The parapharyngeal space is a hypothetical region in the neck that stretches from the base of the skull to the bigger corner of the hyoid bone. The fascia that connects the styloid process to the tensor veli palatini separates the compartment into prestyloid and poststyloid compartments, with the prestyloid compartment being larger. In the general population, tumors of the parapharyngeal area are very uncommon, accounting for less than 1% of all head and neck neoplasms in the population. In this location, CT scanning and magnetic resonance imaging (MRI) exams are complimentary, and both tests should be performed to examine any lesions found. The most critical component of treatment is the total surgical removal of all the cancerous tissue. Identifying and treating primary parapharyngeal space (PPS) tumors are among the most challenging tasks in the treatment of head and neck cancer. They are also among the most aggressive ones. The primary goal of this study is to review our current knowledge at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, which serves as an academic tertiary referral center and a major teaching center. We will focus on clinical findings, tumor structure, tumor histological distribution, and surgical approaches.  The processing starts with two modules. The first module starts with the input images obtained from various patients and collected as a database. The second module starts with the collection of case series of nine patients undergoing excision via multiple different approaches: transoral, transcervical, transparotid, transmandibular, or infratemporal approach. All cases were conducted at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, between 2014 and 2018. All operative interventions were performed by an otolaryngology-head and neck surgeon.  Our study comprised nine patients, of which two underwent transparotid and seven transcervical and combined transcervical/transparotid approach. Complications faced included a hematoma in one of our cases.  The transcervical approach appeared to be the superior surgical approach when facing a pleomorphic adenoma within the parapharyngeal space, arising from the deep lobe of the parotid gland or parapharyngeal space-occupying paraganglioma. Primary parapharyngeal space (PPS) tumors are one of the most challenging tumors to be treated in the head and neck. Parapharyngeal space (PPS) is a well-known anatomical region that has the form of an inverted pyramid with a base, a vertex, and three walls. PPS tumors are considered rare tumors representing just 0.5% of all head and neck tumors . The PPSPSNs are typically indicated with medial movement based on the lateral oropharyngeal tonsil or the wall, dysphagia, cranial nerve participation, a mandibular angle mass, and pain. The PSNs are found with a stated malignant tumor rate in the range of 15–27%.Tumors can arise mainly in the PPS, occupy it by contiguity , or arise as reserved metastases . Basically, indications due to PPS metastasizing can be the first manifestation of positive primaries. Initially, PSNs are neurogenic (35–41%) or salivary (35–45%), while other histological sorts like meningiomas, hemangiomas, or lipomas are tremendously found rare. Treatment classically needs a surgical method for the PPS. Surgical approaches to PSNs are stimulating the complex anatomy, provided by the deep location and the constructions lying in the domain.The majority of PPS tumors, approximately 80%, are of benign origin, whereas malignant tumors represent only about 20% [Our primary objective in this case series is to discuss the differential diagnosis of PPS tumors at our clinical and teaching center of King Abdulaziz University Hospital, Jeddah, Saudi Arabia; to discuss the multiple approaches to a PPS tumor and the most efficient surgical methods with the least complications and the most faced complications of each approach; to compare the gender predominance in parapharyngeal space tumors; and to analyze the most commonly faced histopathology.Literature was reviewed, and observation of our clinical and teaching center by the otolaryngology and head and neck surgeons was used later on for comparing the results with the literature to identify the best approach with the best outcomes and, all in all, the best patient survival and prognosis rates.The current research was done on patients who presented to and were treated at King Abdulaziz University Hospital, a major multispecialty clinic and teaching hospital in Jeddah, Saudi Arabia, between 2014 and 2018, specifically focusing on malignancies that arise from structures that are situated in this anatomical region. There were a total of nine participants in the research. Following radiographic and cytological examination, all of the patients were determined to be candidates for surgical resection and received complete excision of their PPS tumors. The prediction of tumors using computerized technique is divided into two steps, segmentation and classification. Segmentation