Background: The diagnosis of ovarian tumors in dogs is usually complicated because the clinical signs can be very discrete and can be easily confused with other diseases. There are few reports of ovarian tumors with different cellular characteristics in the same dog. Our objective was to describe an unusual case of the concomitant presence of ovarian teratoma and granulosa cell tumors in a female dog presenting symptoms compatible with pyometra at clinical consultation.Clinical history: A non-spayed 6-years-old female English Bulldog was attended at the consultation, with no history of previous steroid hormonal treatment. The dog had presented regular estrus every 6 months; 3 months elapsed between the last estrus and consultation. The dog had presented vulvar discharge for more than 2 weeks.Clinical and laboratory findings: the patient presented a slightly pale oral mucosa, decay, vulvar edema, and mucous-purulent uterine discharge. The ultrasound examination revealed the presence of neoformations in the ovaries, and evidence of cystic endometrial hyperplasia-pyometra in the uterus.Treatment: We performed a ventral ovariohysterectomy. During the surgical procedure, it was found several masses in the left and right ovaries, exhibiting characteristics of other tissues different from ovarian tissue. All samples were sent for histopathological examination. The diagnosis was a granulosa cell tumor in the left ovary and a well-differentiated teratoma in the right ovary.Conclusion: Practitioners must improve the use of diagnostic tools when attending non-spayed dogs at advanced ages (more than 6 years old), which would probably be at high risk of suffering from undetected ovarian tumors, some of them with malignancy behavior. Granulosa cell tumor (GCT) is reported as one of the most frequent ovarian neoplasia in female dogs . TeratomGranulosa cell tumor (GCT) originates from granulosa cells of ovarian follicles  and can A 6-years-old, nulliparous, intact English Bulldog female was referred to the University of Antioquia Veterinary Teaching Hospital . The dog weighed 24.3 kg, had complete immunoprophylaxis and antiparasitic treatments, and was fed with commercial dog food. The owner reported no previous hormonal treatment, and 3 months had elapsed after its last standing estrus, that lasted 21 days. Two weeks before the consultation, the dog started with fetid vaginal discharge.Rectal temperature, respiratory rate, heart rate, and capillary refill time were 38.3°C, 25 rpm (with increased vesicular murmur), 135 b.p.m., and 1 s, respectively, with a strong pulse, rhythmic, and concordant. The oral mucosa was found slightly pale, wet, and brilliant. The dog exhibited a docile attitude, had a 2.5 Body condition score , and was down although she was able to feed with commercial concentrate and drink water. An increased size of mammary glands, edematous vulva, and vulvar secretion of fetid sanguine-purulent aspect were observed. At palpation, the patient exhibited abdominal pain.® automated equipment . The results of blood cell counts were indicative of normocytic normochromic anemia. Also, a vaginal cytology smear was prepared on microscopic slides and stained with Hematoxylin & Eosin, resulting in predominant degenerated polymorphonuclear neutrophils, and erythrocytes. All exams were performed in the Clinical Pathology Laboratory, School of Veterinary Medicine, University of Antioquia. No hormonal measurements were performed.The dog was referred to with the results of blood cell counts , Acepromazine , Meloxicam , Dipyrone . Cefalotine  was administered before initiating the surgery. Anesthesia induction was achieved with Propofol . The deep anesthetic level was maintained with 2 CAM isoflurane. Also, a lumbosacral epidural blockade was done with epinephrine-free Lidocaine . The surgical plans were according to the conventional approach through line alba. All the surgical plans were performed with no complications.The uterus presented a slightly symmetrical distention, occupied with purulent material. The ovaries were found polycystic, measuring 3.0 × 2.5 cm, with normal color and aspect . In a saPost-operative treatment included: Ampicillin, Metronidazole, Ranitidine, Tramadol, and Meloxicam at the recommended doses and treatment schedule. Also, 0.5% of topical chlorhexidine was prescribed for the healing of the surgical incision. The sutures were removed on the 20th post-operative day. The dog recovered with no complications up to the 20th post-operative day.The histopathological exam evidenced a GCT in the left ovary, GCT in a solid tubular pattern containing Call-Exner bodies, tubular structures typical of a Sertoli pattern, surrounded by abundant stromal tissue . The neoIn the right ovary, a well-differentiated teratoma was found , 5 that This report present the concomitant presence of teratoma, GCT, and pyometra in a female dog referred to the University of Antioquia VTH, in agreement with previous reports , 15. TheGranulosa cell tumors are the most frequently diagnosed ovarian tumor in bitches, representing up to 50% of tumor in female dogs, and arise from the granulosa cells in the tertiary follicles . In the In some cases, ovarian neoplasia arises at an earlier age . It appeOne of the most relevant findings in the present report is the concomitant presence of GCT and teratoma in the left and right ovaries, respectively, which could be related to the finding of open-cervix pyometra, presented by the dog at the consultation. After the report by Coggeshall et al. , this isRegarding the origin of two different types of tumors in the ovaries of the same individual, there are two reports with similar findings in women , 21. OvaThe frequency of ovarian neoplasia in dogs is low, in some way underdiagnosed, and represents up to 1.2% of neoplasia in this species . GranuloAll datasets generated for this study are included in the article.Ethical review and approval was not required for the animal study because this is a case report. Even though the owner signed an informed consent. Written informed consent was obtained from the owners for the participation of their animals in this study.CO-P conceived the manuscript and performed the surgery with LH and CR-B. JM-E wrote the manuscript. All authors participated in the critical review of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Malignant transformation of epidermoid cyst into squamous cell carcinoma (SCC) is rare. We report the case of a 39-year-old woman presenting with dizziness and cerebellar ataxia. MR scan revealed a mass in the left cerebropontine angle compressing the brainstem and the cerebellum, with two main components, a cystic and a solid one. The cystic component displayed imaging findings consistent with an epidermoid cyst. The solid component showed dense calcifications, low signal intensity on T1W, T2W and DW images and peripheral nodular enhancement. MR spectroscopy detected high lipid/lactate peaks and choline/creatine ratio. Imaging findings raised suspicion for malignant transformation, which was confirmed by histopathologic examination revealing an SCC. MR imaging with intravenous administration of gadolinium, DW images and MR spectroscopy can play a critical role in the diagnosis of malignant transformation of an epidermoid cyst. Malignant transformation of intracranial epidermoid cysts (IECs) is very rare. Clinical deterioration and contrast enhancement of a known IEC or at the surgical site of a removed IEC should raise suspicion for malignant transformation. There are very few reports and to our knowledge no reviews describing the spectral pattern of IEC undergone malignant transformation. We describe a rare case of initial malignant transformation of an IEC, with special emphasis on the spectroscopic findings. MR spectroscopy (MRS) can contribute towards the correct diagnosis.A 39-year-old woman was admitted to our hospital presenting with dizziness and cerebellar ataxia.Computed tomography (CT) scan revealed a large partially cystic mass in the left cerebropontine angle (CPA) with calcifications, compressing the brainstem and the cerebellum Fig. .th cranial nerve and medially compressing the brainstem. It showed low signal intensity on T1W and high signal intensity on T2W ones and with no enhancement after intravenous administration of contrast media. On DW images the mass displayed high signal intensity, ADC 0.8 and the spectral pattern showed a medium lipid/lactate peak at 1.3 ppm, findings typical for IEC. The juxtaposed solid component of the mass compressed the cerebellum causing perilesional edema. It showed low signal intensity on T1W and T2W images. After intravenous administration of contrast media, it displayed heterogeneous, mainly peripherical and in some sites nodular enhancement. DW imaging showed low signal intensity inside the mass and ADC values of 1.34. MRS revealed a high lipid/lactate peak, Choline/Creatine ratio (Cho/Cr) 2.13 and Choline/N-Acetylaspartate ratio (Cho/NAA) 0.766.MR imaging Figs. , 3 confiSurgery was planned and the mass was completely resected. Histopathologic analysis Fig.  revealedrd–5th week of gestation.IECs are rare lesions, accounting for 0,2–1,8% of all intracranial tumors and may arise from retained ectodermal embryonic tissue in the neural groove at 3Malignant transformation of IECs is very rare. It is postulated that chronic inflammation caused by repeated microruptures of the cysts or iatrogenic irritation after resection of the cysts may trigger malignant transformation of IECs .Criteria for diagnosis of malignant transformation of an intracranial epithelial cyst according to Garcia  and HamlAccording to Hamlat, malignant transormation or intracranial epithelial cysts can be classified into 5 groups: a) initial malignant transformation of a benign cyst, b) malignant transformation from remnant cyst, c) malignant transformation of a dermoid and epithelial cyst, d) malignant transformation with leptomeningeal carcinomatosis and e) other malignancies arising from benign cysts.Our case fulfilled all the criteria of Garcia and Hamlat, and according to Hamlat’s classification, it was characterized as initial transformation of an IEC.Rapid deterioration of symptoms is the most important clinical indication of malignant transformation. Our patient complained of dizziness and cerebellar ataxia.MR imaging of IEC is well known, displaying low signal intensity on T1W and high signal intensity on T2W, FLAIR and DW images. Rim enhancement can be detected in 25% of cases, while calcifications are rare, usually marginal and dystrophic, probably caused by tumoral microrupture and leak of contents . DetectiMR Spectroscopy (MRS) of IECs typically show lactate signals at 1.3ppm, with a small peak at 1.8ppm . Few repOur results suggest that MRS can play a role in the diagnosis of malignant transformation of IECs.Surgery, radiation therapy, stereotactic therapy and gamma-knife radiosurgery can improve the short-term survival, but long-term prognosis is poor.Malignant transformation of an IEC can be suspected by rapid deterioration of symptoms and signs, but MR imaging has a special contribution in diagnosing malignant transformation. Presence of enhancing tissue with low signal intensity on DWI should alert for malignant transformation. Furthermore, MRS can show higher lactate or lipid/lactate peaks, as well as lower NAA/Cho and higher Cho/Cr ratios.The authors declare that they have no competing interests.


