calcification; the former is mainly caused by local microenvironmental changes, rarely accompanied by abnormal calcium metabolism; the latter is the calcium deposition caused by hypercalcemia, which is caused by metabolic disorder. In addition, the blood flow slows down or forms vortex, which causes thrombosis, calcium deposition, and formation of phleboliths. Venous hemangiomas and vascular malformations are common in this kind of diseases. The patient's systemic examination report showed normal, except cerebral infarction caused by hypertension, without any diseases related to abnormal calcium metabolism. Therefore, it is preliminarily speculated that the obvious calcification of the lesion may be caused by dystrophic calcification. The imaging examination showed that the tumor was located in the orbital muscle cone with less blood supply, and the lesion was large up to 17 mm × 22 mm × 24 mm. Due to relatively poor blood supply, calcification may have occurred.Orbital schwannoma is divided into Antoni type A and Antoni type B. Antoni type A is characterized by closely packed spindle cells having fusiform nuclei and eosinophilic cytoplasm. Antoni type B pattern is characterized by haphazardly distributed cells with distinct cytoplasmic margins. Phleboliths are mostly smooth and regular in shape, which often present in vascular lesions and vascular malformations. Irregular calcification is often present in malignant tumors and partially benign lesions. Calcification in schwannoma is rarely found in the orbit. In most typical cases, accurate preoperative diagnosis based on typical clinical and radiographic is usually available. However atypical presentations may pose a challenge. Definitive diagnosis of schwannoma is based on histopathological and immunohistochemical examinations of the surgical specimens.When there is a lesion with calcification in the orbital muscle cone, orbital tumor such as the optic nerve tumors, vascular lesions, vascular malformations, other benign lesions and orbital malignancies should be taken into account. Radiotherapy is an alternative treatment but is limited by unknown efficacy and collateral radiation damage. It is very important to take appropriate preoperative assessment of the tumors by orbital imaging, due to its variable presentation and location. In some cases, the lesions are in special locations, and the total resection can lead to serious complications. The lesion in this case was located in the orbital muscle cone, and the total resection may result in the vision loss, or the orbital apex syndrome, which will severely affect the quality of life. Moreover, the lesion was tightly adherent to its surrounding tissues, It is important to perform intracapsular resection, and remove the visible capsule well. When there are multiple recurrences and in cases where total excision is not possible, addition of topical Mitomycin-C may be an option to bring about tumor regression. However, it was not a best option in our case, because topical MMC may cause the optic nerve damage. In this case, there was no postoperative visual damage, and amazingly her visual acuity improved during follow-up. Moreover, long-term complications such as diplopia, eye movement disorders, ptosis were not detected. The recurrence of the lesion can occur after intracapsular excision. The cases reported in the literature describe late schwannoma recurrence at 1 months, 3, 6, and 22 years after initial excision. Incomplete surgical excision has been attributed to rapid recurrence. In addition, recurrence of orbital schwannoma is most likely associated with neurofibromatosis type 2 or schwannomatosis.,13 Though the clinical follow-up in our patient showed improvement in the visual acuity and no muscle cone lesions in the orbital CT scan, we need to follow-up the patient for a long time period due to the possibility of recurrence.The surgery to completely excise the intact tumor is the best goal for orbital schwannomas.Conceptualization: Mingyu Ren, Yixiang Wu, Ruimiao Li.Data curation: Ruimiao Li, Jingjing Wang, Limin Liu.Formal analysis: Mingyu Ren, Yixiang Wu, Limin Liu.Investigation: Yixiang Wu, Jingjing Wang, Yu Gao.Methodology: Mingyu Ren, Yixiang Wu, Ruimiao Li.Project administration: Mingyu Ren.Supervision: Mingyu Ren, Yixiang Wu.Writing – original draft: Mingyu Ren, Yixiang Wu, Ruimiao Li.Writing – review & editing: Mingyu Ren, Yixiang Wu, Ruimiao Li, Limin Liu.


His past medical history was notable for controlled hypertension and hypercholesterolaemia. He did not follow any particular diet and admitted occasional alcohol use (less than once a week). Laboratory evaluation showed leucocytosis of 14 200/μl, elevated erythrocyte sedimentation rate of 70 mm/h, hypoalbuminaemia, elevated levels of α2- and β-globulins and a decreased albumin-to-globulin ratio. His serum uric acid concentration was 392 μmol/l . Computed tomography revealed destructive changes in the left sternoclavicular joint (A 45-year-old obese male (BMI 40.8 kg/mar joint .With suspicion for malignancy, the patient was referred to the oncological centre, where resection of the left sternoclavicular joint was performed. Histological analysis, including polarized light microscopy, revealed uric acid crystals in the joint and periarticular tissues consistent with gout.Acute arthritis of the left sternoclavicular joint is a very rare manifestation of gout, with only a few reports available in literature , 2. NeveFunding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.Disclosure statement: the authors have declared no conflicts of interest.


This is a case of a 64-year-old white man with a history of CCA, originally diagnosed in May 2018 and returning in November 2019 with growing cutaneous nodules. These were removed for cosmetic and functional purposes. Pathologic findings of the lesions showed likely metastatic disease from his original CCA. This represents a relatively rare presentation of metastatic disease in the setting of CCA. In cases of CCA with metastatic spread, treatment is not curative and should be focused on measures to improve the patient’s quality of life. This includes acceptable cosmesis, as well as factors aiding in completing activities of daily living. According to data from the National Cancer Institute Surveillance, Epidemiology, and End Results program, United States comprise 15% of newly diagnosed primary liver malignancies annually, roughly 6300 cases per year.2 Lung and breast cancer are the leading causes of cutaneous metastasis in men and women, respectively.2Skin metastasis is rare, involving 0.7%–9% of all cancer patients.We present the case of a 64-year-old man with metastatic cholangiocarcinoma. He developed 2 cutaneous, firm, mobile, rapidly growing masses at the angle of the left mandible and in the left axilla. Excision was performed for both diagnostic and aesthetic purposes. The pathologic findings confirmed poorly differentiated carcinoma, whose morphology is similar to that of tissue samples removed from his original mass in the liver. This patient represents an interesting presentation of his disease, and his treatment highlights how surgical intervention in the setting of metastatic disease, while not curative, can be beneficial to the patient for improving quality of life.3 These tumors occur more frequently in Asia than in Western countries. Risk factors include primary sclerosing cholangitis, choledochal cysts, parasitic infections, hepatitis B and C, HIV, Lynch syndrome, and exposure to cigarette smoke. Cholangiocarcinoma most commonly metastasizes to other locations in the liver, regional lymph nodes, or the lung; however, metastasis to the bone have been described in rare cases.4 Curative treatment may only be obtained through surgical resection; however, even in patients with an R0 resection, recurrence rates remain high, between 49% and 64%.3 Chemotherapy in unresectable disease may be used for palliative measures.Cholangiocarcinoma (CCA) refers to cancers arising from the biliary tree. Only 5%–10% of these are intrahepatic. About 19%–43% of iCCA are diagnosed incidentally, as patients may become symptomatic only with advancement of the disease, and may present only with vague abdominal symptoms.The patient is a 64-year-old white man with a history of cholangiocarcinoma, originally diagnosed in May 2018 after he presented with painless jaundice. Over 1 year after diagnosis and subsequent treatment, he began complaining of nodular lesions that had appeared near the left mandible and in the left axilla. These lesions had grown over the course of several weeks and had become bothersome. The lesion on his mandible made it difficult for the patient to shave. He was referred to a plastic surgeon for diagnosis and resection.During his 2018 workup, imaging showed a 3.8 × 3.2 cm ill-defined, irregular heterogenous lesion in the left lobe of the liver. He underwent an esophagogastroduodenoscopy with endoscopic ultrasound and fine-needle aspiration of the lesion, revealing a poorly differentiated carcinoma with anaplastic features. He underwent endoscopic retrograde cholangio-pancreatography and cholangiogram that demonstrated a normal appearing common bile duct and common hepatic duct with an area of stricture extending from above the hilum to the bilateral intrahepatic ducts. He has had multiple stents placed in the intrahepatic bile ducts to relieve obstructive symptoms. He has been receiving chemotherapy under the direction of a medical oncologist; however, his lesions failed to resolve and appear to have seemingly spread, leading to his current presentation.2 lesion at the angle of the left mandible (Fig. He was taken for excision of his lesions in November 2019, 18 months after his original diagnosis. He was noted to have a 1.5 × 1.2 cm5 Metastatic spread typically affects local lymphatics and other locations in the liver. Spread to bone and soft tissue has been described in literature, usually as individual case reports or low-power case series. Data on the frequency of spread to bones or soft tissues remain limited, but the consensus appears to be that overall prognosis is dismal.Cholangiocarcinoma is a rare malignancy that generally presents with symptoms relating to biliary obstruction.6 reported 55 cases of spinal metastases from CCA, with a median survival of only 4.0 months. Chindaprasirt et al4 documented 5 cases of metastases to the appendicular skeleton, most commonly the humerus, and 1 case of metastasis to the scapula, with survival ranging from 4 weeks to 1 year. Liu et al7 compiled a literature review of 30 patients with cutaneous metastases, most commonly to the scalp, also with a median survival of 4.0 months.Dowsiriroj et al3 Preferred treatment for CCA focuses on surgical resection or liver transplant. When not possible, such as in metastatic disease, gemcitabine/cisplatin combination therapy has shown a survival benefit in CCA patients. Palliative options such as radiofrequency ablation, transarterial chemoembolization, drug-eluting bead-transarterial chemoembolization, selective intra-arterial radiotherapy, or external beam radiation therapy have been attempted,3 albeit with limited data on their results.In conclusion, cholangiocarcinoma has been shown to metastasize to bone and soft tissue. However, spread to these sites is rare among cases of metastatic CCA, as well as compared with other cancers known to metastasize to these sites, such as breast or lung cancer. Survival after such distant spread is universally poor; however, it should be noted that even among primary cases of CCA, 5-year survival rates only approach 30%, even with surgical resection.


