Prolapsed intervertebral discs are commonly associated with back ache and sciatica. Management is often conservative with analgesia and physiotherapy. Nerve root injections and discectomy procedures are used where conservative measures fail. Majority of patients present with symptoms of pain and motor weakness; however, a few can present as focal myositis of lower limb muscles in the distribution of radiculopathy. MRI scans of limbs are rarely done in these cases but if done can confound the radiologist. Our case report emphasize the importance of multidisciplinary approach for a L3 nerve radiculopathy with confounding clinical presentation of focal lower limb myositis of unknown etiology. Nerve root injections and discectomy procedures are used where conservative measures fail. The majority of patients present with symptoms of pain and motor weakness, however, a few can present as focal myositis of lower limb muscles in the distribution of radiculopathy. Various cases of S1 radiculopathy presenting as focal myositis have been described in the literature. We present a case of L3 radiculopathy with a confounding clinical presentation of lower limb myositis.Prolapsed intervertebral discs are commonly associated with backache and sciatica. It is most commonly seen at L4–L5 and L5–S1 levels.A 69-year-old male presented to the emergency department with acute worsening of insidious onset backache and burning groin pain, radiating to the left inner thigh and shin. There were associated hypersensitivity and burning sensation along the medial aspect of the left thigh and leg. No associated numbness or weakness. No symptoms related to bladder or bowel. No history of trauma. No weight loss, change in appetite, or other systemic symptoms. Leg symptoms were severe compared to mild backache. He also had a past medical history of Rectal Cancer in 2009 which was treated by Chemotherapy (Capecitabine) and Radiotherapy followed by End Colostomy done in 2010 and treatment was completed thereafter. He also had hypertension and labyrinthitis, for which he takes regular Amlodipine and Statins. He smokes 15 cigarettes per day and drinks 20 units of alcohol per week. He was admitted under the general orthopedic ward which has visiting spinal consultants after review by core trainee Level 2  and Orthopedics registrar .On examination by registrar, he was found to have tenderness overlying the lumbar spine and left sacroiliac joint and was struggling to weight bear. He had some weakness with left hip flexion  but power was otherwise normal throughout both lower limbs. There was hypersensitivity to light touch over the medial aspect of thigh and shin along with muscle wasting of the left thigh. His knee jerk reflex was also absent on the left.a) Spinal - lumbar nerve root impingement, (b) Peripheral - compressive pelvic pathology (c) Post-radiotherapy/Chemotherapy, (d) Nerve infiltration – due to proximity of previous rectal cancer, (e) Neuromuscular junction/Muscular - primary muscle pathology, e.g. myositis, (f) Paraneoplastic – given past medical history of rectal cancer.We divided our differential diagnosis as . It also revealed bilateral lower limb sensorimotor axonal neuropathy , which was suspected of chemotherapy-induced. The conclusion of the report was? Inflammatory v/s infiltrative pathology of L3 and L4 ± L2 with the suggestion that MRI can show diffuse muscle edema in the acute/sub acute phase of denervation., in absence of joint swelling and twitches/cramps, normal serum CK levels (58–73), and absence of myositis changes on nerve conduction velocity studies the experienced consultant was not fully convinced with the diagnosis of myositis and suggested further for a neurologist’s opinion.A Rheumatology Consultant opinion was taken due to the presence of myositis on MRI and modest response in symptoms to nerve root block and steroids. HoweverThe patient was extensively investigated by Consultant Neurologists to rule out autoimmune, vasculitic, and atypical infection. CT-Chest–Abdomen-Pelvis and MRI Pelvis/Lumbar plexus were also done without adding much to this challenging case.This case was again discussed in MDT and it was found that exhaustive investigations failed to rationalize the case in terms of systemic pathology or the disc prolapse. This may have been a presentation of muscle change secondary to denervation. Management was commenced on empirical analgesia, low dose finite steroid regime, spinal and neurology follow up with interval MRI scanning.Further, repeat L3 nerve root block ± discectomy recommended. Repeat L3 Nerve root block  was perfThe last OPD follow-up showed no further deterioration in symptoms. The latest interval MRI scan showed left-sided lumbar plexopathy change  and denervation change, grossly unchanged in comparison with the previous study. Appearances are likely to be due to chemical radiculitis from a small left lateral L3 disc protrusion. Extraforaminal discectomy was offered to the patient if symptoms reoccur or worsens, though the patient asked for some more time to make an informed decision. A fishbone diagram below shows the exhaustive work-up done for this patient. 1 Analgesia and physiotherapy are the first lines of therapies offered to patients. Selective nerve root blocks and discectomy procedures are usually reserved for refractory cases. We followed the same principles in our case and offered the patient analgesia first followed by the L3 nerve root block as per NICE guidelines.2 The absence of response to analgesia and selective L3 Nerve root block leads to a battery of investigations and several discussions at MDT meetings for our case.Radiculopathies are commonly seen in the L5/S1 level and are usually treated conservatively. L3/L4 extraforaminal disc presenting as L3 radiculopathy is itself a rare entity.3 Since the detection of the first case of focal myositis in a patient of S1 radiculopathy by Krendel in 1992, total nine cases of such focal myositis related to S1 radiculopathy have been described in the literature until 2013 by Hemmi et al, however, none of the cases of L3–4 radiculopathy has been described in literature till date.4,5Myositis is commonly associated with myopathic disorders, however, it can be rarely seen with neurogenic disorders. In polyneuropathy or anterior horn cell disease, the presentation is usually bilateral. Unilateral myositis secondary to a neurogenic cause is rare and most commonly has been described with S1 radiculopathy. It has also been reported with L5 radiculopathy, polyneuropathy, and poliomyelitis.6 in a case of adenocarcinoma of the rectum. That happened 5 month post-radiotherapy and 2 month post-chemotherapy completion in their case. We ruled out chemoradiation as the possible cause of myositis due to the onset of symptoms after 9 years of treatment completion in our case.No evidence of infection was found in our case with a normal range of inflammatory markers. Chemoradiation causing myopathy of hip muscles was reported by Florczynski et al7 A few of the cases described happened after laminectomy at L5–S1, responded well to steroids.8Steroid treatment is supported by literature without any other intervention.8 did a systematic review and case report search and found six cases of S1 radiculopathy associated with myositis in 2008. Although the mechanism behind muscle inflammation remains largely unclear, they strongly supported the notion that denervated muscles can develop inflammatory responses.8 In an animal experimental study done on the denervated muscle of mice, Kampmann et al9 demonstrated mononuclear inflammatory response with CD8 lymphocytes. Another theory is the mechanical process in terms of repeated microtrauma due to walking on denervated muscle, which could be the cause of myositis.5The definite cause of myositis in radiculopathy is poorly understood. Gross et al10Although EMG is the gold-standard MRI which is a very useful investigation in muscle pathologies like myositis. MRI is a non-invasive tool that can identify muscle groups even not accessible to EMG. MRI detects edema with T2 and STIR uptake in acute denervation (<1 month) in muscle groups like in our case. The radiologist could be the first person to identify the muscle groups and can classify the stage of muscle denervation as acute (edema with T2 and STIR uptake), subacute (further increase in extracellular water), and chronic . Having a panoramic view of muscles involved in a limb nerve involvement can be identified.11 classified muscle pathologies into four patterns on MRI scans. (a) Abnormal anatomy with normal signal intensity , (b) edema/inflammation related to increases in water content , (c) intramuscular mass causing anatomic distortion  or (d) atrophy resulting in tissue loss, usually accompanied by fatty replacement . Often, the presentation is mixed, e.g. acute denervation starts with edema and later progresses to the atrophy stage. Hence, edema was recognized in our case where a bilateral lower limb MRI scan was done in the acute denervation phase. Edema in itself is very non-specific, therefore diagnosis needs a multidisciplinary approach as in our case.Smitaman et ale.g. the natural history of disc radiculopathies cannot be ignored where symptoms can remit in 6–8 weeks. The second nerve root block was given around this period, and the patient was under cover of empirical analgesia and finite low dose steroid regimen.Empirical analgesia and steroids did not settle the leg symptoms in our case. In an MDT meeting, it was decided not to perform invasive muscle biopsy for our patient. Hence, denervation-related muscle edema should be a correct term rather than myositis for our case. Focal muscle changes are infrequently identified in association with lumbar disc prolapse, as we rarely image the lower limbs. However, if a lower limb scan shows features of possible focal myositis or edema, a spinal cause should be kept in mind as happened in this case. Ours is the only case, where we targeted spinal cause in first place for this L3/L4 disc pathology masquerading as myositis/denervation muscle edema. Unfortunately, there was no response to the first nerve root block given at the L3 level. Therefore, failure to respond doesn't mean wrong diagnosis/treatment. The second nerve root block did provide good relief of acute symptoms and allowed the patient to weight bear again. Although the explanations for this could be multifactorial, L3 radiculopathy has never been described in the literature as a cause of denervation related muscle edema. The pathophysiology is multifactorial, which includes denervation inflammatory response in muscles and repeated microtrauma to denervated atrophic/weakened muscles. If MRI of the limb is performed, it can show features of myositis which can confound the radiologist if the spinal cause is not kept in mind.L3 radicular pain is uncommon but can be a cause of focal lower limb pain.MRI of the limb can show diffuse edema in acute/subacute denervation, therefore spinal cause should be considered.MDTs  are required for the care of the patient.Failure to respond to treatment doesn’t necessarily mean the wrong diagnosis, but even response to treatment should not deter further work-up.