A medulloblastoma was surgically debulked from a 6 year old American Staffordshire Terrier, who then received a modified lomustine (CCNU), vincristine, procarbazine, and prednisolone (LOPP) protocol. The dog improved significantly and continued to do well until deterioration and euthanasia 5 months following surgery. This is the first known published case report of surgical cytoreductive surgery of a medulloblastoma in a dog with documented response to surgery and chemotherapy. Medulloblastoma is a primitive neuroectodermal tumor that is the most common malignant central nervous system (CNS) tumor in children, though it is less common in adults. This case illustrates the value of considering human literature when creating treatment plans for uncommon brain tumors in veterinary patients. Medulloblastoma should be a differential for cerebellar tumors in young to middle aged dogs, and surgery and chemotherapy should be considered. Medulloblastomas are the most common malignant brain tumor in children, making up 40% of pediatric posterior fossa tumors . They arA 6-year-old (28.9 kg) male intact American Staffordshire terrier presented for investigation of a 3 week history of progressive ataxia, falling down stairs, and a left head tilt. Episodes of opisthotonus occurred while the patient was sleeping, and the dog would sometimes appear minimally aware of its surroundings. On presentation the dog was weakly ambulatory and frequently knuckled in the thoracic limbs. Neurological examination identified delayed postural reactions on the left side, absent postural reactions on the right side, and a moderate left head tilt. The remainder of the neurological examination was unremarkable, including spinal reflexes and cranial nerves. The neuroanatomical localization was consistent with a right central  vestibular lesion. A few hours after presentation, the patient rapidly declined. He became laterally recumbent with a decerebrate posture, and his heart rate dropped to 90 bpm, while his blood pressure increased to 170–175 mmHg. Due to the suspected elevated intracranial pressure, a dose of mannitol was administered intravenously (1 g/kg). The patient was premedicated with butophanol (0.2 mg/kg IV) and general anesthesia was induced and maintained with propofol (induction: 4 mg/kg IV) in preparation for magnetic resonance imaging (MRI) of the brain (Siemens Skyra 3T).MRI revealed a 3.1 × 2.4 × 2.3 cm ill-defined mass within the right cerebellar hemisphere . The masThe owners reported the dog was walking better and had fewer episodes of decreased mentation in the next few days following discharge from the hospital. Four days later, the patient was reevaluated and the neurological examination showed ambulatory cerebellovestibular ataxia with hypermetria of the right side, a moderate head tilt (~20 degrees) and intention tremors. The postural reactions were delayed in the right forelimb, while placing was intact in the other limbs. Computed tomography (GE lightspeed 16) of the chest and abdomen was performed under sedation with butorphanol (0.3 mg/kg IV) and propofol (to effect) and no signs of metastasis were seen.In preparation for surgery the patient was premedicated with methadone (0.2 mg/kg IV) and mannitol (1 g/kg IV) and induced with propofol (4 mg/kg IV) and lidocaine (2 mg/kg IV). Total intravenous anesthesia was maintained using propofol and fentanyl. He was positioned in sternal recumbency with the neck ventroflexed and the pinna of the ears sutured ventrally to the face with one simple interrupted suture each. The dorsal aspect of the head, neck, and ears were clipped and aseptically prepared for surgery using chlorhexidine scrub. Surgical debulking was performed with a modified suboccipital and right caudal rostrotentorial craniectomy. A midline incision was made rostral to the external occipital protuberance extending caudally to the first cervical vertebrae. The subcutaneous muscle was dissected and reflected off to expose the right temporal bone and occipital bone, using monopolar and bipolar cautery, and periosteal elevators. Minimal hemorrhage was observed during the approach, which was easily controlled with cautery. A drill was used to create one window in the suboccipital region of the skull and a second window in the right caudal temporal bone. The nuchal crest between the two windows was drilled to expose the transverse sinus, which was cauterized using bipolar cautery, bone wax, and gelfoam until adequate occlusion was accomplished. Drilling was then completed to connect the two windows and expose the cerebellum. A purple-pink mass was visualized in the right cerebellar hemisphere, extending past midline and ventrally, obstructing any view of normal right cerebellar tissue. A large amount of friable mass was removed in one large piece with careful blunt dissection. The margins laterally in the cerebellum appeared normal, however, the mass appeared to extend ventrally into the brainstem. In order to avoid traumatizing normal tissues, further resection was not performed ventrally.Histopathology of the mass revealed a cell-dense mass composed of neoplastic polygonal to elongated cells arranged in dense sheets . The cel2) (2 IV) and started on procarbazine (53 mg/m2 PO Q24 for 14 days). This LOPP protocol was chosen because it is a well-established combination protocol in dogs with lymphoma, so much is known about tolerability and scheduling, and because the drugs included in this combination have all shown activity in treating medulloblastoma in people. Other drugs sometimes used in the treatment of people with this cancer, such as cisplatin, might have caused unacceptable toxicity in dogs. Protocols used in people are often high-dose and require stem cell or bone marrow rescue, which is not readily available in veterinary medicine  –10 and pmedicine .Staphylococcus pseudointermedius which was sensitive to several antimicrobials. A course of cephalexin (25 mg/kg PO Q12) was administered for 2 weeks. Four weeks later, the patient presented for staple removal. However, the site began to dehisce again after only 1 week, so the staples where replaced.Six weeks after surgery the patient continued to do well. However, the surgical site dehisced at the skin and dorsal layer of muscle. The dog was sedated and the site cleaned and a culture was obtained. A drain was placed and the site was closed again in 3 layers, with suture and staples. The culture grew 2 IV) was administered and the dose of prednisone was increased. However, the dog continued to deteriorate and was euthanized a week later. A post mortem examination was not performed.The dehiscence was suspected to be due to ongoing chemotherapy and prednisone causing delayed healing of the surgical incision. The LOPP protocol was discontinued, the prednisone decreased (0.6 mg/kg PO Q24), and a single agent protocol of CCNU was continued monthly. The patient continued to do very well until 5 1/2 months post-surgery when neurological deterioration occurred and the dog became non-ambulatory. A dose of vincristine , and often chemotherapy . SurvivaRadiation therapy was recommended for the dog in this case report after surgery, as it has been shown to improve survival in humans with medulloblastomas , 22. HowThis is the first published case report of a dog histologically diagnosed with a medulloblastoma for which surgery and chemotherapy were administered and responses documented. Medulloblastoma should be a differential for both intra and extra-axial cerebellar masses in any age dog. If a medulloblastoma is suspected, chemotherapy should be considered as an adjuvant treatment option, along with surgery and or radiation therapy.All datasets for this study are included in the article/supplementary material.Ethical review and approval was not required for the animal study because not required for retrospective case report. Written informed consent was obtained from the owners for the participation of their animals in this study.RL helped manage patient from diagnosis through euthanasia, conceived of the case report, drafted the article, critically revised the article, and gave final approval of version to be published. MV interpreted the histopathology, critically revised the article, and gave final approval of the version to be published. DH performed the surgery, helped manage patient from diagnosis through euthanasia, critically revised the article, and gave final approval of the version to be published. DC and KS helped manage chemotherapy for patient, critically revised the article, and gave final approval of the version to be published. KF helped with patient management, critically revised the article, and gave final approval of the version to be published. KS provided chemotherapy recommendations, critically revised the article, and gave final approval of the version to be published.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Central giant cell granulomas are benign tumours of the mandible, presenting in children and young adults. Divided into non- and aggressive subtypes, the aggressive subtype is relatively rare and can occasionally progress rapidly, resulting in significant morbidity.We present a case of an aggressive central giant cell granuloma (CGCG) in a six year-old female. The lesion originated in the right mandibular ramus and progressed rapidly to involve the condyle. Diagnosis was made using a combination of imaging and pathology. A timely en bloc resection of the hemi-mandible was performed with placement of a reconstructive titanium plate and condylar prosthesis.Our case demonstrates the importance of considering CGCG in the differential diagnosis of rapidly progressive mandibular lesions in the pediatric population. Prompt diagnosis and management can greatly improve long-term outcomes. Central giant cell granuloma (CGCG) is described by the World Health Organization as an intraosseous lesion consisting of cellular fibrous tissue that contains multiple foci of hemorrhage, aggregations of multinucleated giant cells, and some trabeculae of woven bone . These tCGCG can be divided into two subtypes, aggressive and non-aggressive . The nonWe report an uncommon case of an aggressive CGCG in a 6-year-old female, originating in the right mandibular ramus with extension into the condyle.A six year-old, previously healthy female initially presented to the dentist with a cavity involving a right mandibular tooth, which was filled. Two days after the appointment, she developed mild facial swelling on the ipsilateral side. Symptoms progressed over the next week, and antibiotics were prescribed for a presumed odontogenic infection. The lesion was refractory to antibiotics, which resulted in her presentation to the Children’s Hospital of Eastern Ontario (CHEO) Emergency Department.An ultrasound of the face and radiograph of the facial bones was completed Fig. . The radThe child was discharged home, with an urgent magnetic resonance imaging (MRI) and computed tomography (CT) ordered and performed one day after the emergency visit. MRI of the head demonstrated a cystic lesion centered along the ramus of the right mandible, measuring 3.6 × 3.8 × 4.8 cm Fig. . CT of tA referral was made to Otolaryngology- Head and Neck Surgery. The patient was taken urgently to the operating room (OR) and a trans-oral biopsy of the mandibular mass was performed. Pathology revealed a multi-cytic lesions. The cysts were devoid of endothelial and epithelial lining and contain areas of hemorrhage. The septa lining the cysts were thick and formed of bland spindle myofibroblasts. Focal hemosiderin deposition and small, unevenly distributed clusters of giant cells were noted. A giant cell granuloma was the favoured diagnosis.After diagnosis, oral maxillofacial surgery (OMFS) was consulted. The patient was taken again to the OR for enucleation of the tumour, decompression of the right inferior alveolar nerve, and biopsy. The child was to be followed-up by oncology after pathology results returned for consideration of interferon therapy.Sixteen days later, while awaiting follow-up, the patient re-presented to the CHEO ED with facial swelling, pain and an inability to tolerate feeds. Additionally, she complained of numbness of the right tongue, which she had not experienced previously. Repeat CT demonstrated significant growth of the mass to 6.4 × 4.9 × 4.4 cm  , 23–26. Surgery is the mainstay treatment of the aggressive variant of CGCG, once confirmed via adequate biopsy, typically performed in an operating room setting. Options include: enucleation, curettage and segmental resection. Enucleation and curettage are favourable due to the possible preservation of the cortex of the mandible and inferior alveolar nerve, however these methods are fraught with a recurrence rate of 30–70% in aggressive CGCG. According to one study, segmental resection has the lowest recurrence rate, specifically for lesions that present with pain, rapid growth, facial swelling, and cortical perforation , 29. It For the patient presented here, segmental resection was felt to be the most likely treatment to avoid further recurrence and airway compromise. Although a controversial topic, due to the potential for impaired growth in the pediatric population and the possibility of poor function and cosmetic outcomes including malocclusion and asymmetry, this influenced the decision to proceed with titanium prosthesis implant versus vascularized free fibula flap reconstruction in our case .CGCG should be considered on the differential of any young child with a rapidly growing lesion of the mandible. Prompt diagnosis and management can greatly improve morbidity and long-term outcomes. Further studies are required to determine the optimal management for these lesions, particularly the aggressive variant of CGCG.