is a strategy for developing tumors in the parapharyngeal space that is based on region growth.Experiments were conducted on images obtained from hospitals to test the suggested textural feature-based parapharyngeal space tumor techniques. It was necessary to build the suggested technique using MATLAB version R2020a.The following case series explains the stages and the various sizes of the tumor at various age groups.A 47-year-old female nonsmoker is presented in On examination, the mass measuring 10.0 × 8.0 cm and protruding into the oral cavity by 4.0 × 5.0 cm was palpated. It extended from the front of the auricle onto the ipsilateral side of the submandibular region accompanied by oral displacement. Neck CT with contrast showed a huge left neck mass. It is heterogeneous, does not look aggressive, and is centered mainly on the left parotid space with no visualization of the left parotid gland, the mass evidence of bony erosion. It extends deeply to the PPS compressing the oral pharyngeal airway. There were no enlarged lymph nodes, and other structures appear to be normal. True-cut needle biopsy of the parotid suggested pleomorphic adenoma. The case was presented to the tumor board. Decision was to go for a left total parotidectomy with or without mandibular split. During surgery, all parts of the facial nerve were dissected and preserved. Two level II lymph nodes were excised and sent to histopathology. Mass was excised completely using the transcervical approach, and there was no need for the mandibular split.A female, being 34 years of age, from Saudi Arabia, and medically free, presented to our clinic complaining of a distressing swelling in the left parotid for 1-year duration. Mass is associated with frequent discharge. In addition, there is a history of hearing impairment on the ipsilateral side. The patient denies any pressure symptoms such as dyspnea, dysphagia, and change in voice, with negative family history of the same complaint.Upon examination, mass, measuring around 4.0 cm, with firm, immobile, and irregular edges, was visible. Palpable lymph nodes were noted on both the right and left side of the neck at level II.The case was presented to the tumor board, and consensus was to go for surgery. The patient was planned for total parotidectomy. Intraoperatively, the decision was to go with partial parotidectomy as preserving the superficial lobe was possible.Pathology report showed a soft tissue mass measuring 5.5 × 4.5 × 3.0 cm, with an encapsulated neoplastic growth and no evidence of malignancy suggesting a diagnosis of pleomorphic adenoma.A female nonsmoker aged 31 years presented with an anterior neck mass with an associated lateral neck mass extending to the oral cavity for a 2-month duration, with no prior family history, no complaint of dysphagia, no change of voice, and no other neurological symptoms.On examination, a left buccal mass and a soft palate bulge were identified with a diffuse thyroid enlargement.Neck CT revealed a focal area of soft tissue mass noted in the left PPS, causing mass effect of the nasopharynx and on the left side fossa of Rosenmüller in the prestyloid compartment, accompanied by enlarged focal lesions in the right thyroid lobe and in the isthmus.After presenting the case to the tumor board members, a decision was taken to perform a left-sided parapharyngeal mass excision followed by a right-sided hemithyroidectomy.Left half apron incision was done, the PPS was approached transcervically, and the submandibular gland was excised. The lingual and hypoglossal nerves were identified and preserved. Parapharyngeal mass was identified and resected. Enlarged left jugulodigastric lymph node was observed and excised. Furthermore, a right hemithyroidectomy was performed.The patient was discharged in good condition, with no complications. With ongoing regular follow-up with the head and neck team, no new events were reported.A 46-year-old male presented to the clinic with a left-sided neck mass for 1-year duration. No change in mass size has been observed throughout the year. The patient suffered from ongoing abundant shortness of breath and change in his vocal sound 6 months ago, with no dysphagia, no facial asymmetry, and no prior family history of the same complaint or any other malignancies. The patient has no previous history of smoking.Neck examination showed a large, left-sided neck mass measuring 3.0 × 4.0 cm at level II; the mass was firm, mobile, not attached to the underlying skin, and nontender, with enlarged lymph nodes. Flexible laryngoscopy showed bilateral mobile vocal folds, with patent airway and normal supraglottis.Neck CT with contrast revealed a mass encasing the inner and outer carotid arteries at the level of the separation measuring around 4.0 × 6.0 cm, eliciting lyre's sign with no airway compromise or mass effect. Features suggest carotid body tumor of the left side of the neck.Histopathology report of the carotid space tumor specimen revealed a firm mass measuring 4.0 × 3.0 × 2.0 cm, all of which goes with the diagnosis of carotid body tumor, with some reactive lymph nodes.The patient's recovery was unexciting, and he was released in a good condition.A male of 22 years of age presented with right-sided neck mass increasingly rising for 5 years then, becoming inferior 1 month prior to his presentation. There was no history of dysphagia, no history of facial asymmetry, and no prior family history of the same complaint or of any other malignancies.On examination, there was a right-sided neck mass measuring 8.0 × 5.0 cm, crossing levels II & III. The mass was firm and nontender and seemed to be attached to its underlying structures. No palpable lymph nodes were felt. Fiber-optic inspection presented bilateral mobile vocal folds with no airway compromise and no intraoral bulging or mass effect.Neck CT with IV contrast was performed, revealing an enhancing homogeneous lesion seen to extend from level of the base of skull surrounding the lateral pterygoid muscle down to the pharyngeal space. It measures 10.0 × 4.8 × 3.5 cm of height, AP, and transverse diameters, respectively.A 59-year-old man presented with a left-sided neck tumor and a tracheostomy tube, which had been put as a result of his increased shortness of breath during the previous year. The patient reported a progressive neck lump that had been growing for 17 years and had become worse in the previous two months. He became aware of a change in his voice a year ago, but his ability to swallow remained unaffected. There was a firm and nontender mass in the left side of the neck that crossed levels II-V. There were no palpable lymph nodes on the left side of the neck.During a CT scan of the neck, it was discovered that there was a big enhancing mass on the left side of the neck, enclosing the distal half of the left common carotid artery and encasing the left inner and outer carotid arteries. As a result of pushing the oropharynx medially and generating a constriction of the airway, the carotid artery on the contralateral right side of the body was reached, superiorly spreading all the way to the base of the cranium, being 9.1 × 9.0 × 6.8 cm in length, width, and height. There were no noticeably enlarged cervical lymph nodes. The lyre's sign was clearly visible on the CT scan.Our team decided to occlude the common, outer, and inner carotid arteries in order to allow for safe excision of the tumor because of its extension to the skull base and because we anticipated the potential difficulties in achieving adequate intraoperative distal control of the internal carotid artery during the procedure. Internally coiling the inner carotid artery helped to ensure that the tumor was safely removed from the skull base bone during a skull base bone excision procedure. The external carotid artery was occluded with the use of a vascular plug device in this study.Excision of the left carotid body tumor was carried out two days after the embolization procedure was completed. The hypoglossal nerves and internal jugular vein were enclosed by the tumor. We were able to save the spinal accessory nerve, sympathetic chain, phrenic nerve, and brachial plexus throughout the procedure. During the procedure, the common carotid artery was ligated at a location near the neck, just above a coiled portion of the artery. The tumor was fully removed from the parapharyngeal region and the base of the skull. The inner carotid artery was ligated at the level of the skull base in order to prevent further damage. In addition, the tumor was separated from the contralateral carotid artery in order to completely mobilize it and enable end bloc excision of the tumor.The patient was released in excellent health and was able to tolerate the oral diet successfully.A 77-year-old female smoker presented with a progressive growing neck mass, complaining of a choking sensation gradually worsening over the past 3 months and associated with progressive shortness of breath and hoarseness of the voice. There was no dysphagia and no facial asymmetry, with negative family history of the same complaint or of any other malignancies.Examination of oral cavity showed a bulge coming from the left side, with no ulceration or fungating. Palpation of the neck revealed a mobile nontender mass that is firm and solitary, measuring around 4.0 × 3.0 cm and not attached to the underlying structures or to the skin. No palpable lymph nodes were felt. Fiber-optic examination revealed bilateral mobile vocal folds with no airway compromise.Neck CT with contrast showed a well-defined, nondestructive large mass that was recognized in the superficial and deep lobe of the left parotid gland, measuring 3.1 × 4.2 cm and causing a pushing effect on the left external jugular vein and facial vein laterally. Moreover, multiple nonsignificant bilateral enlarged cervical lymph nodes were noted. The case was discussed with the tumor board, and the decision was to go for a complete surgical excision.The patient was prepared for total