Osteosarcomas of the jaws are very rare accounting for only 6 to 7% of all osteosarcomas and 1% of all head and neck malignancies.The clinicopathological characteristics as well as the radiological characteristics are not specific, which represents a diagnostic dilemma. Indeed, this lesion is often mistaken for benign lesions of the maxillary.We report a case of osteosarcoma of the jaws in a 45 year man who consulted in our service for a simple painless oral swelling evolving since a five months.The lesion was excised and histopathological report confirmed the diagnosis of osteosarcoma of the jaw.Osteosarcomas are a rarely progressive tumor in the oral cavity that can show up as a case of a benign process of dental origin. During our practice, we often meet similar cases which are treated by usual medication, while a whole malignant process is in the progress and can be life-threatening. The case we present illustrates this perfectly, and owing to a deep clinical investment, the malignant process was stopped at its start.The objective of presenting this case is to draw the attention of the doctors that any lesions even of benign appearance can hide a malignant process. Consider this point and integrate it into its diagnostic approach should be undertaken and should lead to a deepening of the clinical examination by comparing the clinical, radiological and histological data. •Never underestimate a lesion of usual appearence; a whole malignant process can be hidden.•A dippening of clinical and paraclinical investigations is an approch to adopt.•Early diagnosis can improve the management of the desease and save lives. The diagnosis is often wrong leading to treatment of the lesion in 2/3 of cases with tooth extraction and half with antibiotics Swellings are the most common presenting symptoms in cases with osteosarcoma. Pain, paresthesia, and ulcerations are less common The radiological examination is not specific; it can show a lytic, sclerotic or mixed image This article has been reported in line with the SCARE criteria 2A 45-year-old man in good general health condition, without any known health problem or any genetic pathology detected, consulted at the university center for dental treatment and care at the faculty of dental medicine at Rabat, for a maxillary swelling evolving for five months.During the interview, the patient reports the absence of pain or paraesthesia. Exobuccal examination doesn't report any abnormalities. No lymphadenopathy was palpable.The endobuccal inspection shows the presence of a round swelling located at the level of the mucosa of the right upper molar-premolar region . The sweRadiographic exam shows a radiolucency located on the middle third of the roots of the first right molar and the second right premolar .Fig. 2PrAn excisional biopsy was performed at the center for dental treatment  and an aThe patient was transferred to a specialized unit where an extension assessment was performed.There was no extension beyond the oral site and a wide local excision with tooth extraction was performed. No other treatments were performed.The patient benefited from a follow-up at the rate of three times the first year then one time each year. No malignant process or metastasis has been identified.3Osteosarcoma of the jaws accounts only for 6% to 7% of all osteosarcomas The patients are usually older than those who suffer long bone sarcomas, with a rare incidence of metastasis The mandible is marginally more commun site than the maxilla and tends to occur in the body and the ramus, whereas the canine and premolar are more likely site in the maxilla The etiological mechanisms are unknown The most common presenting symptoms are swelling, pain In view of these non-specific symptoms, the osteosarcoma is poorly diagnosed as a periapical lesion or odontogenic lesion Other differential diagnoses include fibrous dysplasia, ossifying fibroma, chondromyxoid fibroma Radiographic examination usually shows a lytic, sclerotic or mixed lesion with soft tissue extension in the majority of cases If the tumor invades the periosteum, many thin irregular spicules of new bone may develop outward and perpendicular to the surface of the lesion producing the so-called “sun ray appearance” Periodontal ligament space widening and lamina dura attenuation around a tumor are other features that may present in jaw osteosarcomas The importance of special investigations such as computerized tomography and magnetic resonance imaging lies in assessing the size of the lesion for staging, intramedullary and extramedullary involvement, tumor calcification and invasion into adjacent tissues particularly pterygopalatine fossa, infra temporal fossa and cranial cavity Histologically, the neoplastic cells are predominately spindle-shaped, with minimal atypia and relatively few mitoses A variable osteoid production is described with several subtypes. Among these, we find osteoblastic, chondroblastic, or fibroblastic subtypes The two therapeutic modalities used in the primary treatment of osteosarcoma include chemotherapy and radical surgery.Chemotherapy is indicated for head and neck osteosarcomas that are unresectable, with metastases, in unusual locations (base of skull) or with aggressive histopathology Radical surgery in the mandible consists of hemi-mandibulectomy. Maxillary lesions are often difficult to be treated as involvement of maxillary sinus, pterygopalatine fossa and orbital fossa often masks the tumor until extensive spread. Often, maxillectomy is inevitable. If cervical lymph nodes are involved, neck dissection would improve the survival Osteosarcoma is particularly resistant to radiotherapy, which should only be considered to prevent local recurrence owing to the possibility of tumor-positive margins after surgical resection Osteosarcoma of the jaws have better prognosis than conventional osteosarcomas 4Osteosarcoma of the jaws is a rare malignant lesion. However, dentists are most confronted with clinical and radiological signs.Hence, this article's main objective is to show the importance of early diagnosis.The latter is the key to a better prognosis avoiding the extension of the lesion and optimizing its management.No external funding.Not required.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Dr Amminou Loubna: Drafting the work conception and design of the work.Dr Taleb Bouchra: Revising the work critically, Acquisition and analysis of work, Final approval to the version to be published.Amminou Loubna.Not commissioned, externally peer-reviewed.The authors declare no conflict of interest.


A cutaneous horn, sometimes referred to as cornu cutaneum, is a projection arising on the skin due to an overgrowth of the epidermal stratum corneum. This lesion is a clinical presentation of an underlying skin tumor. A woman with a verruca vulgaris-associated cutaneous horn is described. Cutaneous horns are often solitary and appear most commonly on the face, ears, and the dorsum of the hands of older patients. The most frequent tumors associated with cutaneous horns include actinic keratoses and seborrheic keratoses; however, cutaneous horns have also been observed overlying other benign and malignant tumors. In conclusion, a cutaneous horn is a common clinical feature; however, the diagnosis of the underlying skin lesion requires a biopsy that permits adequate microscopic evaluation of the associated tumor.  Cutaneous horns are described as exophytic keratotic mounds overlying the epidermis. In order for the lesion to be termed as a “horn,” the height of the lesion must be greater than at least one-half of its greatest diameter. The most common sites for cutaneous horns include the face, ears, and the dorsum of the hands of older patients ,2. Cutaneous horns can be associated with benign, premalignant, or malignant tumors. They are most frequently seen overlying an actinic keratosis; however, they are commonly associated with seborrheic keratosis and verruca vulgaris. When a cutaneous horn is observed, a biopsy is necessary to evaluate and determine the associated underlying tumor .Verruca vulgaris is a human papillomavirus-associated lesion. It typically presents as a papule. Occasionally, a verruca vulgaris will develop massive hyperkeratosis and clinically present as a cutaneous horn . A woman with a cutaneous horn-related verruca vulgaris is described. The incidence of verruca vulgaris-associated cutaneous horn and the histologic features of the lesion are reviewed. Other benign skin neoplasms, precancerous cutaneous lesions, and malignant skin tumors that have been noted to present as cutaneous horns are also discussed. An 81-year-old woman presented for evaluation of an enlarging lesion on her left forearm of two-years duration. She had applied garlic to the lesion; however, there was no improvement. Complete cutaneous exam revealed a tan 11 x 10 x 2 millimeter keratotic nodule with a peripheral collarette and central horn on the left forearm . Summarizing the data, 16.5% (167 of 1013) of the cutaneous horn-related neoplasms were verruca vulgaris , excision, or immunologic treatment  ,8. If thCutaneous horns are keratotic epithelial lesions with an associated underlying benign, precancerous, or malignant neoplasm. We described a woman with a verruca vulgaris-related cutaneous horn. The incidence of verruca vulgaris as the tumor associated with a cutaneous horn is 16.5%. Seborrheic keratosis and cutaneous malignancies of squamous cell derivation are also commonly associated with a cutaneous horn. The observation of a cutaneous horn should prompt the clinician to secure a biopsy that provides adequate tissue to establish the diagnosis of the underlying skin tumor.