Splenic infarction is an unusual cause for a patient to present with left upper abdomen pain. A 47-year-old woman presented to the emergency department with left upper abdomen pain. She reported that she stopped taking warfarin two days prior to presentation. A physical examination revealed fine crackles within the left lower lobe and significant tenderness within the left upper abdomen. Computed tomography of the abdomen showed mild cardiomegaly with a 2.3 cm calcified thrombus in the left ventricular apex. We noted infarction in the spleen and right kidney with bilateral renal scarring. The patient was initially started on a heparin drip and later bridged to warfarin on the third day. She was discharged after seven days with complete resolution of the abdominal pain. The decision to prescribe an anticoagulant should include a consideration of underlying causes, comorbidities, an assessment of risks and benefits, and chances of recurrence. In our patient, her new splenic infarct and renal infarction were most likely embolic in origin due to her left ventricular apical aneurysm with thrombus and nonadherence to her prescribed anticoagulation medication. Splenic infarction is usually asymptomatic and found during radiographic examinations for other conditions. We present a case of a patient with concerns of left upper abdominal pain, which were likely due to splenic infarct.A 47-year-old woman presented to the emergency department with concerns of left upper abdominal pain for one day. She reported that the moderate to severe abdominal pain had a gradual onset, was crampy, constant, and located in the left upper part of her abdomen radiating to the lower chest and back. The pain was associated with diaphoresis, nausea, and several instances of vomiting non-bloody, non-bilious liquid. On admission, her vitals were stable. The results of her complete blood counts, comprehensive metabolic panels, and hepatic function tests were within reference ranges. Her coagulation profile was at a subtherapeutic level. Her past medical history includes nonischemic cardiomyopathy with left ventricular thrombus and four previous cerebrovascular accidents with residual right leg numbness. Her condition was being managed with warfarin. A physical examination showed fine crackles within the left lower lobe and significant tenderness in the left upper abdomen. The patient reported that she had stopped taking warfarin two days prior to admission. Cardiac magnetic resonance imaging (MRI) showed septal and apical predominantly transmural infarct. A transthoracic echocardiogram showed a mildly dilated left ventricle with moderate to severe left ventricular dysfunction, an ejection fraction of 30% to 35% with distal anterior, anteroseptal, and apical akinesis with mild mitral regurgitation. Cardiac catheterization findings were unremarkable. A computed tomography (CT) scan of her abdomen showed mild cardiomegaly with previous infarction on the anterior-inferior wall of the left ventricle. We noted a 37.47 mm calcified thrombus in the left ventricular apex with peripheral calcifications Figure .We also noted infarction in the spleen and right kidney with bilateral renal scarring Figures -3.The patient was initially started on a heparin drip and later bridged to warfarin on the third day. She was discharged with complete resolution of her abdominal pain after seven days, and medication compliance was reinforced before discharge.Splenic infarction is a rare but not uncommon cause of acute abdominal pain in the emergency room. Splenic infarct may occur as a result of occlusion of the arterial or venous supply. The condition can also be caused by infiltrative hematological malignancies such as leukemia, lymphoma, and myelofibrosis. Benign congenital or acquired blood disorders such as sickle cell disorders, polycythemia, and hypercoagulopathies can also result in splenic infarct, as can vasoembolic conditions such as atrial fibrillation, infective endocarditis, valvular heart disease, valve replacement surgery, and aortic atherosclerosis .The most common presenting features of splenic infarct include left upper abdomen pain, fever, left shoulder pain, pleuritic chest pain, back pain, and abdomen distension. Some cases may present with acute abdomen pain from splenic rupture and torsion of the congested spleen. However, most patients with thromboembolic infarction are symptomatic; fever is associated with 70% of cases, and abdomen pain is noted in 80% of cases . HoweverRisk factors for infective endocarditis, heart valve replacement, hematological disorders or associated peripheral vascular disease can be obtained from pertinent history and via physical examination. Significant thrombocytosis, high lactate dehydrogenase levels, and elevated erythrocyte sedimentation rates can be found in laboratory tests. CT, nuclear imaging, and sonography are commonly used for diagnostic purposes, but CT scans are the preferred method often used in emergency departments in most institutions. CT imagery can help identify splenic infarction or associated splenic pathologies, although a liver-spleen scan has higher sensitivity in diagnosis. Sonography is used in circumstances where a CT scan cannot be performed and to follow up on complications of splenic infarction. Jaroch reported that a liver-spleen scan could identify 90% of splenic infarctions while only 75% is evident in CT scans. Mesenteric vasculature can be evaluated via MRI , and an The underlying causes of splenic infarction should be identified to prevent further episodes and complications. A transthoracic echocardiogram should be performed to check for patent foramen ovale as a possible source of emboli, although atherosclerotic disease of the aorta and mesenteric vessels is the most common cause. Consequences of splenic infarction include abscess formation, pseudocyst, infection, and hemorrhage.The incidence rate of complications may be higher in splenectomies performed for splenomegaly . ConservSplenic infarction must be considered as a potential cause of acute abdominal pain whenever a patient presents with left upper abdominal pain with or without shock. Splenic infarction can be a complication of the cardiac embolic disease. Most patients respond to conservative management, and the decision to prescribe an anticoagulant should include a consideration of underlying causes, comorbidities, an assessment of risks and benefits, and chances of recurrence. In our patient, the new splenic infarct and renal infarction were most likely due to left ventricular apical aneurysm with thrombus and nonadherence to anticoagulation medication.


Abdomen computed tomography showed a small linear structure with calcium density, transfixing the wall of the gastric antrum and penetrating the left hepatic lobe; an oval massive hypodensity was observed in the surrounding liver parenchyma (A); pneumoperitoneum, free intra-abdominal fluid or vesicular changes were not observed. The hypothesis of gastric perforation due to ingestion of a foreign body with abscess formation was raised. In a new clinical interview, the patient reported a routine habit of fish consumption. Abdominal surgical approach was performed which confirmed the presence of a fish bone and the hepatic collection with purulent fluid (B). After seven days of surgery and treatment with intravenous ceftriaxone and metronidazole, the patient evolved with clinical and laboratory improvement and was discharged. Gastrointestinal perforation by an ingested fish bone resulting in hepatic abscess is very rare. In these cases, the site of perforation is usually in the stomach or duodenum with the abscess most commonly developing in the left hepatic lobe. The classic indicators of hepatic abscess, such as fever with chills, abdominal pain and jaundice are present in only a small number of patients. Among several causative objects that can perforate the gastrointestinal tract are included toothpicks, sewing needles, hairpins, wire, fish bones, chicken bones and dental plates.A 50-year-old previously healthy male presented with epigastric pain for 10 days and fever in the last three days. Laboratory testing was remarkable for elevated white blood cells at 19,580/mm


Congenital diaphragmatic hernia (CDH), a herniation of the abdominal contents through a defect or hypoplasia of the diaphragm, is a relatively common, severe congenital anomaly. Here we present the first case of two siblings with possibly isolated sac-type CDH and with a suspected genetic etiology. Although sibling recurrence of isolated CDH is rare, the incidence is higher than in the general population. Additionally, the second child had a more severe respiratory disorder than the first child. It is to be noted that siblings of children having isolated CDH are at risk for CDH, and prenatal evaluation should be considered individually. Congenital diaphragmatic hernia (CDH) is a herniation of the abdominal content through a defect or hypoplasia of the diaphragm and is associated with varying degrees of pulmonary hypoplasia. The severity of birth asphyxia varies from lethal to asymptomatic, and the overall neonatal mortality rate of prenatally diagnosed CDH has been reported to be 30%–60% despite optimal postnatal treatments .The malformation commonly manifests as a hole or discontinuity in the diaphragm. Its exact etiology is unknown; however, it is now understood that the diaphragmatic defect develops owing to a failure of the pleuroperitoneal membranes to fuse during fetal development. In very few cases, the defect is not a hole but a thinning or incomplete muscularization of the diaphragm, which is generally referred to as sac-type CDH. Although CDH is usually a sporadic malformation, some sibling recurrences of isolated CDH have been documented –4. Here,A 28-year-old nulligravid Japanese woman was referred to Kumamoto University Hospital at 34 weeks of gestation because of symmetrical fetal growth restriction (FGR). In her family, there was no history of toxoplasmosis; rubella, cytomegalovirus, and herpes simplex virus infections; drug ingestion; consanguineous marriage; or genetic diseases. Her healthy partner had a familial trend of being small for gestational age (SGA) at birth. Cesarean section was performed at 37 weeks of gestation due to FGR and nonreassuring fetal status. A female infant weighing 1,498 g (−3.4 SD) was born with Apgar scores of 8 and 9 at 1 and 5 min, respectively. The newborn infant required 0.25–0.5 L/min nasal oxygen soon after birth, and her chest X-ray examination  1 day afFollowing a miscarriage in the first trimester, the mother was referred to our hospital at 30 weeks of gestation for appropriate management of FGR 5 years after her first parturition. Obstetric sonography showed polyhydramnios and a simple, smooth cystic lesion in the left dorsal thorax, with the fetal heart displaced to the right side . No assoElective cesarean section was performed at 38 weeks of gestation under general anesthesia. A male infant weighing 1,875 g (−3.5 SD) with an Apgar score of 1 at both 1 and 5 min was delivered. He was intubated immediately after birth, and oxygenation with intermittent positive-pressure ventilation was maintained. Furthermore, administration of catecholamine was required to maintain his blood pressure. On the first day after birth, surgical repair of CDH was performed. The left diaphragm was extended into the thorax, and the colon, spleen, and stomach were herniated into the sac. No associated abnormalities were detected. His postoperative course and subsequent development were also uneventful except for short stature. The parents did not wish to have chromosomal or genetic analysis performed on either sibling.CDH is a relatively common congenital anomaly that presents in 1 per 2,500–4,000 births. Its etiology is likely to be heterogeneous. Approximately 50%–60% of all CDHs exhibit isolated findings, whereas the remainder may be complex cases in which this anomaly forms as a part of genetic abnormality.Complex CDHs, which account for approximately 5% of cases of familial CDH, are often associated with midline fusion defects such as neural tube defects, cleft lip and palate, and omphalocele, e.g., Donnai–Barrow syndrome inherited in an autosomal recessive (AR) manner , and an Furthermore, both the siblings were associated with symmetrical FGR and postnatal short stature without postnatal catch-up growth . Their gThis is the first case report of familial sac-type CDH. It remains unclear whether common- and sac-type CDH develop via the same mechanism. In contrast to common-type CDH, sac-type CDH shows a convex, smooth surface of the herniated lesion and is more difficult to distinguish from the normal diaphragm on prenatal ultrasound examination. It has been reported that the presence of a hernia sac in CDH is associated with less visceral herniation, greater fetal lung growth, and better postnatal outcome , 11. ThiIn conclusion, we presented the first case of two siblings with possibly isolated sac-type CDH. Sac-type CDH is more difficult to diagnose prenatally and may vary in severity. Prenatal diagnosis with individual evaluation should be considered in subsequent pregnancies. SGA and short stature may be involved in the clinical etiology of sac-type CDH.