A 16-year-old teenager presented himself with a swollen left elbow, with no associated vascular-nerve complications. The standard radiography was without abnormalities. The echography showed the presence of an oblong vascularized formation occupying the posterior part of the elbow. The magnetic resonance imaging (MRI) showed a hyper vascularized lesion developing at the expense of the brachial triceps muscle with an intermediate signal intensity on the sequences weighted in T1 and a hyper signal in T2. The anatomopathological study of the initial biopsy and of the tumor part concluded with a cavernous hemangioma. Although their origin is vascular, hemangiomas never metastasize and do not undergo malignant transformation. The treatment of symptomatic hemangioma consists of surgical excision. Cavernous hemangioma is a benign tumor of vascular pediculated origin, common in the orbit and the liver , rare inIt is the case of a 16-year-old adolescent, with no particular medico-surgical history, who has been attended for one month by a practising orthopaedist for a swelling of the posterior aspect of the left elbow, appearing for 4 months and rapidly increasing in volume. He was asked for a standard X-ray showing no bone abnormalities, an echography that revealed the presence of an oblong formation occupying the posterior part of the vascularized elbow. Further exploration of MRI showed a hyper vascularised lesion developing at the expense of the brachial triceps muscle, measuring 75 x 70 x 16 mm, unrelated to the ulnar nerve . The youHistologically, hemangiomas are classified into three types: cavernous composed of multiple and dilated vessels, capillary with smaller and arteriovenous vessels made of arteries and dysplastic veins . A combiWe emphasize on ensuring ulnar nerve safety during the surgical procedure of cavernous hemangioma and the anatomopathological analysis for diagnosis confirmation.


Patients with a Wilms tumor are often admitted to the hospital accidentally, with an abdominal mass causing asymmetry of the abdominal wall. Hypertension accompanying a Wilms tumor occurs in about 10–27% of children, but cardiomyopathy associated with a Wilms tumor is very rarely described. This publication presents a case of a 9-month-old girl with a bilateral Wilms tumor accompanied by dilated cardiomyopathy since her initial cancer diagnosis, as well as her off-protocol treatment. The severe condition of the child forced the application of off-protocol treatment, i.e., accelerated resection of a larger tumor, which enabled the improvement of heart performance and made subsequent therapy possible. In the course of the presented treatment, a gradual normalization of cardiac ventricular function and contractility was observed. In conclusion, a massive abdominal tumor associated with abdominal compartment syndrome compromised the functioning of the cardiovascular system in the young child. Therefore, earlier removal of Wilms tumors in patients with heart failure should be considered. This may result in the improvement of cardiovascular function and the possibility of further therapy. Wilms tumors (nephroblastoma) are the most common kidney cancer in children . More ofWT1, WTX, and CTNNB1 underlie the genetic basis of about one-third of Wilms tumors. Another gene mutation found in Wilms tumors is the AMER1 gene. Changes on the short arm of chromosome 11 where IGF2 and H19 genes are located were also associated with development of a Wilms tumor.Wilms tumors are genetically heterogeneous and mutations in Patients with Wilms tumors are often admitted to the hospital accidentally with an abdominal mass causing asymmetry of the abdominal wall. Other symptoms present at the time of diagnosis of a Wilms tumor, such as malaise, loss of appetite, abdominal pain or hematuria, occur in 20–30% of patients . HyperteChemotherapy and surgery, and in some cases also radiation therapy, are an effective treatment . For bilThis publication presents the case of a girl with bilateral Wilms tumors accompanied by dilated cardiomyopathy since her initial cancer diagnosis, as well as her off-protocol treatment.A 9-month-old girl was admitted to the Pediatric Oncology Department due to the abdominal mass noticed by her parents two weeks earlier. She had been born from a second pregnancy at 39 weeks of gestation, with birth weight of 3790 g and the APGAR score of 10. The pregnancy had gone without any complications. Her parents and older brother are healthy.3; acc. to calculation formula V = D cm × S cm × W cm × 0.532) was extending from the diaphragm to the pelvis. The tumor shifted the liver to the left side. In the middle part of the left kidney, three solid pathological lesions of a similar nature were visible—the first one located in the upper-middle pole, 3.0 × 1.8 × 3.2 cm (9.2 cm3), the second one located laterally from the first, 2.2 × 1.6 × 1.9 cm (3.6 cm3), and the third one slightly lower and on the side, measuring 0.6 × 1.0 × 1.2 cm (0.4 cm3) , lack of appetite, increased respiratory and heart rate, and increased blood pressure. Computer tomography (CT) of the abdomen showed bilateral kidney tumors. On the right side, a heterogeneous pathological mass of 11.2 × 10.4 × 15.8 cm (979.1 cm0.4 cm3) .Lung CT did not show metastases. Echocardiography presented dilatation of cardiac ventricles with reduced ventricular function and impaired cardiac contractility—left ventricle (LV) transverse shortening fraction (FS%) was 10–12% , and LV ejection fraction (EF%) was 38–40% . Coronary artery abnormalities were excluded. Electrocardiography (ECG) at rest showed normal sinus rhythm. The heart rate at rest was 170–180 beats per minute. Twenty-four-hour Holter monitoring showed no abnormalities. The girl has rated at 7–8 points (Ross Heart Failure Classification), which indicates moderately severe heart failure.2, Actinomycin 0.045 mg/kg, all drug doses due to body weight below 12 kg according to SIOP scheme were reduced to 67%). Despite chemotherapy and cardiac treatment including spironolactone, captopril and carvedilol, the child still presented tachycardia, tachypnea and moderate hypertension with increasing levels of B-type natriuretic peptide (BNP), lactate dehydrogenase (LDH), high-sensitivity troponin T (hscTnT) and plasma renin activity (PRA).Chemotherapy with vincristine and actinomycin was prescribed  associated with a large Wilms tumor, it was decided to start the surgery from the right side. Uneventful nephrectomy was performed, followed by a prolonged stay at the intensive care unit due to the cardiologic problems. Histopathological examination revealed a stromal nephroblastoma with a medium degree of differentiation. Tumor regression was low, less than 15%. The tumor was mostly stromal, with spindle-like rhabdomyomatous and smooth muscle cells. The kidney tissue was dysplastic, partly cystic.3), the second one of 0.9 × 0.7 × 1.6 cm (0.5 cm3) and the third one of 0.7 × 0.9 × 0.5 cm (0.2 cm3). Due to cardiomyopathy, doxorubicin was omitted, and chemotherapy with etoposide and carboplatin was continued . At week 12 of chemotherapy, magnetic resonance showed that the three lesions in the left kidney were still present. Nephron-sparing surgery was performed. A wedge resection of all three lesions was