Mechanical gastric outlet obstruction (GOO) due to malignancy can occur with cancers in the stomach and duodenum. GOO can cause perforation of the stomach or the esophagus. We present a 65-year-old female with newly diagnosed metastatic pancreatic cancer who presented with acute onset abdominal pain. She was taken for emergent exploratory laparotomy where she was found to have gastric perforation and duodenal obstruction from an invasive large pancreatic head mass. This is a rare case report of gastric perforation due to a malignant gastric outlet obstruction secondary to invasive pancreatic cancer. Gastric outlet obstruction (GOO) is either due to a benign or malignant mechanical obstruction or to a motility disturbance that interferes with gastric emptying. Malignant GOO can occur with cancers in the pylorobulbar area, the antropyloric zone, and the descending duodenum. Distal gastric cancer is the most common cause of GOO, followed by pancreatic adenocarcinoma with duodenal or gastric extension . We presThis case was presented as a poster in the American College of Gastroenterology (ACG) Annual Meeting 2021, Las Vegas, Nevada, USA.A 65-year-old female with newly diagnosed stage IV pancreatic cancer with metastases to the liver, presented with complaints of acute onset, severe diffuse abdominal pain. She was diagnosed with metastatic pancreatic cancer three months prior to her presentation and had elected to pursue hospice. She has had chronic abdominal pain relieved by pain medications. However, on the day of her admission, she started having diffuse abdominal pain that worsened on palpation and was associated with nausea and vomiting. She was diaphoretic, tachycardic, and hypotensive in the emergency room. On physical examination, she was noted to have a distended and rigid abdomen with involuntary guarding. Laboratory studies done on admission were significant for neutrophilic leukocytosis with left shift, high anion gap metabolic acidosis, and normal liver enzymes. A chest x-ray showed free air under the right hemidiaphragm Figure . An abdoGeneral surgery was consulted. She underwent emergent exploratory laparotomy which revealed a large volume of ascites of gastric contents with necrotic debris throughout the peritoneal cavity, approximately 5 cm of perforation just anterior to the greater curvature of the stomach with necrotic edges Figure , and duoCandida tropicalis and Escherichia coli peritonitis, which were treated with the appropriate antibiotic therapy. With the surgical interventions, antimicrobial therapy, and supportive care, including fluid resuscitation, the patient’s condition improved. She was discharged on day 16 of her hospital stay.Pathology revealed foci of mucosal ischemia, ulceration, and acute inflammation with no malignancy identified. Forty-eight hours after her first surgery, she underwent a reopening of the laparotomy, abdominal washout, and Moss gastrojejunostomy tube insertion and gastrojejunostomy. Her hospital stay was complicated by Gastric outlet obstruction is a clinical syndrome resulting from mechanical obstruction that interferes with normal gastric emptying. The etiology of GOO has changed dramatically over the past few decades. Until the late 1970s, benign disease was the most common culprit of GOO, when peptic ulcer disease accounted for the largest number of cases . With thMalignant GOO can lead to perforation of the stomach or the esophagus. There have been case reports of esophageal perforation secondary to malignant GOO, and the location of all the tumors was found to be in the pre-pyloric region -10. TherGastric perforation in adults usually presents with sudden onset abdominal or chest pain, which is believed to be due to leakage of gastric acid into the abdominal cavity. Because gastric pH is low along the gastric luminal surface, sudden discharge of acid into the abdomen causes acute peritoneal irritation, inflammation, and pain. Other presenting features include abdominal mass, emesis, nausea, hematemesis, and hematochezia. The patient in our case presented with acute abdominal pain, nausea, vomiting, and chills. She was also tachycardic, diaphoretic, hypotensive and had guarding and rigidity on abdominal examination, which are commonly seen in patients with perforation.Gastric perforation may be suspected based upon history and physical examination findings, but a definite diagnosis relies upon imaging that demonstrates pneumoperitoneum or complications associated with perforation, such as an intra-abdominal or mediastinal abscess, or gastrointestinal fistula formation. An upright chest and abdomen radiograph is usually the initial imaging modality. It helps to detect free intraperitoneal air and is useful 50-70% of the time . CT scanInitial management of the patient with gastrointestinal perforation includes intravenous (IV) fluid therapy, cessation of oral intake, and broad-spectrum antibiotics. In our case, the patient was taken for an emergent exploratory laparotomy, which remains as the definitive treatment. It helps not only in treating but also in diagnosing the underlying anatomical cause of the perforation. Patients with evidence of perforation and with clinical signs of sepsis, peritonitis, bowel ischemia, or complete bowel obstruction require immediate surgery. GOO can cause perforation, so it is important to diagnose it early and treat it. There are some takeaways from our case. One is that the physicians should keep this in the differential when evaluating a patient with abdominal pain, especially in patients with a history of cancer. Another is that a careful history is important in evaluating patients with abdominal pain as it can help in diagnosing perforation early. Whenever perforation is confirmed or even strongly suspected, immediate surgical consultation is appropriate to determine if immediate surgical intervention is needed and the timing of surgery. Many patients will require urgent surgical intervention to limit ongoing abdominal contamination and manage the perforated site. It can also help in diagnosing the etiology of the perforation.Malignant GOO can lead to perforation of the stomach or the esophagus. A careful history is important in evaluating patients with abdominal pain suspected of having a gastrointestinal perforation. Patients with evidence of perforation with clinical signs of sepsis, peritonitis, bowel ischemia, or complete bowel obstruction require immediate surgery. This case highlights the importance of a thorough history in patients with abdominal pain, especially in the setting of known gastrointestinal cancer. This case shows the rare occurrence of gastric perforation from malignant GOO from invasive pancreatic carcinoma.


The main indications of the use of laparoscopic liver surgery (LLS), in the earlydays, were benign liver lesions. As LLS became more popular, indications formalignant diseases outnumbered those for benign ones. This study aims to ruleout the indications and results of LLS for the treatment of benign livertumors. Out of 445 LLS performed in a single center, 100 (22.4%) were for benigntumors. The authors discuss the indications for resection and present theirperioperative results. In total, 100 patients with benign tumors were evaluated. Specifically,these were as follows: 66 cases of hepatocellular adenomas; 14 cases ofbiliary mucinous neoplasm; 13 cases of focal nodular hyperplasia; 4 cases ofangiomyolipomas; and 3 cases of hemangiomas with a mean size of 7.6 cm(ranging from 3.1 to 19.6 cm). The total morbidity rate was 19%, with 9%classified as Clavien-Dindo grades 3 or 4. No mortality was observed. LLS for benign liver tumors is safe and presents excellent results. However,indications for resection are increasingly restricted and should not beperformed just because it is a minimally invasive procedure. In fact, in the first international consensus in Louisville(2008), more than half of all LLS performed up until that time were for benigntumors. At that time, most of the surgeries (20%) were for liver cysts (notprecisely liver resections) or for debatable indications, such as focal nodularhyperplasia (FNH) or hemangiomas (36% of the cases) This study aims to present our experience with laparoscopic resection of benign livertumors and to discuss the indications and results from an academic point of view.The authors tried to point out the current indications for resection in anevidence-based context.All LLS cases from a single referral institution were reviewed from a prospectiveinstitutional database (Redcap). Resections for benign tumors of the liver between2005 and 2021 were then reviewed. Age, sex, size of the nodules, indication forsurgical treatment, type of liver resection (minor when up to two segments wereresected), necessity of transfusion, morbidity (according to Clavien-Dindoclassification) Preoperative diagnosis was based on computed tomography (CT) scans or magneticresonance imaging (MRI), and in seven cases, a biopsy was necessary. The diagnosiswas confirmed via the histological examination of specimen.Out of 445 LLS, 100 (22.4%) were for benign tumors, 66 (66%) were for liver celladenoma (LCA), 14 (14 %) were for biliary mucinous cystic neoplasms (BMCN), 13 (13%)were for FNH, 4 (4%) were for angiomyolipoma (AML) , and 3 . The average sizes of adenomas, BMCNs, FNHs, AMLs, and hepatic hemangiomaswere 7.0, 7.8, 7.9, 5.8, and 7.6 cm, respectively. In 22.4% of cases, major HVLLLSwas performed. The estimated blood loss was 245 ml , and thetransfusion rate was 6%. The morbidity of the series was 19.3%, but only 9.1% hadcomplications and classified as Clavien-Dindo grades 3 or 4.The most common complications were pneumonia (three cases), intra-abdominal abscess(two cases), and biliary fistulas (two cases). The average length of hospital staywas 4.6 days. No mortality was observed. Preoperative diagnostic error was observedin nine cases; however, all of them were confirmed positive for FNH via histologicalexamination performed postoperatively. In these cases, the preoperative hypothesesfor resection were liver adenoma in eight cases and hepatocellular carcinoma in onecase.The improvements in diagnostic tools during the last few years led to an increase inthe detection of benign liver tumors. In addition, more accurate diagnoses becamepossible, allowing liver surgeons to understand the behavior of these benignlesions. The increase in diagnosis, associated with enthusiasm for the minimallyinvasive technique, led to an increase in indications for surgery. Toro et al. haveshown that the introduction of the laparoscopic approach resulted in an increasingrate of liver resections for benign tumors, even in those with doubtful indicationsIndications for the resection of benign liver tumors are observed as follows: (1)symptomatic diseases that impact the quality of life and/or (2) risk ofcomplications, such as malignant transformation or rupture. The most frequentindications for LLS are LCA and BMCN due to the risk of complications. Theindications for the resection of hemangiomas or FNH are anecdotal cases wheresignificant symptoms are present. In this study, we discussed each of these tumors,focusing on the clinical indications for resection.,,,,There is a consensus that the indications for the laparoscopic resection of benignliver tumors, despite the procedure being feasible and safe, should not be expandedin the face of the adoption of a lesser invasive approach In our experience with 100 laparoscopic resections for benign liver tumors, the mainindication was LCA . In the whole series, there were 22 (22%) major liverresections, and the mean size of the lesions was 7.6 cm. The estimated blood losswas 245 ml, 6.0% of the patients received a blood transfusion, and no conversions toopen surgery were necessary. Significant postoperative complications (Clavien-Dindo≥3) were observed in 9.0% of the patients, with no operative mortality. The meanlength of hospital stay was 4.6 days .Each of the indications for the resection of benign liver tumors is discussedbelow.,,The LCA is a rare benign liver tumor that affects young women of childbearingage, with an increasing incidence due to the widespread use of oralcontraceptives (OCs) Based on the genetic and phenotypic characteristics, four LCA subgroups have beenreported initially: (a) hepatocyte nuclear factor 1-alpha (HNF1α)-mutated LCA,representing 30-40% of LCA cases, is characterized by inactivating mutations inthe gene HNF1α and leads to a fatty phenotype nodule and negative liver fattyacid-binding protein expression, also known as “steatotic adenoma”; (b)inflammatory LCA (I-LCA), representing 40-50% of all adenomas, has inflammatorycharacteristics related to JAK-STAT pathway activation and is morphologicallycharacterized by telangiectasias, inflammation, ductular reaction, and stainingfor C-reactive protein; (c) β-catenin-mutated LCA (β-LCA), representing 10% ofLCAs, has variable morphologies, positive glutamine synthetase staining, andnuclear expression of β-catenin; and (d) approximately 10% of adenomas remainedunclassified, with no characteristic histological features exon7/8I-LCA and bexon3I-LCA). In this newclassification, 7% of LCAs still remain unclassified ,More recently, a new LCA molecular classification was proposed based on themolecular profile in four different pathways: activation of β-catenin,interleukin 6/JAK/STAT, the sonic hedgehog pathway, and HNF1α inactivation.Based on these molecular features, a new subtype was identified (the sonichedgehog LCA [shLCA]), and the β-LCAs were divided into two further subgroupsaccording to the presence of CTNNB1 mutations (exon 3 vs. exons 7/8). Accordingto this new classification, the presence of CTNNB1 mutations on exon 3 isassociated with a high risk of malignant transformation. In addition, the shLCAwas associated with a high risk of rupture and bleeding. Notably, some tumorspresent mixed features common to inflammatory and β-catenin-activated subtypes is well-established The changes in treatment strategy are ongoing, based on the risk of complicationsaccording to the adenoma subtypes. Until recently, in women with adenomasmeasuring 5.0 cm or more, resection was indicated due to the estimated risk of5-8% for malignant transformation or 21-29% for rupture and hemorrhage. Nault etal. have reported a large series with 411 patients, showing that symptomaticbleeding occurred in 14% of the patients and that 3% of the patients presentedmalignant degeneration from LCA to hepatocellular carcinoma ,When surgical treatment is indicated, LLS was found to provide excellent results,even when major resections were required In our experience, 66 patients with LCA underwent laparoscopic resection,including 12 (18.2%) major liver resections, with low morbidity rates (10.6%classified as Clavien-Dindo grades 3 or 4) and no mortality. The open approachwas employed for the resection of centrally located lesions or in patients withvery large tumors (>10 cm).The BMCN is a rare neoplastic cyst that was originally called biliarycystadenoma. These premalignant cystic tumors are often detected incidentally onradiological imaging for other causes BMCNs are typically detected in young women (>90%) between 30 and 50 years ofage and are rarely observed in men. BMCNs are usually large complex cysts oftenlocated in the left lobe of the liver with multiple septations, and papillaryprojections may be seen originating from the septa or the cyst wall. Thefrequency of malignant degeneration has been reported in the range between 20%and 30% of these cases In the largest series to date reporting 221 cases, the 5-year recurrence-freesurvival was 61.4%, and recurrences tended to occur locally, often caused by anincomplete initial resection The FNH) is the second most common benign liver tumor, generally diagnosedincidentally during an abdominal ultrasound. FNH usually affects women between30 and 50 years of age, and its incidence is not influenced by the use of OCs.It is characterized by the presence of a well-delineated hypervascular mass withfibrous septa and a central stellate nonenhancing scar. FNH represents ahyperplastic response to an arteriovenous malformation, being more common inyoung women, although up to 10% of cases may be in men There are rare situations where resection can be indicated, such as a largeleft-sided mass leading to symptomatic gastric compression or a rapid growthlesion.In our experience, we resected 13 FNHs, with 8 misdiagnosed as LCAs and 1 ashepatocellular carcinoma (9 misdiagnoses); one patient underwent surgery due torapid tumor growth and another three due to a large left lateral segment tumorleading to gastric compression symptoms .The LH is the most common benign liver tumor with an unknown etiology and with afemale preponderance  Most patients with LH are asymptomatic, and hemangioma is usually an incidentalfinding on nonrelated radiological evaluation. Large hemangiomas may eventuallycause abdominal pain due to intratumoral thrombosis. LH resection is rarelynecessary except in the following circumstances: symptoms with a poor responseto painkillers, an impact on the patient’s quality of life, the Kasabach-Merritsyndrome, and a large left-sided tumor with symptomatic gastric compression.Complications, including hemorrhage or rupture, are extremely rare. The rareKasabach-Merritt syndrome occurs in <3% of the patients and is caused by thetrapping of platelets within the tumor, leading to an activation of the clottingcascade, resulting in thrombocytopenia and fibrinolysis.A large series from our group retrospectively evaluated 249 patients withhemangiomas, of which 27.3% were larger than 4 cm and 6.4% were larger than 10cm. Notably, 30% of patients were symptomatic; however, only eight patients(3.2%) underwent surgical treatment In our series, a conservative nonsurgical approach was always adopted;considering that although complications might be prevalent, they are extremelyrare. Resection should be avoided even in the presence of pain because liverresection presents higher morbidity rates when compared with the natural courseof the disease. Other etiologies for pain  should be investigated, and if LH is determined to be the cause ofpain, it should be controlled with painkillers. The enucleation of thehemangioma when surgery is indicated is feasible; however, in our experience, itleads to more bleeding; thus, we preferred to cut through the normal livertissue close to the tumor to preserve the parenchyma. Special attention shouldbe given to patients who have hemangiomas larger than 10 cm; in these cases,significant pain is more prevalent (37.5%), but the size of the lesion on itsown should not be an indication for resection. In these large tumors,laparoscopic resection is quite tricky and, sometimes, impossible due to thedifficult mobilization of the liver. In our experience, the median size ofresected LHs was 7.6 cm, and the main indications were abdominal pain (one case)and large left lateral segment tumors leading to gastric compression (two cases). In thesThe AML is a rare solid mesenchymal tumor, usually affecting the kidneys, beingpart of the group of perivascular epithelioid cell tumors. Hepatic AML is rare,with approximately 600 reported cases Hepatic AML usually presents a benign course. However, an aggressive behaviorwith recurrent disease or metastasis can be observed, although there are no dataat the time of writing to predict the natural course of this tumor.Due to its difficult diagnosis and an eventual potentially aggressive behavior, abiopsy to confirm the diagnosis and evaluate cellularity might be necessaryThe criteria to evaluate ALM behavior were recently proposed Benign (no worrisome features): tumor size <5 cm, well-delineatedwith no infiltration, low nuclear grade and cellularity, mitoticactivity ≤1/50 HPF, and no vascular invasion.Uncertain malignant potential: pleomorphism/multinucleated giantcells only or size >5 cm.Aggressive behavior: two or more of the following worrisome features:size >5 cm, peripheral infiltration, high nuclear grade andcellularity, mitotic activity >1/50 HPF, and vascularinvasion.According to the World Health Organization classification of tumors, the mainrisk predictors of a more aggressive disease and metastatic behavior aresignificant nuclear atypia, diffuse pleomorphism, and mitotic activity >1mitosis per mm². Therefore, in the presence of large tumors, or when biopsydepicts pleomorphism or mitotic activity, resection is recommended.Finally, in our series, four patients with hepatic AML underwent resection. Thesecases presented tumors larger than 5 cm and underwent percutaneous biopsy toconfirm the diagnosis. These patients underwent LLS due to an uncertainmalignant potential with excellent outcomes and no recurrence.The LLS for benign liver tumors is feasible and safe, even when major resections arerequired. Moreover, less pain, a shorter recovery time, and better cosmetics are thenorms. Each benign liver tumor has a specific and restrictive indication forresection. These indications are usually due to the presence of symptoms that impactthe quality of life or the risk of complications, such as malignant degeneration orrupture and bleeding. Before considering the surgical indication, amultidisciplinary case discussion is recommended not only to confirm the diagnostichypothesis or the eventual need for a biopsy but also to establish the besttherapeutic approach.The authors reemphasized that indications for resection should be the same as thosefor open surgery and that the range of indications should not be widened justbecause it is a minimally invasive procedure. In the few cases where resection isnecessary to treat benign liver tumors, laparoscopic liver resection should be thepreferred method.


Ganglionic cysts are common swellings of the hands. Various mechanisms are thought to generate these lesions, such as cystic mucoid degeneration and inflammation. Typically, ganglionic cysts are asymptomatic but can cause pain. They usually originate from soft tissues like ligaments, joint capsules, and sheaths of tendons. We present the case of a 37-year-old man with mid-thigh swelling with intermittent mild pain. However, no systemic symptoms like fever or weight loss were present. Workup unmasked the presence of a rare intratendinous ganglionic cyst. Ultrasonography (USG) and magnetic resonance imaging (MRI) can confirm the presence of ganglionic cysts and estimate their sizes and relationships with the surrounding structures. Treatment options range from observation and conservative management to interventions like aspiration and surgical excision. Ganglionic cysts are tumor-like lesions of the soft tissues . Many pa2 in size, with no overlying skin discoloration, redness, or punctum. There were no other swellings or enlarged lymph nodes.A 37-year-old male patient presented to the outpatient clinic with swelling along the posterior-medial compartment of the right thigh for two months. He had a significant history of right foot trauma, extensor digitorum tendon rupture, and/or repair. The swelling was painless and gradually increased in size. He had no history of fever, weight loss, or anorexia. On examination, he was healthy-looking, and his vitals were within normal limits. Thigh examination revealed an oval-shaped swelling in the posterior-medial compartment of the distal thigh, almost 6 × 3 cm2 with no internal vascularity  of the right lower leg was requested for further investigation. MRI revealed a well-defined cystic lesion along the semimembranosus tendon, 5 cm from superior to inferior and 3.6 cm medial to lateral in the lower part of the semimembranosus muscle and tendon. It showed a low T1 and bright T2 signal intensity pattern with no signal drop in fat suppression sequences and there was no contrast enhancement Figures , 3A-3B.These imaging findings were suggestive of an intra-tendinous ganglionic cyst. The patient was given conservative and surgical excision treatment options, and the chances of recurrence were explained. The patient decided to continue with conservative management and was offered analgesics as needed. However, a few weeks later, he started having pain, which worsened gradually. After six months, his pain reached a point where it was intolerable. In view of his severe and progressive symptoms, the surgical excision was made and the histopathology of the excised specimen was consistent with the ganglionic cyst Figure -4B.On follow-up visits after three and six months, the patient remained asymptomatic and there is no recurrence to date.Ganglionic cysts are mucin-filled cystic growths in the soft tissues. They usually arise from tendon sheaths, muscles, joint capsules, ligaments, and menisci. The cause of ganglionic cyst formation is still debatable, and various factors are thought to play a role. Mucinous degeneration due to recurrent injury of associated soft tissue is the most widely accepted mechanism of ganglionic cyst development . CongeniThe majority of ganglionic cysts 60-70%) arise from tendon sheaths and manifest as dorsal swellings on the wrist 0-70% ari. The repRadiological modalities play a key role in diagnosing these cysts, especially when they are present in uncommon locations, as in our patient, leading to thigh muscle swelling. On ultrasonography (USG), ganglionic cysts appear as hypoechoic masses with multiple-sized lobules, septa, and acoustic enhancement . USG canMagnetic resonance imaging can be used to confirm the lesion further and view its relation to the surrounding structures. On MRI, ganglionic cysts show thin enhancement in rim form with low signal intensity on T1 images, while images in the T2 phase show high signals. These features are demonstrated in the MRI findings of our case. It is important to note that if a solid component is seen within a cyst, a contrast-enhanced MRI should exclude any neoplastic lesion of the synovium . Treatment options mainly depend on the location, size, and symptoms of the lesion. Cysts with no accompanying symptoms or cosmetic problems are generally managed conservatively with only symptomatic treatment. Initially, our patient was also treated conservatively for his mild pain; he was given an analgesic. Aspiration of fluid and surgical excision is the treatment choice for more extensive and symptomatic cysts. When our patient developed severe pain, he was managed with surgical resection. Recurrence is a significant drawback of aspiration (50%) and surgical excision (5%), and for this reason, most patients choose to follow observation and conservative management options .Intratendinous ganglionic cysts are a rare cause of soft tissue swelling. We suggest keeping this as a differential while investigating potential causes of musculoskeletal swellings. USG is an initial investigation that can confirm the presence of ganglionic cysts. MRI reveals a much more detailed image and a clearer relationship between the lesion and the surrounding structures. Both the imaging modalities hold excellent sensitivity and specificity for ganglionic cysts. Observation and conservative management are the mainstream treatment options. Patients with larger and symptomatic swellings can undergo aspiration and surgical excision of the cysts.