Scrotal leiomyosarcoma is rare tumor. It presents as a painless, slow-growing cutaneous lesion. It’s often mistaken for a benign condition. It is best treated by wide local excision. A case of scrotum leiomyosarcoma is presented in a 63 year old patient who was treated for the first time as having a benign lesion. Leiomyosarcoma of the scrotum is a rare tumor. More than 95% of scrotal sarcomas arise from the spermatic cord, epididymis, or testes, while their location in the scrotal skin is exceptional . It presA 63-year-old man with a 3 year history of hypertension, presented with a firm mass in the right hemiscrotum. This lesion had appeared four years previously. On local examination, à 4 centimeters mass was noted on the right scrotum, the left testis, both epididymis and the spermatic cords were normal to palpation, while the inguinal nodes were not palpable.Mass excision was performed by another surgeon. Pathologic examination revealed a léiomyosarcome of the scrotum, the nodule was well defined and consisted of a proliferation of cells with cigar-shaped nuclei and eosinophilic cytoplasm, the mitotic count was high. The cells stained positive for actin and H-Caldesmon on immunohistochemestry and were negative for desmin. Resected margins were positive.The patient was referred to our department; he was then evaluated for distant metastatic spread with a total body CT scan that showed no distant metastasis. Wide excision around the scar of the previous excision was performed. Definitive histology showed the absence of tumor on the latter specimen .No recurrence has been recognized 40 months after.Soft tissue sarcomas are 1% of all malignancies . LeiomyoThis case evinces how a leiomyosarcoma of the scrotum can simulated a benign lesion. He had a lesion that was treated for the first time as being a benign lesion. Resected margins were positive, and that may influence the prognosis of the patient.Confirmation of the diagnosis of léiomyosarcome is based up on histological examination of biopsy specimen, which reveals spindle cells with cigar-shaped nuclei arranged in interweaving fascicles , 6 the dIt is best treated by wide excision , inguinaThe prognosis is generally good in the absence of local recurrence. A positive margin at the first excision increases the risk of local recurrence . Long-teScrotal leiomyosarcoma is a rare clinical entity; it often resembles a cyst. The recommended treatment of localized leiomyosarcoma of the scrotum is wide excision. Long term follow up is essential, because of the risk of delayed local recurrence and distant metastasis.The authors declare no competing interests.


A 2 years old dog was brought to the clinic with complains of testicular enlargement. The tissue was diffusely affected as confirmed by ultrasonographic examination, being the right testicle atrophied and the right epididymis enlarged, with loss of echotexture and presence of several anechogenic areas. The situation required the excision of the referred testicle and epididymis. Final diagnose made by histopathological analysis was primary unilateral low-grade paratesticular leiomyosarcoma. Scarce bibliography is found on this matter, with several cases reported on human, and none in dog. This case report is therefore an important milestone on the area of small animal oncology directly related to the reproductive tissue. Paratesticular sarcomas are mesenchymal tumors that can be originated in soft tissues, such as the spermatic chord, inguinal canal, testicular tunic or epididymis . In humaDifferent histological techniques are used to pathologic diagnosis. However, sometimes the tissue line is not obvious and other techniques are required. Indeed, immunohistochemistry (IHC) plays an important role in the diagnosis of soft tissue tumors , 9.A 2 years old Spanish Mastiff was seen for the first time at the Veterinary Teaching Hospital of the University of Extremadura on April 2013. The complaint was scrotal enlargement starting ~3 weeks before. On scrotal palpation it was detected an apparently painless enlarged firm mass inside the right hemiscrotum with slightly increased temperature, when compared with the content of the left hemiscrotum. Physical examination also revealed parameters within normal limits, specifically temperature, mucosae, capillary retention, heart and respiratory rates, pulmonary auscultation and external lymph nodes. The size and consistency of the left testicle were apparently normal. A testicular ultrasonography was performed, major findings being: left testicle normal; right testicle atrophied; right epididymis presenting increased size (~4 cm), loss of normal echogenicity and presence of several anechogenic areas (<2 cm).A presumptive diagnosis of bacterial orchitis/epididymitis was proposed and treatment was started, with anti-inflammatory Meloxicam 24–24 h during 5 days , and broad spectrum antibiotic Ciprofloxacin 12–12 h . The patient returned after 11 days and ultrasonography was repeated, presenting a reduction of the testicular size with persistence of the anechogenic areas. Due to the lack of regression of the lesions, surgical removal of the affected testis was proposed and unilateral orchiectomy was scheduled. Despite recommendation for bilateral castration, the owner decided to maintain the apparently healthy left testicle. Informed consent was signed by the owner respecting all the procedures reported, as well as the publication of this case report. Hematology and most biochemical parameters were within the normal range, except for total protein which presented a slightly reduced value (5 g/dL), with normal serum albumin , 2. HemiAfter 10 days the dog returned to follow-up, presenting increased inflammation on the area of excision, and presence of an anechogenical cavity on the interior. Inguinal lymph nodes were ultrasonographically normal, with no evidence of metastasis. Abdominal and thoracic radiographs were also made, with no gross abnormalities detected. Anti-inflammatory was again prescribed for 5 days, and antibiotic treatment was maintained for additional 15 days, maintaining previously used doses.The excised testicle and epididymis were fixed in 5 per cent formaldehyde in a 0.1 M phosphate buffer (pH 7.2), processed and embedded in paraffin. For histopathological analysis, 5 μm sections were stained with hematoxylin-eosin and Masson Trichrome.Histologically, the testis presented an extensive destruction of seminiferous tubules with a certain degree of intertubular connective tissue proliferation. Spermatogenic cells showed evident signs of degeneration, ranging from cellular swelling to apoptosis. The testicular parenchyma presented multiple inflammatory foci, consisting mainly of monocytes, lymphocytes and lesser degree plasma cells.Surrounding the testis, an abundant proliferation of loose connective tissue was shown, formed by fusocellular cells with slight atypia, without necrosis and with few atypical mitosis (1/10 HPF) . This ceIn order to classify the lesions, immunohistochemical study was performed using an automated slide stainer . Sections were immunostained using vimentin, actin, desmin, CD34, AE1/AE3 and Ki67 primary polyclonal antibodies (Roche®) according manufacturer's recommendations . Bound AAfter 6 months from the surgery, the dog was present for clinical examination, presenting no alterations in the scrotum or in the left testicle, as well as in other structures of the abdominal cavity, assessed by ultrasonography. The owner was asked to return annually but it was not possible to continue follow-up of the animal.Paratesticular tumors are a rare condition in humans  and in dA retrospective study made in 2016 evaluated the most common tumor diagnoses in dogs in Switzerland between 1995 and 2008, comprising 63,214 neoplasic lesions, with soft tissues occupying the second higher risk after mammary gland, although no reference to paratesticular tumors was made . HoweverPrimary malignant neoplasia of the epididymis has been considered a very rare condition in humans . AlthougAll datasets generated for this study are included in the manuscript and/or the supplementary files.CBS and LGG contributed to the writing of the manuscript and literature review. LGG, JCG, and CP contributed to the histopathological study, interpretation and description of the imaging finding. CBS, CO-F, PM-M, and FPV were responsible for the surgery and follow-up of the case. FDC was responsible for the ultrasonography imaging.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Mucin-producing gallbladder carcinoma (MPGBC) is a rare and aggressive subtype of gallbladder carcinoma. We present a case of MPGBC with associated magnetic resonance imaging (MRI) / magnetic resonance cholangiopancreatography (MRCP) findings that may raise suspicion of this diagnosis preoperatively. In the United States, the incidence of gallbladder carcinoma is less than 5,000 cases per year . Though MPGBC often presents with nonspecific, cholecystitis-like symptoms or is found incidentally during a cholecystectomy . It can We present a 78-year-old male with a past medical history of dementia, coronary artery disease, hypertension, and chronic obstructive pulmonary disease (COPD) who presented to the emergency department for evaluation of severe jaundice and itching. He denied abdominal pain. His hypertransaminemia and hyperbilirubinemia suggested obstructive jaundice. Abdominal CT with oral contrast was nonspecific, showing gallbladder dilation and what appeared to be a simple calcified gallstone in the dependent portion of the fundus Figures -2. NotabDuring this evaluation, follow-up US revealed irregular intraluminal masses that raised suspicions for malignancy Figure . SubsequThough a laparoscopic cholecystectomy was performed, the area of invasion was too extensive for full resection. Histological samples confirmed MPGBC Figure . The patMPGBC is extremely rare and can be overlooked or confused with less dangerous entities. It typically mimics acute cholecystitis and, therefore, most cases are diagnosed in the operating room during what is assumed to be a routine cholecystectomy. A careful imaging workup prior to surgery could inform clinicians and patients that they are dealing with a more malignant process. It is important for radiologists and other clinicians to be aware that the unique properties of this cancer may render some imaging modalities inferior to others.Our case demonstrates the difficulty that CT can have in identifying MPGBC. Simply, a CT image is constructed based on the densities of different structures within the patient. Within the lumen of our patient's gallbladder, a hyperdense calcified gallstone is clearly visible. However, in these images, there is little evidence of a large mass surrounding the stone. Other researchers have described similar CT findings in cases of MPGBC. They have speculated that the excessive amount of mucin produced within the tumor may give it a density near to that of water; obscuring the mass by making it impossible to differentiate from fluid already within the gallbladder .Ultrasonography is the initial imaging test of choice for any patient with possible gallbladder disease. Benefits include low cost and ease of use. In most cases, it adequately identifies masses in the gallbladder. However, it is less reliable in determining whether the mass is benign or malignant. It is inferior to other imaging modalities (CT and MRI) for identifying and staging gallbladder cancer. Due to this, current guidelines recommend following up any suspicious US findings with either a CT or an MRI -7.As previously discussed, the MRI for our patient was much more informative than the other imaging techniques. While the CT could only visualize a gallstone, the MRI clearly depicted the large mass totally enveloping the stone and filling the gallbladder. At this point in the evaluation, a malignant process was obviously strongly suspected. Likely due to the rarity of MPGBC, it still came as a surprise when the intraoperative pathology report returned with this diagnosis.Our retrospective investigation revealed that the MRCP may have suggested the lesion was this specific subtype of gallbladder cancer. It is possible that the hypointense striations along the long axis of the patient's gallbladder are unique radiographic signs of MPGBC. To our knowledge, there is no other case study discussing MRCP evaluation of MPGBC in United States literature. Japanese researchers, however, identified multiple patients with MPGBC who had similar linear hypointense areas visible on MRCP. They considered that the highly viscous properties of the mucin were responsible for the appearance of these characteristic striations and named this a “mucous thread” sign .Our case highlights the limitations of CT and US, as well as the value of MRI/MRCP, in the diagnostic evaluation of MPGBC. In addition, we draw attention to a unique radiographic finding of MPGBC (mucous thread sign) that may lead to the early detection of this highly fatal disease.