excision of the left-sided PPS paraganglioma. Through a modified Blair incision, the mass was dissected all around to the deep lobe of the parotid gland. All branches of facial nerve were preserved. Level II lymph nodes on the ipsilateral neck side were identified and dissected. Pathology report of the left parapharyngeal neck mass showed that it was measuring 2.8 × 2.5 × 1.9 cm with an irregular outer surface. The patient was discharged 2 days after the operation, and her regular follow-ups appeared uneventful.A 50-year-old male, previously medically free, complains of a painless localized progressive enlargement in the right side of the neck for one year. The patient does not complain of shortness of breath, stridor, cough, or dysphagia. He is nonsmoker with no prior family history of the same complaint or of any other malignancies.On examination, there is a right-sided neck mass that measures approximately 3.0 × 4.0 cm, being rounded with a smooth surface that appears to be attached to the underlying structure and nontender mass. No visible lymph nodes were detected in the neck.CT angiography of the neck revealed a well circumscribed mass encasing the carotid arteries at the level of the separation resembling lyre's sign. The mass measured around 4.0 × 5.0 cm, with no clear intracranial extension and no aggressive features, all of which goes with the radiological diagnosis of carotid body tumor. The case was presented to the tumor board, and the plan was to go for excision of the right carotid body tumor.Carotid body tumor was approached transcervically, complete excision of the tumor was done around the carotid arteries along their internal and external branches. Unfortunately, internal carotid had to be sacrificed as the mass appeared to be adherent to it; however, the external carotid was preserved alongside cranial nerves XI and XII, both of which were identified and preserved. The mass was delivered completely, and a specimen was sent for histopathology. Postoperatively, the patient received one unit of PRBC due to blood loss due to the injured internal carotid artery. On histopathological examination, the mass was a firm rounded nodule measuring 4.0 × 3.0 × 1.3 cm that appeared to resemble a clear paraganglioma. The patient was discharged home after a period of observation in the hospital, and his regular follow-ups in the clinic were uneventful.A male of 33 years of age presented to our clinic complaining of right-sided increasing neck mass crossing the midline. The patient complaint has been ongoing for a while as he has previously been diagnosed with a right carotid body tumor case outside of our center; he had undergone a previous uncomplicated resection in 2012.Over the last 2 months, the patient started to feel a recurring progressive right neck mass. There was no history of pressure symptoms such as dyspnea, dysphagia, or change in voice and no history of cranial nerve involvement. Review of CNS appeared to be negative. CBT prior treatment did not include radiotherapy or chemotherapy. A follow-up MRI was ordered and performed in 2013, which documented no evidence of a residual or recurrent tumor and no obvious enlarged lymph nodes with a clear operative bed.Examination showed a 2.0 cm mass attached to the underlying muscles, being firm, immobile, and irregularly shaped. Carotid pulsations of good volume were bilaterally palpable. There was no tracheal deviation or palpable lymph nodes.Reviewing the old histopathology report showed that a malignant glom angiosarcoma was the diagnosis in the first surgery.An MRI of the neck was performed and revealed a right retropharyngeal carotid body space mass, lying on the same carotid bifurcation level as the previous surgery, with no invasion of the airway, and pathological right lymph nodes enlargement was observed at level III. The case was presented to the tumor board, and the decision was to undergo revision carotid body tumor excision after the embolization of the CBT with the help of the interventional radiology department. Successful embolization of the inner and outer carotid artery along with resection of the tumor was successfully done. The patient underwent CBT tumor excision through the previous cervical incision, the tumor was removed without any complication, and the carotid arteries were preserved. The patient was discharged a week postoperatively with no complications and followed up regularly.PPS is a well-defined anatomical region that has the form of an inverted triangular pyramid with a base, a vertex, and three walls –5. It isParapharyngeal space (PPS) tumors are infrequent neoplasms  accountiSalivary gland neoplasm is located in the prestyloid space originating from either deep lobe parotid or minor salivary gland. Pleomorphic adenoma accounts for 80–90% of salivary gland neoplasm cases, and 10–20% of cases are malignant mucoepidermoid cancer . NeurogeThe subtle symptoms of a PPS tumor make them very challenging to diagnose. Based on history, clinical examination, FNAC, and