Pediatric malignant adrenocortical neoplasms are among the rarest tumors encountered by pediatric surgeons and oncologists. In Saudi Arabia, only case reports exist due to the rarity of the condition. In this case series, we present five cases of malignant adrenocortical neoplasm and their clinical outcomes from two tertiary centers in Riyadh, Saudi Arabia, from 2012 to 2021. Patients ranged in age from one to eight years. We report the cases of three female and two male patients. All cases presented with hormonally active tumors. In two cases where tumors were excised with negative margins, only surgery and close follow-up were performed. In three cases, neoadjuvant and/or adjuvant therapy was required. In conclusion, for malignant adrenocortical neoplasms, the timing of diagnosis played a vital role in outcomes. Best outcome can be achieved with complete surgical excision as malignant adrenocortical neoplasms show a poor response to other treatment modalities. Pediatric adrenal tumors may arise either from the cortex or medulla. Malignant adrenocortical neoplasms in pediatric patients are rare, with 0.2-0.3 cases reported per one million per year -3. FemalIn most patients, symptoms secondary to hormonal secretion from malignant adrenocortical neoplasms trigger investigation for such tumors in children . The worWe present five cases of malignant adrenocortical neoplasms from two tertiary centers in Riyadh, Saudi Arabia, from 2012 to 2021 along with their clinical behavior, management, and outcome.Case 1A one-year-old full-term child was referred to pediatric surgery for routine circumcision. The patient had an unremarkable medical history. Upon examination, an enlarged penis was noted with some pubic hair. The rest of the examination was unremarkable. The patient was admitted and worked up for suspected precocious puberty.Laboratory workup revealed normal electrolytes, normal cortisol, and adrenocorticotropic hormone (ACTH). Abnormal laboratory findings in the patient included elevated dehydroepiandrosterone sulfate (DHEAS), elevated insulin-like growth factor (IGF), low luteinizing hormone (LH), and low follicle-stimulating hormone (FSH). Radiological workup was performed, including hand-bone age X-ray and CT of the chest, abdomen, and pelvis. A hand-bone age scan revealed an image corresponding to a 30-month-old male. CT of the chest, abdomen, and pelvis revealed a left heterogeneous suprarenal mass measuring 4.1 × 4.7 × 2.5 cm without evidence of invasion or locoregional/distant metastasis  was in the 97th percentile. Upon examination, the patient had a Cushingoid face and pubic hair. The rest of the examination, including the chest and abdomen, was unremarkable, and no palpable masses were appreciated. Laboratory workup showed low DHEAS and high cortisol levels. Other labs, including ACTH, aldosterone, and electrolytes, were within the normal range. Further investigation through CT scan of the abdomen, pelvis, and chest detected a 5.5 × 6.4 × 5.3 cm left adrenal mass Figure .P53. The patient is asymptomatic two years postexcision and shows no signs of recurrence. However, she had persistent contralateral adrenal suppression requiring steroid therapy.The patient was admitted for left subcostal incision with complete gross excision of the left adrenal mass. Pathology tissue reports showed malignant adrenocortical neoplasm that was negative for Case 3A one-and-a-half-year-old female presented with a three-month history of facial acne and pubic hair. The patient had a positive family history of leukemia and ovarian tumor. Her vital signs showed normal blood pressure. Physical examination revealed a Cushingoid face and pubic hair. No palpable masses or other signs of hyperandrogenism were appreciated. Labs revealed high levels of testosterone and cortisol. Other labs, including DHEAS and electrolytes, were within the normal range. Radiological workup through CT scan of the abdomen, pelvis, and chest detected a left suprarenal oval-shaped mass measuring 3.6 × 3.3 × 2.3 cm .After receiving four cycles of chemotherapy and mitotane, the patient could not tolerate continued chemotherapy due to renal toxicity. Reassessment with CT of the chest, abdomen, and pelvis was performed three months postoperatively and chemotherapy and showed a 3.9 × 3 × 2 cm nodule in the left suprarenal space representing relapse. The patient underwent a second-look surgery through the same previous incision for resection of the relapsed mass, which was also achieved with sampling of the regional lymph nodes. Pathological examination showed viable adrenocortical adenocarcinoma with no chemotherapy changes and a positive regional lymph node. Postoperatively, oral mitotane was continued, and chemotherapy was stopped due to patient intolerance. Reassessment with CT of the chest, abdomen, and pelvis was performed one month postoperatively and showed a relapsing tumor that was nonresectable due to involvement of splenic vessels. An attempt to locally control the tumor with local radiotherapy was made, and oral mitotane systemic therapy showed a minimal response. Three months later, reassessment with CT of the chest, abdomen, and pelvis was performed, which showed two new nodules in the right 11th rib along with the tumor in the left suprarenal space with some treatment response and a decrease in size. Resection of the two nodules in the 11th rib was performed, along with continuation of local radiotherapy in the primary tumor bed, and oral mitotane was given.Despite multimodal therapy, the disease continued to progress. CT of the chest, abdomen, and pelvis showed progressing bilateral retroperitoneal heterogeneous lesions, pelvic lesions, multiple peritoneal lesions, and sub-centimetric sub-pleural nodules on the left hemithorax. Due to poor response to the multimodal therapy approach, the patient was elected for palliative care to allow a natural death.Case 5An eight-year-old female presented to the emergency department with seizures and elevated blood pressure. After controlling the seizures and blood pressure, the patient reported a history of changes in voice and pubic hair. Physical examination showed elevated blood pressure, facial acne, hirsutism, and clitoromegaly with a left upper quadrant palpable abdominal mass. Laboratory findings showed elevated cortisol, elevated ACTH, elevated DHEAS, and elevated testosterone. The rest of labs was unremarkable. Brain MRI and CT of the chest, abdomen, and pelvis were performed. Abnormal imaging findings included a large left heterogeneous suprarenal mass crossing the midline and measuring 20 × 16 × 14 cm with inferior vena cava thrombus along with at least 40 lung nodules bilaterally representing metastasis Figure .The patient underwent ultrasound-guided biopsy using coaxial core biopsy needles of the suprarenal mass. The pathological diagnosis was malignant adrenocortical neoplasm. The management plan was to proceed for two cycles of chemotherapy and oral mitotane and to reassess later for resectability of the primary mass. Reassessment with CT of the chest, abdomen, and pelvis showed a minimal decrease in the primary suprarenal mass with progression of metastatic nodules. Due to the progression of multiple metastatic nodules and an unresectable tumor, the patient decided to undergo palliative treatment.TP53 tumor suppressor gene and insulin-like growth factor 2 (IGF2) overexpression secondary to 11p15 chromosomal locus mutation [P53 gene and one was negative. In three cases, testing for the P53 gene was not performed; however, family history was negative for malignancies (Table Malignant adrenocortical neoplasms are extremely rare in children ,3. In admutation ,8. In ouMalignant adrenocortical neoplasms may be functional or nonfunctional ,5. UnlikIn malignant adrenocortical neoplasms, treatment options include surgery, mitotane, chemotherapy, and radiotherapy ,9. ComplThe overall two-year and five-year survival rate in pediatric malignant adrenocortical neoplasms is 61% and 46%, respectively ,14. AddiMalignant adrenocortical neoplasms are rare in children, and our review is the largest known series reported from Saudi Arabia. Based on the cases we reviewed, the timing of diagnosis plays a vital role in prognosis as complete surgical excision provides the best outcome for adrenocortical tumors. Late diagnosis with metastatic lesions predicts an unfavorable outcome as adrenocortical tumors show a poor response to both chemotherapy and radiotherapy. Further studies are needed in our region with a larger patient population to identify predictors of outcome in our region.