performed. The postoperative course was uneventful. All three lesions were removed. The dominating one appeared to be a stromal nephroblastoma with spindle cells and rhabdomyomatous component. No necrotic features were found. Two smaller ones were the foci of kidney dysplasia.A CT scan one week after surgery showed persistent tumors in the left kidney, the first one of 2.7 × 1.8 × 2.4 cm (6.2 cmIn the course of the presented treatment, a gradual normalization of cardiac ventricular function and contractility was observed. The EF% values at the time of diagnosis and further in the course of preoperative chemotherapy were 38–40%. After the first surgical procedure and further in the course of postoperative chemotherapy, EF% rose to 50–55%. The last EF% after the completion of the entire postoperative chemotherapy was 60–65%. Changes in the levels of hscTnT, BNP, PRA and LDH during the hospitalization are illustrated in Hypertension and cardiomyopathy may coexist with a Wilms tumor . HyperteA 9-month-old patient treated in our center was admitted to the hospital with bilateral Wilms tumors with hypertension and concomitant cardiomyopathy already present at the beginning of hospitalization. Despite chemotherapy and cardiology treatment, deterioration of heart function was observed. Both the large tumor itself and the chemotherapy used can be responsible for heart failure. It was decided on the necessity of prompt surgical treatment. After removal of the right kidney with a massive tumor, the parameters of cardiac function gradually improved despite the ongoing chemotherapy. As Stine et al. described in their publication, cases of heart failure and bilateral Wilms tumor are a severe problem in treatment. They recommend surgical treatment of unilateral tumors . We did Several studies have emphasized the important role of surgery in improving the hemodynamic function of the heart. Chavalon et al. described a case of a 7-month-old girl with a unilateral Wilms tumor. After chemotherapy and tumor removal, heart function improved . Parry eMiura et al. described a case of a 3-month-old girl with severe hypertensive heart failure and Wilms tumor with hyperreninemia. The child received mechanical ventilation and antihypertensive treatment. The authors emphasized the importance of preoperative hemodynamic control and sedation that allow safe surgical treatment . Our patThe treatment of bilateral renal tumors is frequently challenging. General policy emphasizes maximum effort to perform nephron-sparing surgery and complete resections on both sides ,9. UnilaThe cited publications were useful in making treatment decisions for our patients ,17. In mIn conclusion, a massive abdominal tumor associated with the abdominal compartment syndrome negatively affected the cardiovascular system, especially in such a young child. Therefore, earlier removal of Wilms tumors in patients with heart failure should be considered. This may result in the improvement of cardiovascular function and the possibility of further therapy.


Intestinal volvulus is rare and responsible for upper bowel obstruction. They occur more frequently in a patient with abdominal surgery history. We report a case of small intestine volvulus on Meckel diverticulum, which occurred in a 21-year-old patient, with no history of laparotomy. The diagnosis confirmation was intraoperative, and the management consisted in a segmental resection of the small intestine with immediate anastomosis. The postoperative follow-up was good. This case underlines the scarcity and the severity of this presentation which therefore requires appropriate care in order to improve the prognosis. Small intestine volvulus is defined by the twist of the bowel around their vascular axis. It results in an upper obstruction presentation due to strangulation. It requires a timely management in order to have a positive impact on the patient's health. Usually, the onset of volvulus is due to the presence of abdominal adhesions in patient with abdominal surgery history. We report a case of small intestine volvulus seen in a patient without any surgical history. The objective is to describe the circumstances of diagnosis and the management and to do a review of the literature.3 and increased lactate level at 4.7 mmol/L. The serum β-HCG level was normal, so was the CRP, ionogram, and the lipase rate. The liver and kidney functions were normal. A pain medication was started made of intravenous analgesic , but the pain was persistent. No plain radiology was performed. A contrast-enhanced CT scan of the abdomen and pelvis revealed a closed-loop small bowel obstruction  and tachycardia (108 ppm). The abdomen was distended and painful with tenderness localized on the umbilical area. The biological analysis revealed leukocytosis at 17 600/mmtruction .A laparotomy was performed in emergency after premedication . At the opening of the peritoneum, a blood-tinged fluid and a very tight volvulus of the small intestine with intestinal necrosis extending about 25 cm at 60 cm from the ileocecal junction were found. Meckel diverticulum was found at the basis of the volvulus, fixed on the adjacent mesentery  measurinThe procedure consisted in a segmental resection of the area of necrosis and Meckel's diverticulum followed by a side-to-side anastomosis and peritoneal lavage. The postoperative follow-up was simple, and the patient was discharged to home on postoperative day 10. Histolopathological examination of the resected specimen revealed ileal ischemic necrosis on Meckel diverticulum without gastric heterotopia and without signs of malignancy.The small bowel volvulus requires emergency treatment because of the risk of generalized peritonitis secondary to bowel perforation. It occurs suddenly with rapid evolution to intestinal necrosis. Biological signs of an inflammation are often found. Management must be appropriate to improve the vital prognosis. The occurrence of the volvulus implies the presence of a fixed point for the rotation. In this way, adhesions represent the most common cause, especially in patients with previous abdominal surgery. This is not the case for the patient in our study. We report a case of small volvulus on Meckel's diverticulum.Meckel's diverticulum is the embryonic remnant of the yolk duct. It is rarely found in adults but is more frequent in the male subject . When prHowever, a few cases have been reported in the literature with no objectified fixation point. In 2015, a 32-year-old patient with no previous surgical history was admitted for an intestinal obstruction. The abdominal CT scan objectified images in favor of a small volvulus. Laparoscopy for diagnostic purposes made it possible to find volvulated but viable small handles on Meckel's diverticulum (neither volvulated nor necrotic). There was no objectified omphalomesenteric duct . In 2019The prognosis is generally good, and the follow-up surveillance is based on clinical sign assessment .Meckel's diverticulum is rare and often asymptomatic. Its discovery results from the occurrence of complications including diverticulitis and intestinal obstruction. The diagnosis is intraoperative with an associated intestinal resection gesture. This case highlights the rarity of small hail volvulus on Meckel's diverticulitis.