Epibulbar complex choristoma, a rare congenital epibulbar tumor, has many diverse forms. Reviewing the literature, it can present clinically as either a circumferential or isolated epibulbar mass, limbal tumor, lateral canthal mass, aggregate of ectopic cilia in the upper eyelid, eyelid mass mimicking chalazion, or lacrimal caruncle mass. The management depends on the extent of involvement, the risk of amblyopia, and cosmetic concerns. Here, we report an atypical presentation of epibulbar complex choristoma with simultaneous eyelid involvement.A 1-month-old full-term boy was brought to our clinic with congenital epibulbar mass of the right eye with simultaneous eyelid involvement. Dilated fundus examination was unremarkable. Survey for linear nevus sebaceous Jadassohn was negative. Due to concerns of possible amblyopia and cosmetics, lamellar keratectomy, sclerotomy, and conjunctivoplasty were performed to remove the epibulbar lesion. The eyelid defect was reconstructed with 6–0 Vicryl sutures. Histopathological examination reported complex choristoma. Upon three-year follow-up, low astigmatism and favorable cosmetics results were achieved.Congenital complex choristoma can present clinically as an epibulbar mass with eyelid involvement. The management depends on the extent of involvement, the risk of amblyopia, and cosmetic concerns. The method of eyelid reconstruction should be tailored according to the residual eyelid defect. Epibulbar choristoma represents a histologically normal tissue in an abnormal location, with reported incidence between 1/10000 and 1/30000 . Limbal A 1-month-old boy was presented to our clinic with a bulky bulging mass in the right eye since birth. He was delivered following an uneventful full-term pregnancy with no particular perinatal insults. Although formal visual acuity measurements could not be obtained, the patient’s gaze could fix and follow and was able to achieve central, steady, and maintained fixation. Physical examination noted the bulging epibulbar mass extending out from his right eye to his eyelid (Fig. Choristoma, histologically normal tissue in an abnormal location, represents 10–33% of conjunctival lesions in children. Limbal dermoid and dermolipoma are the most common type . ComplexMost of the complex choristoma reported in literature were covered by mucous membrane , 6, 10. The association between epibulbar complex choristoma and linear nevus sebaceous of Jadassohn has been well-established. The latter is characterized by seizures, mental retardation, and cutaneous sebaceous nevus of the facial and scalp area , as wellDue to complex choristomas generally regarded as benign and non-progressive lesions, the indications of treatment are mainly for cosmetic purpose or for amblyopia prevention . HoweverThe risk of amblyopia depends on the extent of corneal and visual axis involvement. Close postoperative follow-up is necessary to identify and prevent possible deprivation or refractive amblyopia . Given t


Cancer patients with liver metastasis may be candidates for liver surgery and local interventional techniques as part of their treatment. Although rare in this setting, hepatopulmonary fistula has been described as a possible complication. The clinical picture may be atypical, and, without specific treatment, it usually has a dismal prognosis. As locoregional treatments  in liver neoplasms are being more frequently used we need to include this entity as a possible differential diagnosis of local liver treatment complications. Hepatopulmonary fistula, defined as a communication between the bronchial tree and a hepatic segment, is a rare complication that may occur days to years after surgery .Potential causes of hepatopulmonary fistulas are grouped into five main categories, which have changed prevalence over the years: congenital and hepatic hydatic disease or liver abscess , more frequent in the past, especially in developing countries; biliary tract obstruction secondary to tumors ; blunt or penetrating injury (with or without an expanding hematoma causing obstruction); iatrogenic fistulas, following liver resection, radiofrequency ablation (RFA), external radiation, and thoracic drainage . With thDespite technical advances, even in specialized centers with high volume of liver surgery, postoperative morbidity is still a burden with rates around 20-40% . ComplexA 74-year-old man presented to the Emergency Department (ED) on April 2016, after 4 days of fever, productive cough, and abundant “yellow” sputum; he was started on oral levofloxacin on the diagnosis of tracheobronchitis. As symptoms worsened, he returned to the ED.On initial evaluation in our ED, he complained of persistent moderate dorsolumbar pain and productive cough, without shortness of breath. There was no history of vomiting, aspiration, or other abdominal complaints. Escherichia coli ESBL+, he was started on endovenous meropenem and was admitted to the general ward.On physical examination, there were no signs of respiratory distress and no jaundice and, upon cardiac and pulmonary auscultation, no abnormal sounds were detected. He was hemodynamically stable, with no fever; pain was recorded as 6/10  on arrival but resolved soon after admission. Thoracic X-ray showed no pleural or lung parenchymal lesions. According to previous sputum microbiological isolate, RAS mutated; the disease was staged as oligometastatic liver disease at the beginning. He was treated with primary chemotherapy, mFOLFOX6  and bevacizumab, from November 2013 to November 2014 and had a selective right portal vein embolization in June 2014, in order to be able to perform liver surgery with adequate remnant liver. On February 2015, a sigmoid colectomy was performed as well as liver segmentectomy of the VI and VII segments, conditioned by proximity to vascular structures and cholecystectomy. Surgical resection specimen confirmed liver metastasis with complete pathological response of the primary lesion, staged as ypT0N0M1. It was considered a R1 surgery due to liver margin intersection (vascular margin).He had a metastatic colorectal cancer (CCR), diagnosed in 2013; the tumor was Escherichia Coli, ESBL+.Postoperative period was prolonged due to bilioenteric fistula and liver abscess adjacent to the segmentectomy scar that evolved to septic shock; blood cultures and peritoneal drainage were positive forHe was discharged on the 40th postoperative day (May 2015) after successful medical treatment , with normal liver tests and no abnormal findings on CT scan.He had no further complementary chemotherapy.On January 2016 lung and liver progression  were detected on CT scan. Lesions were considered unresectable. Chemotherapy was restarted with mFOLFOX6 combined with bevacizumab, receiving 4 cycles until this hospital admission. Escherichia Coli ESBL+ respiratory infection associated with same agent bacteremia; the antibiotic susceptibilities test was identical to the previous one; cultural exams turned negative after the first week of antibiotic. Although inflammatory parameters and arterial gasometry improved, he kept daily fever (>38°C) and expelled large volumes of yellow-green sputum (>1L per day); as symptoms kept ongoing he had a chest and abdomen CT scan on hospitalization day 15. In the liver, there was a lesion with air and necrotic component adjacent to the metastatic subdiaphragmatic lesion scar relapse and adjacent lung atelectasis . Interventional radiology drainage for the subdiaphragmatic metastatic abscess was performed; the possibility of a fistula between the abscess and the lung was confirmed after local instillation of radiological contrast that the patient expelled with cough.A bronchoscopy was performed showing right middle bronchus obstruction with a large amount of thick and brown secretions  is a rare condition, which was classically associated with hydatic disease or hepatic amebiasis. However, since its first report in 1850, and according to a review of 68 cases between 1980 and 2010 (published in 2011), etiological primary condition has been evolving and cancer already represents the main cause (primary cancer of the liver or bile duct in 13 cases and liver metastases in 9 out of 68 cases) [There are two major ways of fistula formation described in literature: mechanical (bile duct obstruction) and infectious (subphrenic or intrahepatic abscess), which cannot be completely separated. The mechanical effect of an infected biloma underneath the diaphragm is related also to tissue erosion by bile, reaching the pleural space, bronchus, or both , 6. BiloThe mechanism reported for hepatopulmonary fistula after hepatectomy of liver metastases is through direct fistulization between biliary and bronchial tree.In the present case, we probably have mixed mechanisms, both mechanical and inflammatory/infectious: surgery, electrical margin fulguration, chemotherapy, anti-VEGF, and infection.After liver surgery, there was a postoperative liver abscess, which resolved with antibiotic and liver drainage. Although clinically resolved, the sequelae hepatic parenchyma changes may have contributed to the vulnerable territory for the development of fistulization.Subsequently, there was a liver scar recurrence, and the patient started chemotherapy and bevacizumab. As the patient restarted this therapeutic, the immune system depression coupled with the antiangiogenic effect of the antibody led the way to necrosis, infection reactivation, erosion of the diaphragm, and HPF. The sputum was in fact necrotic liver and purulent material from the liver abscess; there was no confirmation of bile drainage and the fistulography did not confirm biliary involvement.As the microbiological agent identified had the same morphological characteristics and antibiotic sensitivity as the one isolated in 2015, we assumed that the metastasectomy locus might be in fact a silent focus of infection.We reviewed the surgery report and there was no mention of any diaphragmatic laceration that could possibly be associated with the fistula development.According to previous reports, classical clinical presentation of HPF is irritant cough productive of copious dark-yellow sputum (bilioptysis), which is a very specific symptom of biliary bronchial fistula, with pneumonitis or bronchiolitis resulting from inflammatory reaction of the bronchial mucosa secondary to bile .In the literature, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography are considered the methods of election for the diagnosis, although thoracic-abdominal CT scan is the most commonly used method to approach these patients . BronchoThe therapeutic approach depends primarily on the underlying pathology, but always involves invasive techniques of drainage, either percutaneously or endoscopically, eventually coupled with surgery, as conservative medical treatment has been shown to be insufficient in all reported cases , 9, 10.This patient presents a complication that occurs 14 months after liver surgery, and his primary symptoms are respiratory, without gastrointestinal complaints. In addition, no asymmetries of the lung fields or pleural effusion were identified in the chest radiograph, which could indicate a “localized” inflammatory/infectious process.It is not a direct fistulization between the biliary tree and the bronchial tree, due to a stenosis or obstruction by the tumor, but an iatrogenic hepatic abscess with pulmonary drainage.HPF is a rare condition, with increasing incidence secondary to liver surgery and local ablative techniques, occurring at variable time after surgery.In patients with liver local treatments, presenting with fever, respiratory, and upper GI symptoms differential diagnosis should include HPF, as if not adequately treated it has a dismal prognosis. Imaging performing, with CT scan, EPRC, and CPT, may be of help in diagnosis if hepatobiliary fistula is suspected. Also, an accessible and noninvasive way of confirming this hypothesis would be the determination of bilirubin values in sputum analysis.With the increasing use of interventional techniques in primary and secondary neoplasms of the liver, in view of a refractory infectious condition, especially in diabetic patients undergoing liver surgery, this disorder should be considered as a possible late complication, since it implies a very specific and directed approach.