imaging, patients are diagnosed with PPS tumor, and their treatment plan includes surgical excision of the tumor . At the Initially, the majority of our patients were asymptomatic and presented only when the tumor could be detected. One of the most common marks was a neck mass. The largest tumor to be excised was 27.1 cm. The results of our study back the suggestion that PPS tumors cannot be diagnosed at an early stage. Imaging studies were used to guess the origin, side, and size of parapharyngeal tumors. In our patients, CT scan of the neck was performed in 8/9 patients and MRI in 2/9 patients. Lesions were identified in all our cases. CT and MRI were used to preview fat plane displacement and identify the relationship of the mass in association with the carotid artery. An angiography was performed in two of our cases: a case of carotid body tumor and an enhancing lesion at the carotid artery bifurcation; the latter underwent a balloon occlusion test as the internal carotid artery was planned to be sacrificed. Of these 9 sample cases, 5 were neoplasms in the prestyloid region and 4 in the poststyloid region. In all our cases, US guided FNAC was performed to control the nature of the mass, and cyto-histopathological comparison was suggested.FNAC is a reliable procedure of precision with a relatively high specificity of malignant parotid gland tumors and provides valuable preoperative diagnostic information to the surgeon. FNAC reached 100% precision in situations where ultrasound guidance was used . In ordeIn our study, 89% of the cases were benign in origin. Of these, pleomorphic adenomas were one of the most common and accounted for 56% of the tumors. This finding is consistent with the largest systematic review performed to date, a review of 1143 PPS tumors reported over 20 years ago, which states that salivary gland tumors were the main benign PPS tumors and the most common primary lesion is the pleomorphic adenoma . In our Only one of our patients (11%) had a malignant tumor, a glom angiosarcoma. This was also consistent with the systemic review in which 18% of the tumors were malignant.The choice of approach depends on the tumor size, the suspected malignancy, and the tumor's position with respect to the base of the skull and its relationship with the neurovascular bundle .There are various surgical approaches that are suitable for resecting PPS tumors. They comprise transcervical, transparotid, transoral, and transmandibular approaches and combinations of them. (Table) Each one of these approaches has its own advantages and limitations. The transcervical approach is the greatest commonly recognized method for poststyloid crowds appearing from the secondary salivary gland , 9. OverThe transparotid approach advocated for surgical extirpation of most deep lobe tumors . This apTransmandibular approach, also referred to as the mandibular swing/split approach, is used for high position tumors which compress the carotid artery or inner jugular vein . This apIt is possible to get better access to the PPS by the transcervical and transmandibular approaches, which allows for dissection of the primary facial nerve trunk and optimal vascular management. If necessary, the submandibular gland may be removed, and the stylomandibular ligament may be transected to provide a better working field vision. Myers and Carrau made use of this approach extensively . The infWith more than 27 years of experience, Shahab  has newlThe literature supported our results in other studies. A study in China  evaluateFurthermore, a study done retrospectively on PPS tumors  revealedSimilarly a UAE study on 34 patients , with PPSome surgical complications that could be faced during a PPS tumor resection are recurrence, hematoma, infection, fistula, facial nerve palsy, Frey's syndrome, and first bite syndrome. We faced a hematoma in one of our patients due to postoperative bleeding from an injured internal carotid artery. 89% of our patients had no complications, were cleared in acceptable condition, and were followed up regularly. From our patients, 89% were satisfied and in pleasing state and were followed up regularly with no complications.The first choice for surgical removal of PPS tumors is the transcervical method due to its superiority in supply direct entry to the PPS and satisfactory control of neurovascular structures of the neck. Unfortunately, we had some disadvantages in this study. This was a backdated study with inadequate data collection and attrition rate, with limited number of cases which made statistical analysis insignificant and comparison of results between varying surgical techniques difficult. Surgical therapy of PPS tumors is difficult because of their deep position and close association with surrounding neurovascular systems. Radiological investigations of PPS tumors are required for the diagnosis and planning of surgical interventions. Excision of PPS tumors with the use of suitable surgical methods achieves favorable results.