Ultrasound can penetrate deep into tissues and interact with human tissue via thermal and mechanical mechanisms. The ability to focus an ultrasound beam and its energy onto millimeter-size targets was a significant milestone in the development of therapeutic applications of focused ultrasound. Focused ultrasound can be used as a non-invasive thermal ablation technique for tumor treatment and is being developed as an option to standard oncologic therapies. High-intensity focused ultrasound has now been used for clinical treatment of a variety of solid malignant tumors, including those in the pancreas, liver, kidney, bone, prostate, and breast, as well as uterine fibroids and soft-tissue sarcomas. Magnetic resonance imaging and Ultrasound imaging can be combined with high intensity focused ultrasound to provide real-time imaging during ablation. Magnetic resonance guided focused ultrasound represents a novel non-invasive method of treatment that may play an important role as an alternative to open neurosurgical procedures for treatment of a number of brain disorders. This paper briefly reviews the underlying principles of HIFU and presents current applications, outcomes, and complications after treatment. Recent applications of Focused ultrasound for tumor treatment, drug delivery, vessel occlusion, histotripsy, movement disorders, and vascular, oncologic, and psychiatric applications are reviewed, along with clinical challenges and potential future clinical applications of HIFU. In clinical practice, a variety of different energies have been used for thermal ablation of tissues, including radiofrequency currents, microwaves, laser, thermal conductor sources, and ultrasound. Ultrasound provides several important benefits, such as enabling deeper tissue treatment, improved focus on the target tissue through its small wavelengths, and precise control over the shape and location of energy deposition . Using uOver the past two decades, continued advances in imaging, physics, and engineering have enabled precise focusing of ultrasound on deeper targets in the body. High intensity focused ultrasound (HIFU) is one of the more active research areas among non-ionizing ablation methods; such as lasers and microwaves. HIFU treatment is usually guided, assessed, and monitored by either magnetic resonance imaging (MRI) or ultrasound imaging . RecentlThe key to HIFU treatment is that the energy delivered is sufficient to increase the tissue temperature to a cytotoxic level very quickly so that the tissue vasculature does not affect the extent of cell killing. Heat coagulation by HIFU is desired for cell reaction with chronic inflammation, and histological signs of fat necrosis in the surrounding normal fatty tissue . Large bThis review aims to provide an introduction to the physical principles of HIFU, including its heating and mechanical (cavitation) effects in the body, along with a brief overview of the current clinical therapeutic aspects of HIFU.HIFU beam can pass through overlying skin and tissues without harm, and focus on a localized area with an upper size limit of approximately 3–4 cm in diameter for tumors. The basic principles underlying the tissue damage from HIFU are tissue coagulative thermal necrosis due to the absorption of ultrasound energy during tissue transmission  and ultrasound-induced cavitation damage . The heaAnother mechanism involved in HIFU ablation is mechanical effect. This mechanical effect, including cavitation, only occurs with high intensity acoustic pulses . CavitatOverall, HIFU equipment consists of two main components. The first is a piezoelectric ultrasound transducer that is used to deliver the therapeutic ultrasound beam. The most popular type of transducer used is a concave focusing transducer with a fixed aperture and focal length a. Other The second major component of HIFU is the imaging modality used for guidance. Real-time imaging during therapeutic procedure is essential to ensure the safety and efficiency of the treatment. The imaging modalities that have been used for monitoring treatment are sonography and Magnetic Resonance Imaging (MRI). MRI with its high anatomical resolution and sensitivity for tumor detection offers accurate planning of the tissue to be targeted and treated. In addition, MR thermometry enables calculation of the thermal dose and a superimposed representation of the anatomical image of the area where the temperature reaches cytotoxic levels. It provides closed-loop control of energy deposition with a temperature accuracy of 1 °C, spatial resolution of 1 mm, and temporal resolution of 1 s during HIFU treatment . Within Compared to MRgFUS, ultrasound imaging is more convenient and mechanically compatible, and provides the same form of energy for image guidance as used for therapy. It provides the benefit of verifying the acoustic window with sonography in real time, which means that if the target region is not visualized by ultrasound imaging before and during HIFU therapy, then it is unlikely that HIFU therapy will be effective in that specific region. The ablated target region is not visualized on standard B-mode images unless the gas bubbles produced within the focal zone appear as hyperechoic spots in the image . USgFUS There are three different ways to apply HIFU to the human body based on the accessibility of the targeted organ to ultrasound. When the organ is readily accessible, such as the kidney, HIFU is applied through an acoustic window on the skin by external or extracorporeal transducers a. In othTransrectal and interstitial transducers usually operate at higher frequencies and lower power so they can be applied from smaller distances to the target area. The devices developed for transrectal use have combined therapy and imaging transducers incorporated into the head of the transducer probe with a fixed but adjustable focal point that can be mechanically moved to treat a larger tissue volume b. ProstaDepending on the geometric size and acoustic parameters of the transducers applied in a HIFU system, the beam size of a −6 dB HIFU system at its focal region is typically 1–3 mm in width and approximately 10 mm in length . HoweverOverall, the therapeutic ultrasound frequency depends on the application-specific treatment depth and the desired rate of heating required for treatment. Higher frequencies have lower penetration depths while lower frequencies have higher penetration depths. Frequencies as low as 0.5 MHz have been used for deep treatments  or high absorption situations and as high as 8 MHz for superficial treatments (including prostate applications) . FrequenMany benefits justify further exploration of HIFU for additional future clinical applications: HIFU ablation results in reduced toxicity compared with other ablation techniques; it is non-invasive and causes minimal pain; it is a low-cost procedure compared with surgery; less anesthesia involvement and suitable for patients at high surgical risk; it leaves no scars on the patient; lower infection risk; recovery is faster compared with traditional surgery techniques; any bleeding that occurs during the procedure can generally be stopped by ultrasound; it has excellent repeatability as there is no dose limit;, there is no exposure to ionizing radiation due to being guided by MRI or diagnostic ultrasound as opposed to X-ray imaging, precise energy delivery to a targeted point in soft tissue without affecting the skin integrity; system maintenance costs are low; it causes very limited side effects to normal surrounding tissues ; patientIn terms of limitations, HIFU treatment is sensitive to patient movement, and near-field heating, and the treatment time can be as long as several hours. When an extracorporeal device is used to distribute the incident energy over a large skin area, the device has a wide aperture and long focal length to decrease the acoustic intensity at the wave site to avoid skin burn. However, severe full skin burns following extracorporeal shock wave lithotripsy (ESWL) for renal calculi  or seconHIFU has been used to treat a variety of solid malignant and benign tumors. HIFU has the advantage of being completely non-invasive, extracorporeal, and non-ionizing modality compared to conventional cancer treatment methods such as chemotherapy, radiotherapy, and open surgery. It is also considered as the only non-invasive technique for both primary solid tumors and metastatic disease treatment. Non tumorous conditions such as prostate hypertrophy have also been treated using HIFU technique. Here we discuss the most frequently used clinical applications of HIFU.Hepatocellular carcinoma (HHC), is one of the most common and often one of the most difficult to treat liver cancer, especially when multicentric. This can make the outcome of surgical resection poor, with high risk of tumor recurrence . ExtracoHIFU can be an effective nonsurgical technique for breast cancer treatment particularly for high-surgical-risk patients and breast-conservation therapy. This is because of its local tumor necrosis effect, lessened requirement for anesthesia , shorterProstate cancer treatment trials using trans-rectal HIFU has shown promise over the past decade in more than 100 sites across the world . Different studies have reported significant drop in prostate-specific antigen (PSA) (to ≤0.2 ng/mL) and promising survival rate in patients ,40,41,42HIFU has been shown to be a safe technique with minimal side effects; however, some uncommonly encountered complications have been reported including urinary retention, infection, incontinence, urethral stenosis, impotence, rectal fistulas, and chronic pain , which hWhen renal tumors are small in size, non-invasive HIFU ablation therapy is an attractive alternative method compared