Chondroblastomas, which account for approximately 1% of all bone tumors, typically occur in long bones, such as the femur, humerus, and tibia. However, in extremely rare cases, they may also occur in the craniofacial region where the tumor is often found in the squamous portion of the temporomandibular joint (TMJ) and in the temporal bone.This case report describes a large chondroblastoma  that occurred in the TMJ. The tumor was sufficiently aggressive to destroy the TMJ, mandibular condyle neck, external auditory canal (EAC), mandibular fossa of the temporal bone, and facial nerve. The tumor was completely excised using a pre-auricular approach. The EAC and surgical defect were successfully reconstructed using a temporoparietal fascia flap (TPFF) and an inguinal free fat graft. There was no local tumor recurrence at the 18-month follow-up visits. However, the patient developed sensory neural hearing loss, and his eyebrow paralysis worsened, eventually requiring plastic surgery.Large, invasive chondroblastomas of the TMJ can be completely removed through a pre-auricular approach, and the resulting surgical defect can be reconstructed using TPFF and free fat grafts. However, preoperative evaluation of the facial nerve and auditory function is necessary. Therefore, a multidisciplinary approach is essential. Chondroblastomas are cartilaginous neoplasms that account for approximately 5% of all benign tumors  and apprThe chondroblastoma reported in this paper was uncommonly large , occurred in the craniofacial region, and involved the TMJ, temporal bone, and neck of the mandibular condyle. Although it was a benign tumor, it was aggressive and destroyed adjacent anatomical structures. We report this case because it illustrates a method for the successful excision of this type of tumor, and the successful reconstruction of the resulting large defect.A 52-year-old man was referred to our department by an otolaryngologist for an evaluation of a mass that was detected on his TMJ, using computed tomography (CT) and magnetic resonance imaging (MRI). The patient had an operative history that included the repair of a hernia and a ruptured cruciate ligament, but with no other specific medical history. The patient’s chief complaints were swelling and asymmetry of his right TMJ area, which occurred approximately 2 weeks before the first visit. He also experienced tenderness in the TMJ area upon palpation, but without spontaneous pain. In addition, paralysis of the right eyebrow was observed, suggesting that the mass had damaged the temporal branch of the facial nerve. The detected mass was then fixed and confirmed. The EAC swelling was confirmed by the otolaryngologist. The mandible deviated to the right at the maximum intercuspal position. The maximum mouth opening was limited to 30 mm. The patient had a history of TMJ dislocation approximately 25 years earlier.CT clearly showed a mass of eccentric soft tissue (approximately 37 × 28 × 28 mm) surrounding the right TMJ and extending into the right pterygoid space; the tissue had also eroded the temporal bone of the skull base. In addition, bone destruction (having the appearance of being moth eaten) was observed in the right mandibular condyle neck Fig. A. The CTUnder general anesthesia, complete surgical excision was performed using a pre-auricular approach. Local anesthesia  was injected into the temporal and pre-auricular skin regions to reduce intraoperative bleeding and postoperative pain. Access was obtained via an extended pre-auricular (hockey-stick) incision, with an oblique anterosuperior extension into the hair-covered temporal region  chondroblastoma that was affecting the TMJ was successfully removed. The main tumor had aggressive characteristics and had destroyed the mandibular fossa of the temporal bone, but it was delicately removed, avoiding perforation of the dura mater. Additionally, half of the lateral condyle neck was damaged by the tumor, but the condyle head was preserved to the extent possible to preserve the vertical height of the mandibular ramus. Therefore, the patient did not complain of facial asymmetry, trismus, or deviations when opening his mouth. The anterior part of the articular disc was invaded by the main tumor and resected, and an inguinal free fat graft was connected to the remaining posterior part of the articular disc. Although the patient did not experience abnormal occlusion or a masticatory disorder, it was unreasonable to expect significant improvement in mouth opening due to the loss of half of the articular disc.The main deficiency associated with the diagnosis of this patient was that the region of the EAC that had been invaded by the tumor was incorrectly diagnosed, based on the preoperative CT, as fluid collection due to external otitis. Hence, the destruction of the EAC was not predicted. Due to this tentative diagnosis, a preoperative puretone audiometry (PTA) examination was not performed. Sensorineural hearing loss (SNHL), at 2 kHz, was detected during postoperative PTA, which may have caused the postoperative tinnitus. We could not confirm whether SNHL existed prior to the operation. If we had preoperatively confirmed SNHL, we could have used minimally invasive surgery to avoid worsening the SNHL. Preoperatively, the patient complained of eyebrow muscle paralysis, which might have been expected due to tumors affecting the temporal branch of the facial nerve. Paralysis of the right eyebrow and ptosis of the right eyelid worsened after the operation. This observation suggests that additional facial nerve damage was caused intraoperatively due to electric cauterization or overly aggressive traction.Complete surgical excision is the most effective treatment for a chondroblastoma. When en bloc excision is not possible, curettage may be considered as a treatment option. The recurrence rate following complete surgical excision is 20%; however, when treated with curettage, there is a 50% probability of recurrence . In our The reconstruction of damaged craniofacial areas, especially at the cranial base, is a very delicate operation. The TPFF receives its blood supply from the superficial temporal artery and has a high survival rate, even after radiation therapy. In addition, deep and superficial temporal fascia layers have the advantage of being thin, flexible, and adjustable in length; therefore, they are useful for reconstructing skull base defects. The TPFF is used to reconstruct lateral skull base defects and prevent CSF leakage; they are also used to rebuild defects in the ventral skull base by passing the TPFF through the infratemporal fossa. The modified TPFF can be used to reconstruct anterior skull base defects via the supraorbital epidural corridor . The useAlthough most authors insist that the surgical excision of chondroblastomas is the most effective treatment, there is an argument that suggests that invasive methods should be avoided. Among the recently published papers, several cases involving the use of a microscope and an endoscope have been reported. The microsurgical instruments were used to access the main mass by drilling through the tympanic region and the mandibular condyle. Although a safety margin could not be obtained, there was the advantage of preserving the functioning of the cochlea, facial nerve, jugular vein, and TMJ. Recurrence was observed in some of the cases treated in this manner; however, they were well managed using radiotherapy .There is a debate about the role of radiation therapy in chondroblastoma treatment. In one report, radiation therapy helped prevent recurrence after complete resection of the chondroblastoma . Thus, rA large, aggressive chondroblastoma affecting the TMJ was successfully removed using a pre-auricular approach. The EAC and resulting surgical defect were reconstructed using TPFF and inguinal fat grafts. Postoperative complications may occur, depending on the degree of tumor invasion into the surrounding anatomical structures, and a close multidisciplinary approach was necessary.


Chondroid tenosynovial giant cell tumour (TGCT) is an extremely rare disease affecting the temporomandibular joint (TMJ). This report details the peri-operative findings and treatment with custom TMJ replacement of an initially misdiagnosed chondroid TGCT involving the TMJ. Tenosynovial giant cell tumour (TGCT) is a remarkably rare benign proliferative disorder of the synovium and can be categorized into localized-TGCT and diffuse-TGCT (D-TGCT) types . The occA 33-year-old woman complained of a 3-month history of left-sided TMJ morning stiffness. She had never been treated nor undergone any previous TMJ procedures and reported an unremarkable medical history. Examination findings showed a small left-sided preauricular swelling with tenderness worse at the joint level. Mouth opening restricted by pain was 35 mm. Normal excursive movements and no malocclusion or lateral deviation was observed. Computed tomography (CT) and magnetic resonance imaging (MRI) of the TMJs showed: superior joint space effusion, multiple small low-signal intensity foci within the fluid and extensive erosions within the glenoid fossa, articular eminence and root of the zygoma  and 2. TArthroplasty (capsulectomy and discectomy) of the left TMJ with abdominal fat graft was performed. Capsule and soft tissue lesions extending into the bone were curetted and sent for histopathological analysis, which showed multinucleated giant cells and nodular immature chondroid metaplasia deemed to be a form of synovial chondromatosis.The patient was regularly reviewed reporting no improvement to stiffness on mouth opening. At her 3-month post-operative review, she complained of worsening stiffness to mouth opening. A follow-up CT of the TMJs portrayed extensive progressive bony erosion to the mandibular condylar head. This provoked a discussion with the pathologist to reconsider the diagnosis of the previously sent specimen. A histopathological revision reported a chondroid fibrohistioctyic lesion with overall features more in keeping with PVNS with chondroid metaplasia .The patient was subsequently planned for a second operation for resection of the affected tissue. To achieve clear surgical margins, this included the total resection of the left TMJ and the entire root of the zygoma along with the glenoid fossa. The TMJ was planned to be reconstructed with a custom TMJ prosthesis. Consequently, a three-component custom TMJ prosthesis (Zimmer Biomet) was fabricated. This included: (i) a titanium zygomatic root component to be fixated to the zygomatic arch and temporal bone, (ii) an ultra-high molecular weight polyethylene (UHMWPE) fossa component to be fixated into the zygomatic root component and (iii) a titanium (Ti-6Al-4V) alloy with titanium alloy coating mandibular component to replace the articular surface of the mandibular condyle . OrderinD-TGCT is an articular pathology originating from a tendon sheath, joint capsule or bursae. The aetiology of this locally aggressive and proliferative tumour involves both inflammatory and neoplastic processes. This rare disease has an annual incidence of 1.8:1000 000 and predominantly affects the knees and hips of patients in their second to fourth decade of life with female predominance . D-TGCT Chondroid TGCT can mimic other cartilage-forming pathologies such as chondrosarcoma and synovial chondromatosis rendering its diagnostic challenge even greater , 6. BetwNevertheless, chondroid TGCT is a rare disease of the TMJ, which poses diagnostic delays and uncertainty. Our case demonstrated a definitive diagnosis and treatment were reached 8 and 18 months, respectively, following the patient’s initial presentation, in keeping with the delays described in the literature. The authors believe it is advisable to consider D-TGCT of the TMJ on the differential list of preauricular swellings, and treatment with complete resection, and close follow-up is paramount. The authors have demonstrated a custom TMJ prosthesis extending to local extra-articular surfaces is a viable solution for TMJ reconstruction in instances with extra-articular disease spread.