We present a rare case of complicated sigmoid diverticulitis presenting as a peri-anal abscess from an extra-sphincteric fistulous tract. This presentation of a colocutaneous peri-anal abscess is extremely rare, with only a handful of cases described in the literature. Most are managed with an open sigmoid colectomy, however, this case was successfully managed laparoscopically. It highlights the need to consider extra-levator causes of peri-anal abscess, such as pelvic sepsis causing fistulating disease, and to consider early magnetic resonance imaging if there is clinical suspicion of underlying pathology. It also demonstrates that a safe and potentially less morbid outcome is possible via laparoscopic approach when compared to traditional open surgical approach. We present a rare case of complicated sigmoid diverticulitis presenting as a perianal abscess from an extra-sphincteric fistulous tract. Only a handful of cases are described in the literature, which have been mostly managed with open sigmoid colectomy. This case was successfully managed laparoscopically. Usually, presentations of peri-anal abscess proceed swiftly to examination under anesthetic (EUA). This case highlights the need to consider extra-levator causes of peri-anal abscess and to have low threshold for early imaging. It also demonstrates a good outcome through first managing the sepsis, then proceeding with a laparoscopic approach to definitive surgical management once the disease was quiescent.A 55-year-old male presented with a 1-month history of perianal swelling with increasing discomfort. Other than malaise, he remained systemically well. He reported 3 months of intermittent abdominal discomfort, thought to be related to constipation, which had resolved by the time of his presentation. He had no prior history of perianal abscess and had a medical history that was significant only for conservatively managed diverticulitis, with a recent colonoscopy confirming mild disease. On peri-anal examination, there was fullness and tenderness over the right ischiorectal space. The tenderness extended from 9 to 11 o’clock ~4 cm from the anal verge. No external opening was obvious, and there were no masses on per rectal exam. His abdomen was soft and non-tender.9/l). An external computed tomography (CT) scan performed 3 weeks prior showed sigmoid diverticulitis for which the patient had not been treated. A tiny pocket (<1 cm) of extra-luminal air was noted, but there was no abscess or collection. When reviewing these external images, there was suspicion of a right peri-anal abscess.Bloods upon presentation revealed a mild leucocytosis  identified a fistulous tract extending from the sigmoid colon, around the anterior aspect of the anal canal, with small collections in the ischiorectal and ischioanal fat. CT fistulogram showed a long fistulous tract extending from the right peri-anal region to a sigmoid diverticulum above the recto-sigmoid junction  and 2. TThe patient underwent an elective laparoscopic Hartman’s procedure, with prophylactic ureteric stenting. Intra-operatively, significant inflammation at Denovillier’s fascia was found. The recto-sigmoid junction was diseased with chronic diverticulitis and numerous indurated appendages were attached to the pelvic sidewall. The rectum was predominantly healthy. A fistulous opening was laparoscopically visualized at 11 o’clock, originating at the junction of the TME plane . This opHistopathology showed benign diverticular disease. The patient recovered well post-operatively and was discharged on Day 5. He has since been followed up in the outpatients’ clinic and is well. He will be considered for reversal of Hartmanns’ following review of MRI and rectal gastrograffin enema to ensure all peri-anal tracts are addressed prior.Diverticulitis and its complications are common and can include fistulae, predominantly colovesical or colovaginal. Only 1% of diverticular fistulae are colocutaneous in nature . Peri-anet al. described an uncomplicated post-op course, healing of the external opening and no residual fistula or anastamotic leak on follow-up gastrograffin studies [Presentation with seemingly acute peri-anal abscess can conceal the underlying cause of fistulating diverticular disease, which can delay diagnosis and management. In our case, lack of abdominal pain at presentation masked the contribution of underlying active diverticulitis. This patient also lacked previous risk factors of colocutaneous fistulating disease . Colocut studies . Two cas studies , 7. One  studies , while a studies , 7.There has been previous reported successful laparoscopic management of colocutaneous fistula to the groin . Our casDiverticular disease presenting with peri-anal abscess from spontaneous colocutaneous fistula is rare. This case highlights the importance of considering occult causes of peri-anal abscess and demonstrates successful laparoscopic management of such acase.None declared.None.