to total or partial nephrectomy. The few clinical studies that have examined HIFU for ablation of kidney cancer tumors have reported promising outcomes of histology-proven irreversible and homogenous damage of treated areas , tumor nEsophagus cancer is often identified as a small localized intraluminal squamous-cell carcinoma. Common treatment methods involve surgery and chemotherapy with or without radiation therapy. These methods have overall poor outcomes; with 5-year survival rates of 13–18% . ClinicaPancreatic cancer is typically detected late with 5-year survival rates of <5%. While surgery is only a possible option for 20% of patients, HIFU is emerging as a potential treatment technique. HIFU has been increasingly used either alone, in combination with chemotherapy (gemcitabine), or as additional therapy after failure of chemo/radio therapy ,57. ResuReports on side effects and complications of the HIFU treatment have been variable. While some studies have reported no complications , others Glioblastoma is the most common malignant tumor of the central nervous system. It is commonly treated with surgical resection and chemo/radiation therapy. Main challenges in management of brain tumor is the diffuse spread of the tumor throughout the brain and inability of chemotherapy regimen to cross blood brain barrier (BBB) . HIFU, dReports of HIFU used to treat bone include applications for destruction of tumor microvessels and thrombosis to prevent haematogenous tumor cells dissemination , pain paCommercially used HIFU systems in the reported studies are ExAblate 2000   and ModeUterine fibroids or uterine leiomyomata are benign smooth muscle tumors of the uterus, fallopian tubes, broad ligament, or cervix, affecting about 25% of women . HIFU is3 volume, in less than 15 min has also been demonstrated on excised tumors using an inserted interstitial ultrasound ablator [Commercially available systems used in these studies are ExAblate 2000 , a Haifu JM therapeutic system , HIFUNIT 9000 , and a custom made mobile HIFU unit . HIFU treatment of large fibroids; ~4 cm in dameter, >45 cm ablator . The HIF ablator . Althoug ablator . Overall ablator .Fibroadenomata (FAD) are benign breast lesions typically removed surgically. In addition to conventional surgical removal of the lump or vacuum-assisted mammotomy, other techniques such as HIFU, cryo- or laser ablation have also been used. A comprehensive review of these techniques by Peek et al. indicated that all these ablative techniques are minimally invasive and promising for FAD treatment .The ability to focus and target the US beam through the intact skull to areas as small as a couple of millimetres has been a considerable milestone in enabling precise, local ablation of intracranial brain tissue to overcome certain brain disorders . HIFU haEssential tremor (ET) is a movement disorder affects the upper extremities and dominant arm. When severe it is often managed by surgical disruption of the ventral intermediate nucleus of the thalamus; achieved by insertion of the invasive probe and radio frequency (RF) thalamotomy at 75–80 °C or by deep stimulation of the brain that may cause infection and/or hemorrhage . Recent Parkinson disease is characterized by progressive degeneration of motor neurons. Disruption of key motor nuclei can lead to significant improvement in motor symptoms . HIFU caCentral- and peripheral-type pain syndromes are challenging conditions to treat especially when common pharmacological medications are ineffective. Destructive procedures can be used to ablate the sensory or affective components; brain and spinal cord in central- and nerves or nerve bundles in periphery-type chronic pain cases . HIFU haHIFU treatment of benign prostate conditions presents different problems compared to malignant prostate cancer, since prostate cancer is generally a multi-focal disease. Whole gland HIFU ablation has been more successful in benign tumors . ProstatThyroid nodules have been treated using a variety of different techniques, with surgery still the most common and effective approach. This involves risks and complications of hypocalcemia, transient or permanent recurrent laryngeal nerve palsy, bleeding, postoperative infections . RecentlThe main HIFU device used to deliver medication into human brain for a wide variety of brain diseases and also for scalpel-free surgery of brain tumour is the ExAblate Neuro , which consists of a spherical, phased array, multi-element (1000 transducers) helmet that is computer controlled for wave front distortion compensation . PatientDiagnostic imaging systems have been used along with HIFU devices to provide improved safety, therapy navigation, and provide assessment of vascularity or ablation quality during or after treatments. The main reported imaging methods are ultrasound guided FUS (USgFUS) ,62,104 8HIFU is emerging as a potential technique for occluding blood vessels in different diseases or conditions such as in arteriovenous malformations to control hemorrhage or in shrinking a solid tumor by blocking/interrupting its blood supply . FurtherThe mechanical disruption ability of HIFU, mediated by cavitation, makes it an attractive technique to locally open the blood brain barrier (BBB); Cavitation bubble-induced BBB disruption can be performed either by very high HIFU exposure, which may cause blood vessel rupture or occlusion , or moreIntracerebral hemorrhage is currently treated with thrombolytics and surgery. HIFU offers the capability to liquefy blood for facilitated aspiration, which can help decrease clot burden and mass effect to avoid craniotomy . Blood cAbscesses especially when caused by methicillin-resistant Staphylococcus aureus (MRSA) bacteria may be difficult to treat. A recent feasibility study applied HIFU, at two focal temperatures of 52 and 64 °C, on targeted MRSA-induced abscesses in mice. Post HIFU ablation of 64 °C, significant reduction in bacterial load and abscess external size was observed at day 4 and 10, respectively . No sideIntegrating focused ultrasound with different existing therapeutic technologies can improve clinical outcomes. Enhanced skin permeabilization using this technique may replace multiple needle use for medicines such as heparin and insulin or enable diffusion of large molecules (>500 Da) through stratum corneum ,115. FocBoth thermal and non-thermal (cavitation) effects play a very important role in all therapeutic applications of ultrasound. The side effects of these two mechanisms of action can be injurious biologically and are therefore avoided in diagnostic applications of ultrasound but can be beneficial in therapeutic applications. The ability to focus the ultrasound beam to a small area a couple of millimeters in size enhances both the thermal and non-thermal effects of ultrasound and results in ablation and necrosis of cells at the applied focal point. This makes ultrasound an excellent non-invasive therapeutic ablation technique for deep-seated targets within the body. HIFU therapy provides a less invasive approach to cancer therapy that minimizes discomfort to the patient and length of hospital stay. Initial studies have demonstrated HIFU to be generally safe and clinically effective and to have high potential clinical acceptance. However, HIFU is still in its infancy and further studies are necessary  regarding the long-term medical benefits, technical considerations, and treatment delivery before transition to more widespread use. The range of HIFU applications may expand in the future with improved imaging. MRgFUS is one of the most successful imaging guide approaches. However, there is a need for additional studies with longer-term follow-up.


Some neoplasia—such as adrenal and thyroid glands tumors—have been associated with “tumor thrombi” both in humans and dogs. The detection and characterization of these venous tumor thrombi is important for both surgical planning and prognosis. In human medicine, contrast-enhanced ultrasonography (CEUS) is considered an accurate diagnostic technique for differentiating malignant from benign portal vein thrombosis in hepatocellular carcinomas. Data regarding the characteristics of tumor thrombi in dogs are currently lacking. Therefore, the aim of this study was to assess the feasibility of CEUS for the characterization of malignant venous thrombosis in dogs. On the basis of our results, CEUS appeared to be useful in the detection of malignant intravascular invasion; contrast uptake of the thrombus was present in all cases. In addition, CEUS may clearly detect newly formed vessels within the thrombus, and arterial-phase enhancement and washout in the venous phase were the main features in malignant thrombosis in our dogs. As CEUS is an easy to perform, noninvasive technique, its application in the detection of malignant thrombosis in dogs may be used to improve the diagnosis in oncological canine patients.Tumors of adrenal and thyroid glands have been associated with vascular invasions—so-called tumor thrombi, both in humans and dogs. The detection and characterization of venous thrombi is an important diagnostic step in patients with primary tumors for both surgical planning and prognosis. The aim of this study was to describe the use of contrast-enhanced ultrasonography (CEUS) for the characterization of tumor thrombi. Dogs with tumor thrombus who underwent bi-dimensional ultrasound (B-mode US) and CEUS were included. Seven dogs were enrolled in this retrospective case series. On B-mode US, all thrombi were visualized, and vascular distension and thrombus-tumor continuity were seen in three and two cases, respectively. On color Doppler examination, all thrombi were identified, seemed non-occlusive and only two presented vascularity. On CEUS, arterial-phase