Peritoneal and retroperitoneal hematoma are usually secondary to trauma, an obstetrical pathology, an aneurysmal pathology or a tumorous pathology. A spontaneous idiopathic form remains rare, especially when it occurs to a pregnant woman, which makes the clinical and etiological diagnosis difficult, as well as the therapeutic management both the mother and the fetus.We report the case of a spontaneous idiopathic hemoperitoneum and hemoretroperitoneum of a 26-year-old woman, pregnant (30th week of amenorrhea), presenting a hemodynamic instability and a clinical acute surgical abdomen. No secondary cause was identified during exploratory laparotomy, neither through imaging. The therapeutic management relied on hemodynamic stabilization after exploratory laparotomy.Idiopathic spontaneous peritoneal and retroperitoneal hematoma -in the presence of several differential diagnoses-remain an extremely rare entity to evoke in front of an acute surgical abdomen in a pregnant woman. •Idiopathic spontaneous hemoperitoneum and hemoretroperitoneum is a rare condition, with only few cases reported in literature.•The occurrence of an idiopathic spontaneous hemoperitoneum and hemoretroperitoneum in pregnant women is a serious condition engaging both the patient's and the fetus's prognosis.•Management consist of a thorough investigation in search of an etiological process before retaining the diagnosis, as well as a hemostatic procedure. She did not report any notion of trauma, vasculitis, or coagulopathy. Clinically, the patient was shocked with a low blood pressure (83/51 mmHg), tachycardia (121 bpm), oliguria, generalized pallor, and confusion  without externalized bleeding . Clinical examination revealed a diffused abdominal guarding with right iliac fossa and hypogastric sensitivity with negative fetal heart sounds.Initial management consisted of stabilizing the patient by perfusing 500 ml of Hydroxyethylamidon followed by transfusing 6 units of packed red blood cells, 6 units of fresh frozen plasma, infusing 3g of fibrinogen, administration of 1g of tranexamic acid, 4g of calcium and 5 mg of norepinephrine with invasive monitoring of blood pressure.3, a prothrombin at 68%, and fibrinogen at 2.1 g/L. liver and kidney function tests were strictly normal. An abdominopelvic ultrasound showed a very considerable hemoperitoneum and hemoretroperitoneum.Blood work revealed a hemoglobinemia at 8.5g/dl, a platelet count at 252000/mmThe patient was sent to the operating room urgently. The exploration revealed a huge expansive retroperitoneal hematoma , Fig. 2 The gesture involved a fetal extraction, with a triple ligature and B-LYNCH of the uterus because it was atonic . Then, sAfter surgery, an injected abdominopelvic CT showed a regression of the retroperitoneal hematoma with no signs of recurrence, and persisting peritoneal hematoma .Fig. 6Ax3Hemoperitoneum and hemoretroperitoneum during pregnancy are often fatal for the fetus and remain a rare entity shadowed by many differential diagnoses. Among others, retroplacental hematoma, uterine rupture, rupture of a splenic artery aneurysm, placenta percreta, spontaneous rupture of hepatic hemangioma, rupture of utero-ovarian veins, or hemorrhagic cysts with a pre-existing coagulopathy.According to a literature review, other cases of idiopathic spontaneous retroperitoneal hematoma have been reported . It is aTherapeutic management usually starts with hemodynamic stabilization by infusion of fluids, transfusion of blood derivatives, administration of vasoactive drugs and correction of coagulopathy. After that, hemostasis should be maintained. Indeed, endovascular treatment has an important role, but should be recommended only for stable patients. On the other hand, laparotomy should be reserved in case of failure or non-availability of endovascular treatment and for hemodynamically unstable patients, as is the case with this patient. However, the best approach can be difficult to assess .In obstetric care, it would depend on gestational age. Indeed, when the age of the pregnancy is less than six months, a therapeutic abstention is essential with strict supervision of the mother and the fetus. In case of fetus death, therapeutic management will proceed to evacuation. But if the pregnancy continues, a caesarean section is recommended at term . If the 4Idiopathic spontaneous peritoneal and retroperitoneal hematoma, in the presence of several differential diagnoses, remain an extremely rare entity to consider in front of an acute surgical abdomen presented by a pregnant woman. The diagnosis is difficult, affecting the therapeutic management; which should be rapid and codified to ensure maternal and fetal rescue.This paper has been reported in line with the SCARE 2020 criteria .Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer reviewed.This is a care report; therefore ethical approval isn't needed.Our case report did not receive any funding.SAFAA KACHMAR: participation in the management of the patient, redaction of the article, bibliographic research, submission in your journal. YOUNES OUJIDI: participation in the management of the patient, bibliographic research. ZAKARIA BOUAYED: contributor, submission to the journal. HOUSSAM BKIYAR: correction of the article before submission, orientation of the article's redaction and bibliographic research. BRAHIM HOUSNI: correction of the article before submission, orientation of the article's redaction and bibliographic research.Name of the registry:Unique Identifying number or registration ID:Hyperlink to your specific registration (must be publicly accessible and will be checked):Dr. SAFAA KACHMAR.There are no conflicts of interest.


Background: Both primary pancreatic lymphoma (PPL) and primary splenic lymphoma (PSL) represent rare entities. PPL typically arises in the head of the pancreas but may arise in other locations also. PSL usually presents with nonspecific symptoms, including left upper quadrant pain, weight loss, and fever. This report describes a patient with a large left upper quadrant mass, which initially was believed to be a primary pancreatic mass, but which on final pathology appeared to be consistent with a PSL.Presentation: The patient is a 64-year-old woman who initially presented with symptoms of left upper quadrant abdominal pain and distension; she subsequently was found to have an 18 cm heterogeneous mass arising from the pancreatic tail. She underwent a distal pancreatectomy with splenectomy. Final pathology confirmed a diffuse large B cell lymphoma arising from the splenic parenchyma.Conclusions: Both PPL and PSL are rare causes of left upper quadrant masses. In this case, we describe a large lymphoma that appeared to arise from the tail of the pancreas, but on final pathology was found to be splenic in origin. Differentiating these two clinical entities is important for prognostication and treatment. A multimodal approach with surgical resection followed by chemotherapy is preferred. BCL2 expression. The tumor did not express c-MYC. Fluorescence in situ hybridization (FISH) showed BCL6/IGH translocation, multiple copies of BCL2, and no copies of c-MYC.The patient is a 64-year-old female who presented with left upper quadrant pain and abdominal distension. Computed tomography imaging  demonstrPostoperative lactate dehydrogenase (LDH) was elevated at 443 U/L. R-CHOP  therapy was initiated 2 months after surgery. Four months postresection, the patient had completed four of six chemotherapy cycles with good response.1–3 and not commonly diagnosed in the tail of the pancreas.4 It is important to differentiate PPL from pancreatic adenocarcinoma because the treatment and prognosis vary significantly between these two entities.We describe in this study the case of a patient with a lymphoma arising from the area around the pancreatic tail and spleen. Preoperative imaging and intraoperative findings suggested a primary pancreatic mass, but final pathological analysis demonstrated splenic lymphoma. Tissue biopsy was not pursued in this case but could be considered. It is important to note that fine-needle aspiration does not provide tissue architecture information and lacks diagnostic accuracy in the setting of lymphoma. Primary pancreatic lymphoma (PPL) is often, therefore, only diagnosed postoperatively5 Treatment for PPL includes chemotherapy and surgical debulking, with better survival outcomes being associated with a combination of the two.5 Similar to PPL, primary splenic lymphoma (PSL) often presents with symptoms of mass effect rather. Similarly, it is often treated initially with surgery because the diagnosis is not clear preoperatively. In contrast to PPL, for which some authors advocate neoadjuvant chemotherapy and radiation, splenectomy is the first-line treatment for PSL, often with adjuvant chemotherapy and radiation.6As in this case, PPL usually presents with symptoms resulting from the mass effect of the tumor. Behrns et al. have proposed criteria for PPL, for example: (1) tumor predominantly located in the pancreas, (2) only peripancreatic lymph nodes involvement, (3) no hepatic/splenic involvement, and (4) normal white blood cell count.We present in this study a case of a large left upper quadrant mass, which preoperatively was concerning for PPL but was ultimately found to be consistent with PSL. The mass reported in this study is among the largest of those previously reported in the literature. Although diffuse large B cell lymphoma is curable, CD5 positivity is associated with more aggressive disease and a higher rate of recurrence with central nervous system relapse. Understanding the clinical and pathophysiological differences between these two manifestations of gastrointestinal lymphoma allows for more accurate diagnosis and treatment of these two rare entities.


Lipomas are benign tumors that originate from mesenchymal tissue, such as subcutaneous tissue. Intrathoracic lipomas are rare, and they can occur in the chest wall, mediastinum and bronchi. In the present case, the patient had an intrathoracic lipoma that was located in the horizontal fissure of the right lung. Retrospective review of chest radiographs taken at a previous health checkup confirmed that the tumor was growing. The patient had no symptoms, and computed tomography and magnetic resonance imaging suggested that the tumor was a hamartoma. The tumor was resected by video-assisted thoracic surgery, and was diagnosed by pathological analysis as an intrathoracic lipoma consisting of no atypical fats. Lipomas are benign tumors comprised of fat tissue. They usually develop subcutaneously, and intrathoracic lipomas are rare . Large iThe patient was a 48-year-old man, in whom a round mass lesion was detected in the hilum of the right lung by chest radiography performed at an annual health checkup . The imaThe growing tumor was resected by VATS under general anesthesia with differential pulmonary ventilation. The tumor was located under the visceral pleura on the horizontal fissure of the right lung . The sizLipomas, which originate from adipocytes, are common benign tumors. These tumors are usually located in mesenchymal tissue, such as subcutaneous tissue, and are easily removed for treatment and diagnosis. It is rare for lipomas to grow in the thoracic cavity, and in such cases, diagnosis requires surgical resection of the tumor under general anesthesia. In a previous report, the locations of intrathoracic lipomas were found to be the chest wall, mediastinum and bronchi . In prevChest radiography performed at an annual health checkup was useful for the detection of a benign growing tumor, which was an intrathoracic lipoma in a rare location.