Panniculitis ossificans (PO) is a heterotopic ossification, benign recurring lesion, presenting in a variety of presentations anywhere in the body. The condition can sometimes be mistaken for a malignant bone tumor or long list of other differential diagnoses which have been mentioned in our report and that may lead to unnecessary wrong management. We report a case of a patient with subcutaneous ossification in the posterior aspect of the left knee. PO was confirmed histologically showing subcutaneous fat necrosis associated with osteoid material. Heterotopic ossification (HO) is a broad term and involved in many pathological and histological findings. Based on etiology, it can be classified to primary or secondary (more common), in which heterotopic ossification can present as an acute painful lesion or can be asymptomatic. Panniculitis ossificans is a rare, self-limiting form of heterotopic ossification that might involve the subcutis as a reaction to trauma or with unknown etiology. However, HO is a general non-specific pathological finding, while panniculitis ossificans is a specific pathological diagnosis. The condition is benign but sometimes be mistaken as malignant bone tumor.A 46-year-old male presented to an emergency department complaining of non-progressing left thigh swelling for two years discovered suddenly. He has no associated pain, limitation of activities, no history of discharge, or skin changes. The patient is diabetic and was on metformin and gliclazide. He didn’t seek medical advice prior to his current presentation. There is no history of trauma. No family history of the same compliant or previous history of other lumps in other regions was noted.There is a well-circumscribed hard lesion in the posterior aspect of the left thigh. The swelling is about 5x6 cm in size, hard, superficial not attached to underlying muscle, and with no skin changes. There was no deep or superficial inguinal lymphadenopathy. No other abnormalities were detected on examination.Ultrasound of the left lower limbA well-defined subcutaneous hard lesion measuring 40x35x12 mm was seen on the posterior aspect of the left knee. The lesion showed ill-defined margins with multiple flecks of calcifications. However, no cystic areas and no evidence of increased color flow were noticed inside the lesion. Differential diagnosis includes post-traumatic, calcified fat necrosis, and less likely vascular malformation. No abnormal collections were noticed.Skin biopsy was performed and showed a small fragment of soft tissue consisting of interlacing bundles of spindle cells arranged in fascicles and admixed with fatty tissue exhibiting fat necrosis with fibrosis. Multiple fragments of ossification were noted. No abnormal mitoses were seen. The features were consistent with a solitary fibrous tumor. Pathological findings of the resected specimen fixed in 10% neutral buffered formalin revealed an irregular, tan-to-gray mass, and measuring 5x3x0.8 cm. Serial sections of the specimen revealed a heterogeneous tan/yellow-to-brown/white surface with a soft center and gritty sensation at the periphery  near a joint was ﬁrst reported in the literature in 1978-1994. A total of four cases all at the distal phalanx were reported during this period. It is an uncommon disorder that consists of deposition of ectopic bone outside the extra-skeletal tissues .Unlike calcification lesions, HO leads to a complete bone microenvironment within bone tissue cells, microcirculation, and neuroendocrine function. HO patients can experience pain and limited range of motion, which seriously impairs their activity of daily living . PathogeThe radiological findings of panniculitis ossificans are variable depending on the age and maturation of the lesion. In the early stages as in our case, plain radiography is negative due to lack of sufficient amount of calcification. However, ultrasound and magnetic resonance imaging with gadolinium contrast can diagnose and differentiate early cases of heterotopic ossification from sarcomas, as the pattern of enhancement is a rim in the periphery, while it is diffuse and homogenous in cases of malignancy .Differential diagnosis depending on the clinical and radiological findings include nodular fasciitis, myositis ossificans progressive, myositis ossificans circumscripta, osteoma, chondrosarcoma, and osteosarcoma which should be excluded the most. Malignant fibrous histiocytoma, rhabdomyosarcoma, and slowly calcifying lesions like synovial sarcoma must be excluded as well.As discussed earlier, patients may present with different complaints. Symptomatic treatment is recommended for HO in the formative stage that was revealed by bone scanning and radiographic examination while surgical excision can be done after complete maturation of bone. Stabilization and even regression have been reported before . When HOHO is usually symptomatic, but it can be asymptomatic for years (as what happened with our patient). When symptomatic, it depends mainly on the size and anatomical site. Histologically, like in this case report, it's usually a lesion comprised of an admixture of mature adipose tissue, bone, and granulation tissue-like fibroblastic proliferation with distinct zonation. In some cases also defined as subcutaneous fat necrosis with a sequela of heterotopic bone formation. The condition is benign but can sometimes be mistaken for a malignant bone tumor .We conclude that panniculitis ossificans  can occur in any age and with a wide variety of presentations. It can present anywhere as an asymptomatic silent lesion as in our case or acutely affecting activity of daily living. The crucial point in diagnosis is imaging and biopsy . The other anatomical presentations reported  have no alternative management rather than what already has been discussed in this report. Early diagnosis and management can prevent deformities and mobility restriction, which result in loss of function and esthetics.