Fibrin-associated diffuse large B-cell lymphoma (FA-DLBCL) is a rare Epstein-Barr virus (EBV) positive lymphoproliferative disorder included in the current World Health Organization (WHO) classification. It arises within fibrinous material in the context of hematomas, pseudocysts, cardiac myxoma or in relation with prosthetic devices. In these clinical settings the diagnosis requires an high index of suspicion, because it does not form a mass itself, being composed of small foci of neoplastic cells. Despite overlapping features with diffuse large B-cell lymphoma associated with chronic inflammation, it deserves a separate classification, being not mass-forming and often following an indolent course.A 64-year-old immunocompetent woman required medical care for cerebral hemorrhage. Computed Tomography (CT) angiography identified an aneurysm in the left middle cerebral artery. A FA-DLBCL was incidentally identified within thrombotic material in the context of the arterial aneurysm. After surgical removal, it followed a benign course with no further treatment.The current case represents the first report of FA-DLBCL identified in a cerebral artery aneurysm, expanding the clinicopathologic spectrum of this rare entity. A complete literature review is additionally made. In the current WHO classification, diffuse large B-cell lymphoma associated with chronic inflammation (DLBCL-CI) is defined as an EBV-driven neoplasm, occurring in longstanding chronic inflammation in restricted spaces . The proIt has been reported in association with pseudocysts, cardiac myxoma, valve prosthesis, fibrin thrombus, synthetic tube graft, hydrocele, metallic implants, and chronic subdural hematoma –25. Diffinset; Fig. inset left), CD30 and MUM1  with partial expression of CD79α and CD20. The proliferative index . Single descriptions at unusual sites as within testicular hydrocele, ovarian teratoma and testicular hematoma are also reported. The intracranial location appears to be rare, with only 4 cases within chronic subdural hematomas , 22–24 aHistologically all cases were remarkably similar and found incidentally, being composed of microscopic foci of large lymphoid cells, embedded within fibrin and not invading adjacent tissue structures. Most cases had a non-germinal center B-cell phenotype and high proliferative index. A strong association with EBV infection is present; as 41/43 evaluated were positive for EBV by EBER-ISH. Notably a type III EBV latency profile, with positivity for LMP-1 and Epstein-Barr nuclear antigen-2 (EBNA-2) was found in most cases (18/22 tested). Type III latency of EBV infection is the hallmark of lymphoproliferative disorders arising in the setting of severe immunosuppression. EBV-infected cells expressing EBNA-2 do not survive in immunocompetent individuals, because destroyed by cytotoxic T-lymphocytes. As patients with FA-DLBCL are immunocompetent, it has been assumed that the restricted environment where FA-DLBCL occurs, allows the EBV-infected B-cells to escape T-cell surveillance . Clonal Our case arose in a previously unreported setting, being identified in a cerebral artery aneurysm of a patient with a brain hemorrhage. The disease was totally confined within thrombotic material occluding the artery. After surgical removal, it pursued a benign course with no additional treatment.In conclusion, FA-DLBCL is a rare EBV-related lymphoproliferative disorder, arising within fibrinous material in different clinical settings. Intracranial location is very rare. This represents the first report within a cerebral artery aneurysm. Diagnosis can be tricky, being FA-DLBCL not mass-forming and composed of tiny neoplastic foci. Clinical behavior is mostly indolent. The limited number of FA-DLBCL reported so far makes difficult to draw definitive conclusion regarding the best treatment. Further cases with longer follow-up would help to adopt the most appropriate therapeutic options for each individual patient.


A retro-odontoid pseudotumor is an uncommon non-neoplastic mass. They are mostly associated with rheumatoid arthritis and atlanto-axial subluxation. The pathogenesis is degeneration of the transverse ligament due to chronic mechanical stress. In this case report, an atlanto-occipital assimilation altered the biomechanics of the cervical spine, causing chronic mechanical stress on the transverse ligament and subsequently the development of a retro-odontoid pseudotumor. This is in accordance with previous studies that have attributed the development of retro-odontoid pseudotumor to a loss of mobility of the cervical spine, in cases without associated rheumatoid arthritis or atlanto-axial subluxation. A retro-odontoid pseudotumor is a non-neoplastic mass posterior to the odontoid process of the axis. Compression of the myelum with myelopathy and severe neurological symptoms is a serious concern due to the location of the mass.A 67-year-old female, with a typical presentation of carpal tunnel syndrome in the right hand, presented initially with numbness in digit IV and V a year later. A few months later, she developed numbness in all five fingers on the left side. Furthermore, the patient mentioned that she had had a burning sensation in both feet for a few years. Another few months later she complained of weakness in all four limbs and was sent for a neurological consultation with electromyography. Clinical examination revealed a Hoffmann-Trömner reflex on the left side, mild loss of strength in both hands, loss of vibratory sense and hypoesthesia in the distal end of all four limbs and loss of proprioception in both legs. The electromyography showed disturbed sensorimotor signals in the left hand and mildly disturbed sensorimotor signals in the right hand. The disturbed electromyography was attributed to carpal tunnel syndrome, which was presumably less severe on the right side due to treatment with long acting corticosteroid injections. The paresthesia in digit IV, digit V and both feet, however, could not be explained with the diagnosis of carpal tunnel syndrome. Therefore, magnetic resonance imaging (MRI) of the cervical spine was performed. Imaging showed an extra-dural soft tissue mass posterior to the odontoid process of the axis. The mass extruded through the transverse ligament of the atlas with severe compression of the myelum and myelomalacia at the level of C1 Figures  and 2B.A plain radiograph of the cervical spine was performed to check for atlanto-axial instability. The radiograph during flexion shows a slightly widened atlantodental interval, measuring 4 mm  Figure  and B.Pre-operative imaging of the cervical spine also revealed an anatomical variant of the craniocervical junction, atlanto-occipital assimilation of the massa lateralis bilaterally Figure .The patient was treated with laminectomy of C1 to decompress the spinal canal followed by posterior fixation of C1-C2 for stability.A retro-odontoid pseudotumor is most commonly associated with rheumatoid arthritis and atlanto-axial subluxation . The pat451The transverse ligament provides atlanto-axial stability and often contains fibrocartilaginous tissue as an adaptation to bony compression 10. The hIn our patient, the degeneration of the transverse ligament could not be attributed to rheumatoid arthritis, as the patient had negative serology. Furthermore, pannus formation as seen with rheumatoid arthritis is accompanied by erosion of bone anterior and/or posterior to the dens. These were absent in this case. Other typical craniocervical pathologies such as meningioma and CPPD had been excluded on post-contrast imaging.The cause of the excessive tissue formation in this case was attributed to a congenital anomaly, atlanto-occipital assimilation with secondary altered biomechanics in the craniocervical junction. Fusion of the atlas to the occiput in atlanto-occipital assimilation causes the mechanical stress during movement of the head to be transferred to the transverse ligament.This is in accordance with previous studies that have attributed the development of retro-odontoid pseudotumor, in cases without associated rheumatoid arthritis or atlanto-axial subluxation, to a loss of mobility of the cervical spine, usually adjacent to the level of C1-C2. The altered biomechanics of the cervical spine in these cases resulted in excessive mechanical stress to the atlanto-axial ligaments 111.Correct diagnosis of a retro-odontoid pseudotumor due to degeneration of the transverse ligament is important because of its specific treatment, atlantoaxial fixation. The need for dangerous interventions such as biopsy or resection can be avoided. Some cases show spontaneous regression of the fibrocartilaginous tissue after fixation of C1-C2 .MRI is the primary imaging modality to evaluate the extensiveness and possible myelum compression and to demonstrate the ligamentous and fibrocartilaginous characteristics of a retro-odontoid pseudotumor . ComputeRetro-odontoid pseudotumors usually originate from a degenerative transverse ligament due to chronic mechanical stress, most commonly seen in atlanto-axial subluxation. However, previous studies have shown that abnormalities of the cervical spine resulting in decreased mobility, especially adjacent to the level of C1-C2, can also cause excessive mechanical stress on the transverse ligament. In this case report, a congenital anomaly, atlanto-occipital assimilation, resulted in chronic mechanical overuse of the transverse ligament and the development of a retro-odontoid pseudotumor.