enhancement and washout in the venous phase were observed in all cases. Non-enhancing areas were identified in the tumor thrombi most likely representing non-vascularized tissue that could potentially be embolized in the lungs after fragmentation of the tumor thrombi. On the basis of these preliminary study, CEUS appeared to be useful for the characterization of malignant intravascular invasion. Tumor thrombi are defined as tumors extending into a vessel—typically a vein. It is crucial to distinguish tumor thrombi from non-malignant thrombi in the setting of neoplasia, as this often impacts staging and treatment approaches ,3,4,5,6.Ultrasound examination is fast and less invasive method to examine intra-abdominal structure, thyroid lobes and adjacent vessels, showing high sensitivity 100%) and specificity 96%) in detecting vascular invasion . In anot00% and s% in deteThe purpose of this study was to describe CEUS features of tumor thrombi in dogs, with particular attention to the risk of fragmentation and endothelial invasion and compare them with their conventional ultrasound (US) and CFD characteristics.Medical records of dogs admitted to the Veterinary Teaching Hospital of the University of Bologna from January 2012 through January 2016 were reviewed and dogs with primary masses and associated venous thrombi were selected. Dogs were included in the study if they had a complete US examination of the mass and associated thrombus, including B-mode US, CFD examination and CEUS. Only dogs with a cytological or histological diagnosis of the primary mass, associated venous thrombus or both were selected.The following information were recorded for each case: breed, sex, age, anamnesis, results of physical examination, laboratory tests and histological or cytological findings.Two-dimensional US, CFD and CEUS images were reviewed off-line. Bi-dimensional findings recorded were: Localization, shape, dimension, echostructure of the primary lesion, presence of intravascular thrombus showing anatomic continuity with the primary lesion and dilation of the invaded vessel. The evaluated CFD findings were: Presence of residual flow within the invaded vessel and presence of intralesional signal within the primary lesion and the thrombus. Finally, CEUS findings evaluated were: contrast uptake (present or absent), aspect of the contrast uptake (homogeneous/heterogeneous), margination of the thrombus (regular and well-defined/irregular and ill-defined), comparison between timing in contrast uptake by the thrombus and the invaded vessel and comparison between timing in contrast uptake by the thrombus and the primary lesion.Histological or cytological findings of the primary tumor or of the thrombus, when available, were recorded. Samples were collected by ultrasound-guided fine needle aspiration (FNA) and/or tissue core biopsy (TB) or at necropsy.Seven dogs met the inclusion criteria. The median age was 11 (7–13) years, and the median body weight was 27 (9–33) kg. Information regarding the signalment and clinical signs are summarized in ® diagnostic, Milano, Italy) through an indwelling cephalic venous catheter, followed by a rapid immediate bolus of 5 mL saline. The arrival of the contrast medium at the level of the target organ was then visualized using dedicated imaging software of the ultrasound machine that selectively displaces the signal deriving only from the contrast medium, allowing perfect definition of the perfusion pattern of the region of interest. Bi-dimensional US, CFD and CEUS findings are summarized in Bi-dimensional US and CFD examinations were performed using an ultrasound unit  equipped with different micro-convex, convex and linear array probes of different frequencies (2–9 MHz). For the CEUS examination, a linear array probe (3–9 MHz) was used. Contrast-enhanced US was performed by intravenously injecting 0.05 mL/kg (0.02 mL/lb) of a second generation US contrast medium  had surgical removal of the primary tumor and the thrombus. Histopathological diagnosis was consistent with solid-follicular thyroid carcinoma with neoplastic vascular invasion in the first case and with adrenocortical carcinoma associated with intravascular neoplastic thrombosis in the other one. Two dogs died few months after the US; necropsy showed a thyroid carcinoma with neoplastic invasion of the thyroid vein in one case (case 2) and a cortical adrenal gland carcinoma with neoplastic thrombotic caval invasion in the other (case 4). Necrotic areas within the tumor thrombus were detected at histology in one case (case 3) and endothelial invasion in another case (case 1).In 3 cases the neoplastic mass extending into the caval vein was associated with multiple hepatic lesions detected on US. In these cases, cytology of the liver nodules suggested adrenal medullary neuroendocrine tumor (cases 5 and 6) and retroperitoneal liposarcoma (case 7) as primary diagnoses. Surgery was recommended, but declined by the owners; accordingly, histopathology of the intravascular mass was not available for these last three cases, and the diagnosis of tumor thrombi in these cases was only presumptive.In this study, CEUS could identify all tumor thrombi, whereas B-mode US allowed their visualization but could not establish the continuity with the primary tumor in every case. In addition, CEUS could better describe the vascularity of the tumor thrombi compared to CFD.Conventional B-mode US is a fast and noninvasive tool to examine intra-abdominal structures, superficial neck structures, thyroid lobes and adjacent vessels. A recent study showed that conventional US is 100% sensitive and 96% specific in detecting vascular invasion of the caudal vena cava in dogs with adrenal gland tumors . HoweverConventional B-mode US detected venous thrombosis in all patients of our study. Bi-dimensional features of tumor thrombi have been previously reported in literature and they are characterized by continuity between the primary mass and the thrombus ,19 and dColor-Doppler examination of the thrombus may be helpful in detecting intralesional signal due to presence of newly formed tumoral vessels, suggesting a neoplastic origin of the thrombus. However, this technique is limited by the low sensitivity of Doppler in detecting small vessels, low velocity blood flow and microvascularization in general . In thisIn human medicine, CEUS showed higher sensitivity in detecting vascularized tumor thrombosis when compared to CFD examination ,15. In hIn dogs, some studies have been carried out in order to determine the utility of contrast-enhanced CT in the detection of vascular luminal invasion by adrenal gland masses ,24. TheyIn our case series, contrast uptake of the thrombus was considered the main feature of malignancy, and it was present in all cases. Contrast-enhanced US may also clearly detect new-formed vessels within the thrombus. Studies in humans, however, reported that CEUS may misdiagnose a benign thrombus when some of its portion are revascularized, mimicking a vascularized malignant neoplastic thrombosis .For this reason, other features were evaluated. Particularly, the timing of thrombus enhancement was always compared to the invaded vessel and in three cases to the primary neoplastic mass. Malignant thrombi showed a contrast uptake synchronous with the primary mass while the enhancement was always anticipated in the thrombus when compared to the invaded veins. This behavior is meant to be a consequence of newly formed arterial vessels inside the malignant thrombi  that typically receive the contrast before it reaches the systemic venous system .The aspect of the contrast uptake of the tumor thrombi was homogeneous in two dogs with thyroid tumors, while was heterogeneous, with several non-enhancing areas within the thrombus in the caval tumor thrombi. This aspect could reflect the presence of necrotic areas within the thrombus . The necrotic areas within a tumor thrombus could lead to its fragmentation and predispose to pulmonary thromboembolism. For this reason, the possibility of a thrombus to fragment should be taken in account when deciding the treatment, in case of surgery in deciding the timing for the surgery and to formulate a prognosis.Similarly, the possibility of CEUS to detect endothelial invasion could be extremely useful for surgical planning, as, for instance, a cavectomy is required in case of endothelial invasion from the neoplastic adrenal tissue. The irregular and ill-defined margination of the thrombus, with particular attention to the portions adjacent to the vessel walls, could reflect the endothelial invasion, as confirmed histologically in one of our cases.This study has some limitations mainly related to its retrospective nature. First of all, the limited number of cases associated with the absence of dogs affected by benign thrombi prevented the possibility to evaluate the accuracy of CEUS in distinguishing benign from malignant thrombi. The lack of histological confirmation of thrombus malignant origin in three cases and confirmation of necrotic areas within the thrombus or endothelial invasion in only two cases are others limitations of this study. Further studies, including cases of nonneoplastic thrombi, are needed in order to confirm the peculiarity of CEUS features of malignant thrombi.In conclusion, this is the first report describing the use of CEUS to characterize intravenous thrombosis in dogs with malignancies. On the basis of these preliminary experience, CEUS appeared to be easy to perform and useful for the detection of malignant intravascular invasion. In particular, the presence of an arterial-phase enhancement of the thrombus and a washout in the venous phase were consistently identified for the malignant thrombi characterized in this study.