Idiopathic hemoperitoneum in the newborn is an entity very rarely encountered in clinical practice.A case of scrotal hemorrhage (SH) associated with intrabdominal hemorrhaging and acute anemia is presented. Indications for early surgery included a massive scrotal hematoma, rapid onset of severe anemia, and unknown etiology.Clinical and diagnostic approaches in a case of neonatal scrotal hematoma should be given careful consideration as abdominal in origin, and a pre-operative computed tomography (CT) scan or magnetic resonance image (MRI) in addition to an abdominal/scrotal ultrasound should be added as part of the diagnostic work-up. Idiopathic hemoperitoneum (IH) is a rare condition in newborns that is generally due to rupture of the spleen , 2. AlsoA baby boy with vertex presentation was born with vaginal delivery associated to the Kristeller maneuver at 39 weeks of gestation. Obstetric history was significant for maternal trauma due to an accidental fall down the stairs at 37 weeks of gestation. An accurate prenatal ultrasound did not show trauma-related lesions or abnormalities.Newborn birth weight was 3470 g. Apgar score was 8/9 and 9/9 at 1 and 5 min, respectively. At birth, the newborn presented an initial right hydrocele. Right scrotal swelling with bluish discoloration Fig.  that conSeven hours after birth, the general condition of the child suddenly worsened with the onset of paleness, blood pressure decrease, and development of tachycardia. For these reasons, he was admitted to the neonatal intensive care unit (NICU).3, and platelet count of 282,000/mm3.Physical examination revealed poor general appearance, hypoactive pupils, icteric sclera, a globular and not very treatable abdomen, and bluish discoloration of the right hemi scrotum. Vital signs indicate a pulse of 155/min, respiration 38/min, body temperature 36.7 °C, and blood pressure 60/40 mmHg. The X-ray was performed during orthostasis before the child underwent surgery and showed moderate abdominal distension without clear hydro-air levels and the absence of a subdiaphragmatic sickle and non-empty rectal ampulla. Laboratory tests showed pH 7.1, hemoglobin 8.2 g/dL, hematocrit 25.4%, white blood cell count of 28,280/mmTotal and direct bilirubin levels were 10.71 and 0.43 mg/dL, respectively. Other signs were normal. Prothrombin time and activated partial thromboplastin time were normal. A blood transfusion of 50 mL of concentrated red blood cells was sufficient to stabilize the patient. Although the neonate was stabilized and diagnostic workup completed, the cause of bleeding was still unknown; a scrotal origin was suspected, indicating the need for surgical exploration. The laparoscopic approach in neonates is routinely used at our institution but not for scrotal disease . A written consent for surgery was obtained from parents. Under general anesthesia, an inguinal incision was made to explore spermatic vessels and testis. We found severe adhesion between spermatic and surrounding tissues; however, this adhesion could not be explained by the recent bleeding episode. Also, the peritoneal vaginal duct was filed with red clotted blood while the testis appeared structure and perfused normally. After the cause of scrotal bleeding could not be found, we decided to extend the inguinal incision and reached the right iliac fossa through a subcutaneous dissection. At this point, the fascia was opened, and an hemoperitoneum was drained. At the same time, all intestinal segments, epigastric vessels, liver margins, and surrounding structures were explored; however, no cause of bleeding could be found. After drainage, the bleeding appeared completely stopped, and it was then decided not to proceed with a xifo-pubic laparotomy to further investigate the origin of bleeding. In fact, the modern approach to abdominal blunt trauma recommends not proceeding with the extended laparotomy if bleeding has stopped and hemodynamic parameters are stable.The following day, in consideration of the unknown origin of bleeding and lack of useful information offered by abdominal ultrasound (clearly operator-dependent), we performed an abdominal computed tomography (CT) scan with contrast that showed some bloody collection in the subphrenic space and between splenic and renal vein Fig. . An abdoThe newborn was evaluated 2 months after discharge at which time the abdominal and testicular ultrasounds were normal with no sign of residual liquid. Growth parameters of the baby were normal.Intra-abdominal bleeding in the newborn is uncommon , 2. AlsoIn addition, a differential diagnosis, including hemorrhagic disease of the newborn, sepsis with disseminated intravascular coagulation, and a solid organ injury  was performed. However, we still were unable to make a pre-operative diagnosis. This finding confirmed that SH may prove to be a very difficult diagnostic challenge. Also, the post-operative CT scan did not clearly define the cause of the SH.Adrenal hemorrhage in the newborn is one of the most frequent causes of intraperitoneal hemorrhaging and although it is an uncommon entity, SH is an extremely rare manifestation of NAH , 10. AdrIn our case, the accidental trauma during the last 2 weeks before delivery most likely provoked a partial vascular lesion of unknown origin. This partial injury was made worse by the vaginal dystocia delivery that caused bleeding into the abdominal cavity and scrotum. Several papers have shown an increase in the incidence of birth injury with the use of forceps or vacuum assistance during delivery . PignottAcute SH in the neonatal period is a rare condition that requires prompt diagnosis and possible urgent intervention with a more limited surgical approach. Clinical and diagnostic approaches toward a neonatal scrotal hematoma should receive careful consideration as abdominal in origin and pre-operative CT scan or MRI in addition to abdominal/scrotal ultrasound should be added as part of the diagnostic work-up.SH most commonly occur because of testicular torsion, adrenal hemorrhage, birth trauma, and/or thrombocytopenia. However, if an SH occurs in the first few hours after delivery, a high suspicion of trauma-related delivery should be considered.SH could underlie a more severe condition, such as hemoperitoneum with life threatening events, which requires immediate surgical intervention. A self-limiting hemoperitoneum should be managed conservatively.Careful evaluation of any reported trauma during pregnancy could prevent acute condition, such as an intrabdominal hemorrhage leading to SH associated with severe anemia.


Mature cystic teratoma (MCT) is a common benign ovarian germ cell tumor. It is more predominantly seen in premenopausal women and contains at least two or more well-differentiated germ cell layers. It is termed a dermoid cyst if the ectodermal tissue is the predominant component. The complications of a dermoid cyst include torsion, malignant degeneration, rupture, and infection. The incidence of a ruptured dermoid cyst is around 1%-2% resulting in chemical aseptic peritonitis from spillage of the cyst contents. Usual clinical presentation is with diffuse abdominal or pelvic pain and abdominal distension. Around 93-96% of dermoid cysts demonstrate fat in the cyst cavity however, minimal or no fat poses diagnostic challenges. In this case, we discuss a rare case of spontaneously ruptured lipid-poor and thyroid tissue-rich left ovarian dermoid presenting with chemical peritonitis. Special magnetic resonance (MR) Imaging sequences such as fat saturation imaging, chemical shift imaging, and gradient-echo imaging assist in detecting scant amounts of fat in the cyst cavity or cyst wall. Teratomas are the most common ovarian germ cell tumors which arise from primitive germ cells . ConstitA 33-year-old nulligravida presented to the emergency department with acute onset of non-radiating left lower quadrant abdominal pain. The patient reported worsening pain with movement, which gets relieved by lying still. She also reported a progressive increase in abdominal girth over the past several weeks. Denied new vaginal bleeding, discharge, or usage of contraception. Diagnostic imaging with ultrasonography (US), computerized tomography (CT), and magnetic resonance imaging (MRI) were performed in the emergency room and are described in Figures Discovering findings of a ruptured adnexal mass on imaging, the patient underwent exploratory laparotomy with left salpingo-oophorectomy. Intraoperative findings revealed a ruptured left ovarian cyst on the inferior aspect emanating serous fluid into the peritoneal cavity. The tumor was identified as mature lipid-poor cystic teratoma on the frozen section. The postoperative recovery was uneventful. The histopathology of the resected specimen is shown in Figures Ovarian germ cell tumors (OGCTs) are a group of tumors that include benign (mature cystic teratoma [MCT]) or malignant  neoplasms . TeratomUltrasonography (US) is the first line of imaging used in the evaluation of adnexal masses . DiffereIn combination with findings from US, the CT assists in additional fat detection with a sensitivity of 93%-98% . The HouT1-weighted and T2-weighted MRI in MCTs will show a hyper-intense signal representing sebaceous fluid. It can be differentiated from hemorrhagic cyst by fat suppression, chemical shift artifact, or gradient-echo imaging. The fat becomes hypointense on fat-saturated MR Figure , 6, wherThis case study emphasizes the importance of a multimodality approach to complex pelvic masses that present with pelvic pain. Advancement imaging modalities like Pelvic MRI can detect acute complications from these masses like torsion or rupture. Hence, aiding in more accurate diagnosis and pre-operative planning. Surgery is performed for definitive diagnosis and treatment. In the current case of the ruptured teratoma leading to peritonitis, the patient underwent exploratory laparotomy and salpingo-oophorectomy with peritoneal lavage. The ascitic fluid was serous without significant fat content. Histologically, the tissue demonstrated abundant colloidal material and minimal fat consistent with Struma ovarii. The tumor is termed struma ovarii when the thyroid tissue is predominant and comprises >50% of the tumor .In the emergency room setting initial work up for pelvic pain in female patients starts with a good quality ultrasound examination. Upon discovery of a complex mass further evaluation should be done with a pelvic MRI with IV contrast. Pelvic MRI can help identify immediate complications and determine the correct surgical approach. Identifying components of MCTs across multiple imaging modalities assist in differentiating adnexal masses. The wide range of presence of fat in the dermoid cyst makes it easily detectable on CT and MR imaging. Although some cases demonstrate low fat, using special techniques such as fat suppression MRI plays a vital role in early detection and emergency management. Once rupture and peritonitis are suspected, patients should be managed by emergent laparotomy (lower spillage rate than laparoscopy) followed by cystectomy.


Cystic lesions of the spleen are rare lesions and can be parasitic or nonparasitic. Nonparasitic cysts are of two types: primary cysts and secondary pseudocysts. Primary cysts of the spleen are very rare and are also called true, congenital, epidermoid, or epithelial cysts. Splenic cysts are usually asymptomatic and often found incidentally during imaging studies. We are presenting a case of a 19-year-old female with a large splenic cyst which was surgically treated by open splenectomy. Echinococcus granulosus infestation [Cystic lesions of the spleen are infrequently seen in routine surgical practice and have been classified according to the pathogenesis of the cyst . Nonparaestation . Nonparaestation . True spestation . We presA 19-year-old female immigrant worker presented to the surgical outpatient department with complaints of dull upper abdominal pain of several days duration. There was a history of an increase in pain after food intake, not relieved on medications like antacids and pain killers. There was no complaint of diarrhoea or constipation or fever. She had no other traumatic event in the abdomen. Her medical history was notable only for appendectomy performed several years ago. On physical examination, vital signs were stable and all laboratory findings were within the normal range. Abdominal examination revealed a soft, smooth non-tender mass palpable in the left-upper quadrant. Ultrasonography abdomen showed a large cystic mass of the spleen with a query of splenic abscess. On X-ray chest, the left dome of the diaphragm was seen raised  of the abdomen was conducted after administering oral and intravenous contrast. Axial sections showed a huge cystic lesion of the spleen filled with fluid, compressing the stomach and displacing the left lobe of the liver and left diaphragm upwards, which measured 15 x 12 x 10 cm in size (Figure Total splenectomy was planned, intraoperatively the huge splenic cyst was found occupying more than the upper two-thirds of the spleen involving the hilum Figures , 4. The About 1300 ml of straw colored cystic fluid was carefully aspirated to avoid rupture into the operation field, followed by the total splenectomy. A drain was left near the splenectomy site. The cystic fluid cytology showed foamy macrophages only and histopathology revealed epithelial splenic cyst Figure .The patient was vaccinated postoperatively and was discharged on the seventh postoperative day without complications.Splenic cysts are categorized based on the presence or absence of an epithelial lining, etiology, and pathogenesis. On the basis of the causative agent, splenic cysts are divided into two types: parasitic cysts and non-parasitic cysts , 6. ParaAlthough the diagnosis of splenic cyst is made by imaging preoperatively, histopathological examination is required to ascertain the type, whether the cyst is true or false. Total splenectomy - either by open or laparoscopic technique - is the treatment of choice, especially if the cyst is large and is extending into the hilum, to avoid recurrence and complications.