Primary malignant tumors of the spine are rare and mainly include chordoma, chondrosarcoma, Ewing sarcoma or primitive neuroectodermal tumor, and osteosarcoma. The final diagnosis is based on the combination of patient age, topographic and histologic features of the tumor, and lesion pattern on computed tomography (CT) and magnetic resonance (MR) imaging. Imaging evaluation includes radiography, CT, bone scintigraphy, and MR imaging. CT is more useful than radiography for evaluating location of the lesion and analyzing bone destruction and matrix, whereas MR has unmatched ability to assess soft tissue extension. This pictorial review provides an overview of the most prevalent primitive malignant tumors of spine. Primary malignant tumors of the spine are rare and mainly include chordoma, chondrosarcoma, Ewing sarcoma or primitive neuroectodermal tumor (PNET), and osteosarcoma . In patiOsteosarcoma is a primitive malignant bone tumor characterized by the production of osteoid or immature bone from neoplastic cells . Spinal 5MR of spinal osteosarcoma is usually nonspecific. Mineralized component of the tumor shows low signal on T1-weighted images (WI) and T2-WI, whereas the nonmineralized component displays a high signal on T2-WI. Fluid-fluid levels have been described in association with telangiectatic osteosarcoma . ExpansiLocal recurrence is estimated at 20% after en bloc excision and 60% after locoregional excision 8.Chondrosarcomas represent a heterogenous group of tumors characterized by their capacity of cartilage formation . ChondroMost lesions represent primary chondrosarcoma; however, secondary chondrosarcoma may also occur when osteochondroma (solitary or multiple with hereditary multiple exostoses) undergoes malignant transformation . RadiogrOn MR the tumor is of low signal on T1-WI Figure  and heteChordoma is a rare malignant neoplasm arising from the embryonic remnants of the primitive notochord and accounts for 2–4% of all primary malignant bone neoplasm, with an estimated prevalence of 0.51 per million. Chordomas generally occur in middle-aged patients, with a peak prevalence in the 5th–6th decades. Spinal chordomas have a 2:1 male–female ratio .Eighty-five per cent of chordomas occur in spheno-occipital skull base (35%), sacro-coccygeal area (50%) , and theRadiographs and CT scan usually show a lytic lesion of a vertebral body associated with a soft-tissue mass with a “mushroom” appearance, spanning several segments and sparing the disks. Areas of amorphous calcifications are noted in 40% of chordomas of the mobile spine and in up to 90% of sacrococcygeal lesions . Bone seChordomas show signal characteristics parallel to nucleus pulposus of the disk (notochord) on MR being low to intermediate signal on T1-WI Figure  and veryChordoma should be differentiated from giant embryonic remnants of the notochord . Unlike in chordoma, radiographs and CT fail to demonstrate a distinct lesion in giant notochordal rest, instead showing either normal bone or a variable degree of sclerosis . Bone scChordoma is a low-grade and slowly growing tumor but generally has a poor long-term prognosis. Metasases are rare, estimated between 4 to 43% of patients , but locEwing sarcoma and PNET are defined as round cell sarcomas that show varying degrees of neuroectodermal differentiation . Ewing sPain is the most common symptom of patients suffering from spinal Ewing’s sarcoma . NeuroloThe prognosis in Ewing sarcoma/PNET has improved in the modern era of treatment and current survival rate is estimated to be 41% . The besLymphoma is categorized as primary osseous lymphoma if bone is the only known site of disease for six months . It is aHistologically, most bony lymphomas show a mixed cell infiltrate in which the cellular size and shape differ considerably. The very characteristic infiltrative pattern should suggest the diagnosis of lymphoma. The medullary bony trabeculae may show reactive sclerosis .Radiologically, the lesions are lytic Figure , mixed, The treatment options of the primary bone lymphomas are surgical, chemotherapy, and radiotherapy . IsolatePlasmocytoma Figure  is a cliThe most common symptom is local pain in the region of the affected spine, radicular pain or neurological deficit.The spine is involved in 25–50% of the cases. Thoracic vertebrae are most commonly involved . The malThe treatment of choice is chemotherapy and/or radiation therapy at 40 Gy to 50 Gy . SolitarIn 2014, the International Myeloma Working Group (IMWG) revised diagnostic criteria for multiple myeloma (MM), allowing the use of specific biomarkers and modern imaging tools to define the disease in addition to the established CRAB features . MultiplSkeletal involvement occurs in 80–90% of patients with MM . VertebrTen to 20% of patients with multiple myeloma are normal on radiography 43. PathoAlthough new or enlarging lesions generally mean disease progression, lytic bone lesions rarely show evidence of healing on plain radiographs, and routine follow-up skeletal survey is of no benefit .Whole-body multidetector computerized tomography (WB-MDCT) is a preferable imaging tool over whole-body X-ray (WBXR) surveys for assessment of fracture risk and characterization of compression fractures . LimitatMR in patients with clinical and laboratory findings of symptomatic myeloma provides prognostic information and may detect unsuspected myeloma lesions . Five diAbnormal signal can also be observed after chemotherapy and the use of growth factors or in young individuals with hyperplasia of normal haematopoiesis. Thus, the clinical context should be taken into account when evaluating MR, and MR should not be performed close to chemotherapy. Diffuse marrow infiltration has a decreased signal on T1-WI and an increased signal on STIR. The overall performance of MR is enhanced by applying dynamic contrast-enhanced MR and diffusion-weighted imaging sequences, providing additional functional information on bone marrow vascularization and cellularity .Posttreatment MRI typically demonstrates a gradual replacement of marrow infiltration or focal lesions by marrow fat, but this may be delayed up to four or five years in some focal lesions .FDG PET/CT is particularly sensitive for the detection of extramedullary disease and can help detect the metabolically active lesions that often precede evidence of osseous destruction at conventional radiography . Both MR


Appendicular schwannomas are very rare condition with nonspecific clinical symptoms and frequently recognized during pathological examination. They arise less frequently in the gastrointestinal tract and comprise ~1% of all malignant gastrointestinal tumours. We presented a rare case of an appendicular schwannoma that was discovered incidentally in a 25-year-old student diagnosed with appendicular mucocoele with a suspected obstructing tumoural lesion based on computed tomography findings. A colonoscopy examination showed a bulging, nodular, erythematous lesion at the base of the caecum . Biopsies showed mixed inflammatory infiltration in the lamina propria, with lymphoid-filled formations. No evidence of dysplasia or neoplasia. Tumour markers were negative. Appendicular neoplasms, such as schwannomas of the appendix, are rarely associated with nonspecific clinical symptoms and are frequently recognized during pathological examination of the resected appendix. Laparoscopic surgery with a clear resection margin is the cornerstone of treatment for appendicular schwannoma, and it is associated with a favourable prognosis. Schwannomas are benign neurogenic tumours that arise in the Schwann cells, which form a sheath around the peripheral nerves, providing support and protection. In most instances, schwannomas occur in the head, neck, upper and lower limbs as well as the third to twelfth cranial nerves. They arise less frequently in the gastrointestinal tract  and comprise ~1% of all malignant gastrointestinal tumours –6, with A 25-year-old dental student was referred to our institution for the management of vague abdominal pain in the right lower quadrant for a duration of 5 years. The pain was colicky, intermittent and relieved by analgesia. It was associated with nausea, vomiting and anorexia. The primary diagnosis was mucocoele of the appendix with suspected obstruction by a tumoural lesion based on an abdominal computed tomography (CT) scan.The patient had no history of fever or change in bowel habits. There was also no history of weight loss, fatigue, night sweats or previous attacks of abdominal pain, no family history of a similar clinical picture and no history of malignancy. His medical and surgical history were irrelevant.On examination, the patient was conscious, alert and oriented and not in pain. His vital signs were as follows: heart rate of 88 beats per minute, respiratory rate of 22 cycles per minute, blood pressure of 123/86 mmHg and oxygen saturation of 98%. A digital rectal examination revealed soft stool in the rectum.After an initial examination by a colorectal surgeon, the patient was referred for a colonoscopy. Further investigations included laboratory workup, histopathology, an abdominal X-ray and a CT scan of the abdomen. The patient was offered laparoscopic-assisted ileocecal resection following the results of the investigations.Blood was drawn for a complete blood count, urea and electrolytes, liver function test, coagulation profile, serum glucose level, carcinoembryonic antigen and cancer antigen, which were all within normal limits.The colonoscopy revealed a bulging, erythematous nodular lesion at the base of the caecum  Fig. A, B. SamThe abdominal X-ray was reported as normal. The abdominal CT scan revealed a dilated appendix measuring 1.6 cm in maximum diameter with no surrounding fat stranding or free fluid. No free air was noted. The wall of the appendix was not interrupted. The liver showed homogeneous enhancement with no focal lesion Fig. . No intrAfter the laboratory and radiological investigations, the patient underwent laparoscopic-assisted ileocecal resection with side-to-side anastomosis.A repeat histopathological examination, performed after surgery, showed hypertrophied bundles within the lamina propria, consistent with appendiceal schwannoma. No evidence of malignancy was identifiable.The rarity and unusual clinical presentation of appendicular schwannomas may contribute to underreporting because there are overlapping features with several other tumours and inflammatory conditions. In about 30–50% of appendicular tumours, patients present clinical symptoms and signs typical of appendicitis , 8. HoweAs demonstrated in our case, conventional imaging modalities, such as CT and endoscopy, are useful in determining tumour location. Other investigational modalities that can help identify tumour location include ultrasound, barium enema and magnetic resonance imaging . In someThe only treatment option that was explored in our patient was laparoscopic-assisted ileocecal resection with a clear margin 5 cm proximal and 5 cm distal, which was also offered in other reported cases and is considered the treatment of choice in these patients –5, 10. TIn conclusion, we presented a rare case of an appendicular schwannoma that was discovered incidentally in a 25-year-old patient diagnosed with appendicular mucocoele. Appendicular neoplasms, such as schwannomas of the appendix, are rarely associated with nonspecific clinical symptoms and are frequently recognized during pathological examination of the resected appendix. Laparoscopic surgery with a clear resection margin is the cornerstone of treatment for appendicular schwannoma, and it is associated with a favourable prognosis.