Castleman’s disease (CD) is a rare and mainly asymptomatic cause of lymph node swelling. Often it is unicentric and located in the mediastinum. Due to rarity of the disease as well as a lack of symptoms, diagnosis proves to be challenging, especially when CD affects another region.A 51-year old male underwent resection of a malignant melanoma. Further staging revealed an unclear abdominal mass located in the mesentery with close contact to small intestine. Under the assumption of metastasis, complete tumor removal including intestine resection and anastomosis was performed. Both, operation and postoperative phase proved uncomplicated. Surprisingly, however, histology revealed a benign lymphoproliferative disorder, CD.e.g. lymphoma) can only be achieved through pathology, in that specific tests fail yet to exist. The etiology of CD remains barely understood and based upon few cases reported complete surgical resection is recommended. However, the common form is meant to be benign.There are several differential diagnoses for abdominal soft tissue tumor, such as: gastrointestinal stromal tumor, sarcoma, lymphoma, or metastasis. In reference to the resected melanoma described above, metastasis was assumed with subsequent oncological resection. Both, the reliable detection of CD as well as the exclusion of malignant disease (The potential diagnosis of CD should be made more common to surgeons, especially in completely asymptomatic patients and non-superficial lesions, whereby close follow-up examination might be offered to patients. This disease was first systematically described in 1956 by and later named after Benjamin Castleman ,3. Never299mTc-Nanokoll) defined sentinel lymph node was performed. This subsequent resection revealed the necessary 2 cm safety margin. The lymph node was histopathologically free of malignancy. As part of the extended staging, a whole-body CT was undertaken. Cerebral or pulmonary tumor manifestations could not be detected, however, an unclear lesion of 4.2 × 4.1 × 3.3 cm in size was observed intraabdominally in the left middle abdomen  appeared possible, as well as a benign lesion such as, for example, sclerosing mesenteritis. The lesion was inaccessible to a CT-assisted puncture, therefore after endoscopic tumor exclusion , the decision for surgical exploration was made. Post sparing median upper abdominal laparotomy, the above-described tumor was located within the mesentery, very close to the small intestine and approximately 100 cm post ligament of Treitz. The tumor and the surrounding mesentery presented palpably solid and suggestive of malignancy. A small intestine resection was carried out along with the mesentery to the aorta, so that ultimately 33 cm small intestine and an 18.5 × 11.5 × 3.7 cm large piece of mesentery were resected. The anastomosis was uncomplicated, and the surgery was completed without any complications. The postoperative phase was also uncomplicated, so that we were able to discharge the patient to outpatient follow-up on the fifth postoperative day.51-year old, male patient with a basically insignificant medical history except for arterial hypertension, a recent meniscus surgery, and an appendectomy in childhood was first referred to the Department of Dermatology with a highly suspicious for melanoma mass in the transition from the back to the right gluteus maximus. Post resection, subsequent histopathological workup revealed a superficially spreading, malignant melanoma with a diameter of 3.5 cm and a depth of 3.5 mm. The tumor formula was: pT3 L0 V0 R0. However, due to an only minimally tumor-free margin (approx. 1 mm), yet another surgical resection including puncture of the scintigraphic  and the remaining 23% were discovered intraperitoneal, particularly within the mesentery [CD is a rare diagnosis with little clinical expertise. As first described by Benjamin Castleman, the most common site of manifestation is suspected to be the mediastinum. The disease, however, can affect any lymph node, though rarely occurring within extra lymphatic tissue ,6. Interesentery .Talat et Schulte advocate a classification of the disease according to clinical-pathological findings in which the unicentric, hyaline-vascular CD, as in the presented case, is classified as class I with a 3-year disease-free survival of 92.5%. [The etiology of this disease remains poorly understood. From a clinical point of view, two variations are distinguishable: the unicentric form, which usually affects only one lymph node or at the most one lymph node region, and the multicentric spread. The latter is often coincident with the human herpesvirus 8 (HHV-8), but there are also idiopathic forms. Unicentric CD is generally not associated with HHV-8 and is usually characterized pathologically as a hyaline-vascular type, whereas the variant of the so-called plasma cell type or a mix type is less common [f 92.5%. ,11. As ‘f 92.5%. .e.g., lymphoma, sarcoma) or a lymph node metastasis is therefore challenging [The greatest challenge for the physician, however, is usually not the correct choice of therapy, but instead to initially establish a correct diagnosis. Due to the rarity of the disease, it is seldomly considered in the differential diagnosis. Additionally, the symptoms are nonspecific and lymph node swelling is usually a chance finding . The sigllenging . Informallenging .Intraoperatively, the CT finding of a large, inhomogeneous mass in the mesentery was confirmed and a complete oncological resection was performed. However, pathology revealed CD of a hyaline-vascular type, which are commonly considered to be benign. Due to the temporal correlation with the malignant melanoma, as well as the nonspecific presentation of the lesion on CT, a metastasis was assumed. Accordingly, oncological resection with partial resection of the adjacent small intestine was performed. Frozen section analysis was not performed, in that it might have rebutted the idea of melanoma. However, it seems very unlikely, that a lymphoma could have been precluded in that way. Finally, from a surgical point of view, the operation was carried out to the best of our knowledge. In retrospect, a close follow-up could have revealed the benign nature of the disease. Nonetheless, a bowel-preserving resection would have been almost impossible due to the close contact with the pathologic lymph node.4Diagnosis of CD is challenging and is often discovered by chance. An awareness of this benign disease in the instance of asymptomatic, isolated lymph region swelling may lead to the development of a correct diagnosis. In most cases surgical resection appears to be therapy of choice, as it is relatively uncomplicated and allows certain diagnosis by histopathology.None.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Not commissioned, externally peer-reviewed.This study is exempt from ethical approvalWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Kim R. Liedtke, MD, BSc: wrote the draft for case report, carried out the literature search, and wrote up the literature review.Nina Waldburger, MD: performed the histopathological preparation and analysis, edited the draft.Anne S. Glitsch, MD: assisted the surgery, edited the draft.André Schreiber, MD: planned and performed the surgery, edited the draft, and helped to analyze the literature review results.This retrospective case report is not registered in a public database, yetKim R. Liedtke, MD, BSc; André Schreiber, M.D.


Primary mucinous eccrine carcinoma (PMEC) is a quite rare malignant tumor that typically involves the head and neck region in approximately 75% of patients and the periorbital area is the most common area. A 57-year-old man was seen with a painless red mass involving the left lower eyelid for the past 7 months. Examination revealed a small mass measuring 0.6 cm with shiny red smooth appearance of the skin. H&E stained examination revealed a tumor mass that composed of polygonal cells in nests, lobules and islands separated by large amount of mucin. The neoplastic cells showed eosinophilic cytoplasm and round nuclei with mild pleomorphism. There was no necrosis, no atypical mitosis, no lymphovascular and perineural invasion. Rare mitotic figures were found. Tumoral nests present on all surgical margins. Primary MEC is a slow-growing neoplasm that may recur after incomplete surgical excision. This tumor is often clinically mistaken for other cutaneous tumors due to its variable appearance. Recurrent tumor tends to be locally invasive with a rare metastatic rate of 9.6%. As a result of the recurrence risk, patients should be followed up regularly. Thus, our patient was recommended to have a regular follow-up every six months. Thiset al. in 1971(The first case was reported by Mendoza . in 1971, 6, 7. H. in 1971. The tum. in 1971, 5, 8. OThe local recurrence rate and metastatic rate of PMEC are 29.4% and 9.6%, respectively . Majorit