Cases of extensive nasal polyps rarely occur and may mimic more aggressive lesions of the nose and paranasal sinuses. A case of extensive nasal polyposis with unusually aggressive behavior and its management is presented.  A 27-year-old male patient visited the emergency department of a tertiary center, complaining of recurrent episodes of epistaxis. The patient presented with a large polypoid lesion protruding from the right nostril and producing asymmetry of the face. Diagnostic imaging illustrated a lesion of the right maxillary sinus producing excessive bone remodeling and extension into neighboring structures in every direction. Fine limits were noted, however, with no invasive characteristics. Biopsy under local anesthesia was performed, showing findings consistent with nonspecific inflammation. Open surgery through a lateral rhinotomy under general anesthesia was performed, and the mass was readily mobilized and removed. No macroscopic invasion of neighboring structures was noted. Permanent histology confirmed the diagnosis of nasal polyposis. Postoperative follow-up has shown no evidence of recurrence after 12 months.  Nasal polyps do not typically expand in an aggressive manner, producing bone resorption or extending into neighboring structures. However, nasal polyposis should be included in the differential diagnosis of nasal tumors with such behavior. Sinonasal tumors are rare entities with distinctive clinical, etiological, and pathological features. Nasal and paranasal cavities, although small spaces, represent complex areas, where a wide range of benign and malignant tumors may occur. Primary benign and malignant tumors account for approximately 3% of all head and neck neoplasms –3.The diNasal polyposis develops in 0.2-1% of the general population and concerns all races, increasing with age . PrevaleIn this case report, we present a patient with aggressive nasal polyposis causing bone remodeling and extension into neighboring structures, and thus mimicking much more aggressive disease. We present in detail the clinical evaluation as well as surgical technique and postoperative follow-up. This case report is compliant with the SCARE Guidelines and PROCESS Guidelines.A 27-year-old male, with Crouzon syndrome phenotype, visited the emergency department of a tertiary referral center, reporting multiple episodes of epistaxis in the past few days. The patient also reported nasal obstruction and impaired nasal breathing for the previous several months. Rest of the medical history was free. On clinical examination, a polypoid lesion protruding from the right nostril was noted. In addition, asymmetry of the face and projection of the ipsilateral canine fossa were evident.Computed tomography of the paranasal sinuses showed an inhomogeneous soft-tissue mass, which completely occupied the right nasal cavity, maxillary sinus, and anterior and posterior ethmoidal cells. The lesion produced extensive bone remodeling of the right maxillary sinus with complete absence of its anterior wall, as well as erosion of the posterior wall and entry of the lesion in the pterygopalatine fossa. There was also erosion of the ipsilateral lower as well as median orbital wall, and entry of the lesion in the orbital cavity. Despite its large size, the lesion seemed to be well defined without invasive characteristics Figures –5.Routine laboratory tests were within normal range. Preoperative maxillofacial consultation excluded pathology of odontogenic origin. The patient underwent a biopsy under local anesthesia, and the findings showed nonspecific inflammation. Open surgery under general anesthesia was undertaken via lateral rhinotomy and medial maxillectomy . The max7Nasal polyposis is a very common entity with prevalence between 6 and 11% in the Western world. Cases with aggressive behavior , howeverSinonasal angiomatous polyp is a rare variant of sinonasal polyp that may mimic inverted papilloma, juvenile angiofibroma, and malignant tumors in its clinical and radiological aspects . The CT In addition to nasal polyps, other inflammatory conditions of the nose may occasionally follow an aggressive clinical course. Vorasubin et al. reported a rare case of invasive actinomycosis presenting with extensive midface destruction involving the maxilla and paranasal sinuses, with mucosal necrosis mimicking an aggressive neoplasm. Although this is very rare condition, it should be included in the differential diagnosis .Clinical evaluation of a patient presenting with a nasal mass may be quite complex. Endoscopy, imaging studies, and evaluation of the symptoms are crucial in differential diagnosis and therapeutic planning. Computed tomography (CT) is the gold standard in the radiologic investigation of the paranasal sinuses for diagnosis of sinonasal lesions as well as pre- and postsurgical assessment . ComputeThe most frequent reported symptoms of nasal and paranasal masses at the time of diagnosis are nasal congestion, headache, nasal discharge, diplopia, facial swelling, proptosis, auditory impairment, and epistaxis . Nasal cSurgical treatment protocols have evolved from extensive craniofacial resection to more conservative endoscopic sinus surgery in order to lower morbidity rates and improve treatment outcomes. With the development of functional endoscopic sinus surgery (FESS), indications for classical surgical procedures have been limited significantly. While the majority of patients may be adequately managed endoscopically, we highlight the importance of having the option of combined and open craniofacial approaches for extensive and complicated disease. Reported relapses after endoscopic surgery reach 60% for chronic sinusitis with nasal polyps, and some patients with frequent recurrences may benefit from classical approaches in order to achieve better disease control over prolonged periods of time . Extent There is an overlap between symptoms, clinical signs, and imaging findings in many pathological entities of the nasal-paranasal cavities. Nasal polyps typically do not expand aggressively, leading to bone resorption and extension into neighboring spaces. However, nasal polyposis should always be included in the differential diagnosis of nasal tumors with such behavior. Extensive surgery may be warranted in these cases, and excellent results should be expected.


Mediastinal bronchogenic cysts are encountered relatively often, but in many cases, diagnosis using imaging modalities, is difficult. Early surgical excision of bronchogenic cysts is recommended as a diagnostic and therapeutic measure. Here, we report the case of patient with a lower mediastinal bronchogenic cyst, who was treated using thoracoscopic surgery with prone positioning and include a review of literature on diagnosis and treatment of this condition.The patient was a 66-year-old woman with an asymptomatic cystic lesion in the posterior, lower mediastinum. The lesion was diagnosed as an esophageal cyst using preoperative imaging and was scheduled for thoracoscopic removal with the patient in the prone position. Intraoperatively, the lesion was found to have no continuity with the esophageal wall and was easily separated from it. Moreover, a cord extending to the lesion, appeared to arise from the crura of the diaphragm. On histopathological examination of the extracted mass, the lesion was diagnosed as a bronchogenic cyst. Postoperatively, the patient recovered uneventfully and was discharged after 7 days.Thoracoscopic mediastinal cystectomy with the patient in the prone position may be an optimal surgical strategy for the treatment of bronchogenic cysts in the posterior, lower mediastinum. BroncThis work has been reported in line with the SCARE criteria .23, on the right side of the esophagus in the lower part of the mediastinum  and carbohydrate antigen 19-9 (CA19-9) at 0.8 ng/mL and 4.8 pg/mL, respectively. Chest computed tomography (CT) showed a localized area of low density, measuring approximately 2.8 × 2.5 × 2.3 cmiastinum . T2-weigiastinum . Endoscoiastinum . Therefoiastinum A. Duringiastinum B and C. iastinum . Thus, t3Bronchogenic cysts are considered to be caused by an aberrant germination or the abandonment of a tracheobronchial rudiment originating from the ventral lung bud of the foregut, during the embryonic period . Most brWhile chest CT examination clarifies the relationship between the cyst location and the surrounding organs, its utility in identifying the type of cyst varies, depending on the nature of the cyst contents. Hence, the usefulness of CT in the preoperative diagnosis of bronchogenic cysts is limited, with a diagnostic rate of 60–70% . The difThe typical histopathological diagnostic feature of bronchogenic cysts is the presence of ciliated columnar epithelial cells along the inner surface of the cyst. The inner cyst wall may also contain cartilage and smooth muscle components, though these are not essential for diagnosis. In this case, the cyst was covered with multi-rowed ciliated epithelium on the inner surface, the cyst walls were surrounded by smooth muscles of variable thickness, and glandular tissue  was also observed, aiding in the diagnosis.In adults, the treatment for suspected bronchogenic cysts is surgical removal. Early surgical excision is preferred because, making a definitive preoperative diagnosis is difficult in some cases, the risk of surgery is higher after the appearance of symptoms, and parts of the cyst have been reported to be malignant in previous studies . Some stMost thoracoscopic mediastinal cystectomies are performed with the patient in the lateral position. However, in this case, we performed thoracoscopic surgery with the patient in the prone position, as is our practice for esophageal cancer resection. The reasons for positioning the patient in this manner included a preoperative misdiagnosis as an esophageal cyst, a greater familiarity with this positioning as it is regularly used by us for esophageal cancer patients, and the location of the lesion in the posterior and lower mediastinum, which provided us with a good visual field on prone positioning, as the lungs moved ventrally due to gravitational effect. Some studies have reported that surgery in the prone position is not as beneficial as that in the semi-prone position because lung contraction due to gravity is better with the latter positioning, and it is easier to transition to open thoracotomy, if required ,13. Howe4Although mediastinal bronchogenic cysts are encountered relatively often, they are rarely diaphragmatic in origin. As imaging has low diagnostic reliability for these cysts, surgical excision is the most definitive diagnostic and therapeutic modality. We suggest that thoracoscopic surgery with the patient in the prone position may be an optimal approach for the excision of bronchogenic cysts in the posterior mediastinum and should be implemented, depending on the location of the lesion, the patient’s general condition, and the skill of the operator.The authors declare that they have no conflict of interest.No source of funding to be declared.Ethical approval was not required and patient identifying knowledge was not present in the report.Written informed consent was obtained from the patient for publication of this report and accompanying images.Yoshihiro Ota: Drafted the manuscript.Takafumi Watanabe, Kosuke Takahashi, Takeshi Suda and Shingo Tachibana: Managed the patient.Jun Matsubayashi: Diagnosed the pathological findings.Yuichi Nagakawa, Yoshiaki Osaka and Kenji Katsumata: Supervised the writing of the manuscript.Akihiko Tsuchida: Approved the final manuscript.Our study does not require registration.Akihiko Tsuchida.Not commissioned, externally peer-reviewed.