Schwannomas or neurilemmomas are benign and slow-growing tumors that arise exclusively from Schwann cells in peripheral nerve sheaths. These neoplasms theoretically can occur anywhere in the body, but they most frequently affect extremities, as well as head and neck region. However, their presentation in the abdominal wall is extremely rare and only few cases have been reported in the literature. Subcutaneous lesions may be asymptomatic and only incidentally discovered upon physical examination or imaging. However, occasionally they induce mass effects on surrounding large nerves. We present the case of a 34-year-old man with abdominal wall pain localized in the right iliac fossa and palpable subcutaneous mass. Ultrasound and CT scan revealed a solid well-defined mass of the abdominal wall. Following surgical excision under general anesthesia, histological examination was consistent with the diagnosis of benign schwannoma. Schwannoma or neurilemmoma is an uncommon benign tumor arising from the Schwann cells in the peripheral nerve sheath , 2. MostA 34-year-old man was admitted to our institution for chronic and intermittent abdominal wall pain localized in the right iliac fossa. This pain, evolving for the past one year, was not related to any particular position, oral feeding, or bowel movements. There was no history of weight loss or any gastrointestinal symptoms such as nausea-vomiting, diarrhea-constipation, or signs of gastrointestinal bleeding. He denied any abdominal trauma or past surgical operations.On physical examination, a well-defined subcutaneous mass was palpable in the right iliac fossa. The mass was firm, non-tender, and not fixed to the skin or the muscular plane of the abdominal wall. It was sensitive to both light touch and deep pressure. No peritoneal signs or overlying skin changes were found. All routine laboratory tests including blood cell count, CRP (C-reactive protein), serum electrolytes, and hemostasis tests were completely unremarkable. Tumor markers including carcinoembryonic antigen and carbohydrate antigen (CA 19-9) were within the normal ranges.An abdominal ultrasound examination was performed, which showed a solid and heterogeneous mass developed in the right abdominal wall. A basal computed tomography (CT) revealed a 7×5 cm well-circumscribed tissue-mass located in the subcutaneous plane of the right iliac fossa . After iSurgical resection of the mass was proposed and the patient was then operated under general anesthesia. The mass was easily enucleated after a direct anterior approach by a selective incision in the right iliac fossa . It was exclusively involving the subcutaneous plane without any connection to the musculofascial layer or the parietal peritoneum of the abdominal wall. Pathological examination of the resected specimen revealed an encapsulated mass measuring 7x7x5 cm with heterogeneous appearance and presence of multiple areas of hemorrhagic and mucoid changes. Macroscopically, no obvious necrosis was observed . Microscopically, the tumor was composed of proliferating spindle cells arranged in bundles without cytonuclear atypia or abnormal mitoses . ImmunohPeripheral nerve sheath tumors are a heterogeneous group of neoplasms that originate from different components of the peripheral nerve sheath . These neoplasms can be divided into two separate groups with different histologic features: benign tumors mainly represented by schwannomas and neurofibromas and malignant tumors grouped under the term of malignant peripheral nerve sheath tumors. Benign and malignant peripheral nerve sheath tumors may develop sporadically or as part of neurofibromatosis , 4, 6. Schwannomas are benign, encapsulated, slow-growing tumors that arise exclusively from Schwann cells in neural sheaths -9. TheorThese neoplasms can present at any age, and most commonly occur between 40 and 60 years of age . There iIn peripheral topography, most schwannomas arise from the nerve sheath of large peripheral nerves and occur at the level of the subcutaneous plane , 10. TypHowever, they occasionally produce pressure effects on surrounding large nerves, as found in our patient. Although schwannomas may be imaged by ultra-sound or computed tomography, magnetic resonance imaging (MRI) is the most reliable means of defining these tumors. On CT scan, schwannomas usually appear as a well-defined homogeneous softtissue mass wich is iso to hypodense compared to muscular structures.. The lesions show minimal or mild heterogeneous enhancement after the administration of contrast agent. On MRI, schwannomas appear as hypointense on T1-weighted and hyperintense on T2-weighted images. Typically, small schwannomas tend to enhance uniformly after gadolinium while larger lesions show a more heterogeneous enhancement , 15, 16.In pathology analysis, most schwannomas are unilobular masses surrounded by fibrous capsule derived from epineurium of the involved nerve. The identification of a nerve entering and exiting a mass is suggestive for a peripheral nerve sheath tumor, while the eccentric association with the nerve trunk is considered to be pathognomonic for schwannoma . MicroscThe optimal treatment for benign schwannoma is complete surgical excision with intact margins. The prognosis of these lesions is good, the recurrence is unusual, and the malignant degeneration is exceedingly rare , 24. Sch


Bronchogenic cyst usually presents along the tracheobronchial tree. Rarely, it is found inside peritoneal cavity. Here is a case of 30-year-old man who presented with concerns of abdominal pain. On evaluation, contrast-enhanced CT scan showed hypodense cystic lesion in epigastric region related to right crus of diaphragm. The patient underwent laparoscopic marsupialization/deroofing of cyst. Histopathological examination of resected specimen showed respiratory epithelium. Postoperative period was uneventful. Bronchogenic cyst is an abnormal developmental anomaly of foregut which is usually present in mediastinum. Occasionally, it is found at unusual locations, such as retroperitoneum. Microscopically, it is lined with ciliated pseudostratified columnar epithelium, and its wall contains fibrous elastic tissue with normal bronchial elements. Mostly it is asymptomatic, but sometimes it may get infected or produces compressive symptoms . Here isA 30-year-old gentleman from Faridabad, India, presented with concerns of upper abdominal pain along with a sense of discomfort for last one day, which was sudden in onset, progressive, and radiating towards back. There was no prior history of similar event. No other specific complaints were noted.On examination, his vitals were normal. Abdomen was soft, non-distended and tenderness was present over epigastric and supra umbilical area. There was no palpable lump or organomegaly nor any thrill could be appreciated. Ultrasonography of whole abdomen showed a well-defined hypoechoic lesion with internal echoes (5.9 × 4.2 × 4.2 cm) in pre-aortic region in the epigastrium with no definite intralesional color flow on Doppler. Contrast-enhanced CT (CECT) scan of whole abdomen revealed a well-defined thin-walled homogeneous hypodense cystic lesion (70 × 45 mm) in epigastric region related to right crus of diaphragm near the midline. The lesion was indenting the stomach and abutting the adjacent liver, pancreas, left adrenal, inferior vena cava, aorta, and celiac axis Figure . Based oAfter obtaining an informed consent, laparoscopic marsupialization/deroofing was done. Complete excision could not be achieved due to dense posterior adhesion to abdominal aorta and inferior vena cava. Intraoperatively, a 7 × 5 cm large well-defined cystic lesion was present in the midline in the retroperitoneum having both true and false capsules and containing approximately 100 ml of white colored fluid. Relations of the cyst are as follows: anterior relation - posterior surface of stomach and body of pancreas, posterior relation - abdominal aorta and inferior vena cava, on the right side - lesser omentum with right gastric vessels. on the left side - posterior surface of stomach, superiorly related to inferior surface of diaphragm and inferiorly to the body of pancreas Figure .Histopathological examination revealed specimen lined with respiratory epithelium (ciliated columnar epithelium) Figure .Postoperative period was uneventful, and he was managed conservatively and recovered well.During early embryonic life, tracheobronchial analge of primitive foregut sometimes gives an abnormal budding which becomes bronchogenic cyst later in life. When its attachment to primitive foregut persists, it is associated with tracheobronchial tree or esophagus .Retroperitoneal bronchogenic cyst is rare. During early embryonic life, pericardioperitoneal canal links thoracic and abdominal cavity. When the canal is obliterated by the pleuroperitoneal membrane, a part of tracheobronchial tree pinched-off and migrate, resulting in the development of bronchogenic cyst .Most of the retroperitoneal bronchogenic cysts found in the superior border of pancreas or near the left adrenal gland. Most of the patients are asymptomatic, and the cyst is found incidentally on radiological investigations. Symptomatic patients present with epigastric or back pain. Most of reported cases are less than 5 cm in size, and the largest reported case is 10 cm in size in which patient presented with pheochromocytoma like symptoms due to external compression of cyst and subsequent release of catecholamines .In 2004, Kim et al. reported a very unusual presentation of bronchogenic cyst which was located at inferior surface of liver and clinically mimicked as gallbladder tumor [In 2015, Trehan et al. reported a case of brochogenic cyst in the right side of retropeitoneum in Ludhiana, India. The patient presented with right flank pain. CECT revealed a large cyst in the right hypochondrium. Excision of the cyst was done, and histopathological examination showed bronchogenic cyst [In 2020, Bakshi et al. reported a case of bronchogenic cyst in lesser sac with intermediate grade neuroendocrine tumor arising from its wall. Hydatid cyst of liver was also concomitantly present in this patient .In 2002, Sullivan et al. reported a case of adenocarcinoma arising in a retroperitoneal bronchogenic cyst in a 55-year-old female .CT and MRI are the mainstay of diagnostic modality. CT scan of bronchogenic cyst typically shows sharply marginated masses of soft tissue or water attenuation. Most of them appears cystic. Few lesions appear solid and can be confused with other lesions. MRI can also be used to elucidate the cystic nature of disease .Treatment of bronchogenic cyst is surgical excision. Majority of cysts are asymptomatic and benign in nature. Surgical excision is done to confirm the diagnosis, alleviate the symptoms, and prevent the future risk of infection and malignant transformation .Retroperitoneal bronchogenic cyst is a rare entity. Mostly, it is asymptomatic and found incidentally on CT or MRI scan. It should always be kept in mind as differential diagnosis of retroperitoneal cyst, Treatment is laparoscopic excision of cyst.