Diagnosis of intestinal tuberculosis poses a dilemma to physicians due to nonspecific symptoms like abdominal pain, fever, nausea, and a change in bowel habit. In particular, the distinction between inflammatory bowel disease and intestinal tuberculosis remains challenging.Mycobacterium tuberculosis (MTB) were negative, empirical MTB treatment was initiated on suspicion. Due to a massive post-stenotic atrophied intestinal bowel, MTB medications were administered parenterally in the initial phase of treatment to guarantee adequate systemic resorption. The complicated and critical further course included an intra-abdominal abscess and bowel perforation requiring a split stoma, before the patient could be discharged in good condition after 3 months of in-hospital care.A 27-year-old man from Colombia presented with fever, night sweats, and progressive lower abdominal pain. Computed tomography revealed a thickening of the bowel wall with a mesenterial lymphadenopathy, ascites ,and a pleural tumor mass. Histology of intestinal and pleural biopsy specimens showed a granulomatous inflammation. Although microscopy and polymerase chain reaction (PCR) for This case highlights the clinical complexity and diagnostic challenges of intestinal MTB infection. A multidisciplinary team of physicians should be sensitized to a timely diagnosis of this disease, which often mimics inflammation similar to inflammatory bowel disease, other infections, or malignancies. In our case, radiological findings, histological results, and migratory background underpinned the suspected diagnosis and allowed early initiation of tuberculostatic treatment. Mycobacterium tuberculosis (MTB) [It is hypothesized that almost one-quarter of the global population is latently infected with is (MTB) . In 5–10is (MTB) , 3. In 2is (MTB) .A 27-year-old man from Colombia presented to our emergency department with fever (38.9 °C) and progressively worsening lower abdominal pain for the last 6 months, peaking at the day of admission. The patient also reported mild nausea, intermittent night sweats, weight loss, and fever during the last few months prior to admission. Physical examination revealed no noticeable findings aside from pressure pain in the lower right abdominal region. Laboratory inflammatory markers were elevated . The patient was admitted to our hospital. Due to findings of ascites in an ultrasound examination, a computed tomography (CT) scan was performed and revealed a pleural mass, necrotic abdominal lymph nodes, and bowel wall thickening -guided biopsy of the pleural tumor was performed. While histopathological results were still pending, the patient developed increasing abdominal pain and vomiting, so another CT scan was conducted, which showed a small bowel ileus. Subsequently, a laparoscopy with peritoneal biopsy and creation of a protective ileostomy was performed. The histological examination of the pleural and abdominal specimens showed granulomatous inflammation without direct microscopic detection of acid-fast bacilli. Polymerase chain reaction (PCR) for M. tuberculosis complex strain.As intestinal malabsorption was assumed due to a massive post-stenotic atrophied intestinal bowel, parenteral nutrition and empirical intravenous MTB treatment with ethambutol, levofloxacin, rifampicin, and isoniazid was initiated using a totally implantable venous access device (port). After 5 weeks, MTB cultures of pleural biopsy and intra-abdominal lymph nodes showed growth of a pan-sensitive In the further in-hospital course, the patient developed severe abdominal pain in the region of the ileostomy as well as high inflammatory markers. A CT scan displayed free air within the peritoneal cavity indicating a bowel perforation and an intra-abdominal abscess, leading to the performance of a laparotomy with small bowel segment resection and preparation of a split stoma. Two months later, the split stoma was reversed. After 3 months of in-patient care, the patient was discharged in good condition, and MTB treatment was switched to oral therapy with isoniazid and rifampicin. After a total duration of 10 months, a CT scan showed no evidence of persistent MTB disease, so the MTB treatment was terminated.We demonstrate a case of abdominal MTB with small bowel affection resulting in a complicated course with a small bowel ileus, massive post-stenotic atrophied intestine, and consecutive small bowel perforation with intra-abdominal abscess requiring segmental bowel resection. The patient was discharged after 3 months of in-patient care and finished tuberculostatic therapy after 10 months.Due to the limited function of the post-stenotic intestinal bowel tract, oral nutrition had to be replaced by parenteral nutrition. Simultaneously, anti-tuberculosis treatment was administered intravenously via a port. In the present case, parenteral administration was switched to oral therapy after 12 weeks.et al. reported a perforation rate of 6.6 % (6/91) in abdominal MTB [The complications of this case—an ileus and ileum perforation with intra-abdominal abscess—both required surgery. In 2017, a study on intestinal tuberculosis showed a complication rate of 44 % 27/61), including formation of abscesses, fistulas, strictures, perforation, and obstruction . Lee et 1, includSevere complications of intra-abdominal tuberculosis can be avoided if adequate treatment is provided in a timely manner. However, early diagnosis of intra-abdominal tuberculosis is challenging. Diagnosis of abdominal MTB is often hampered by nonspecific symptoms like abdominal pain accompanied by nausea and a change in bowel habits . Less frContrast-enhanced CT is the recommended imaging tool in abdominal MTB. Abdominal lymphadenopathy and short-segment strictures with symmetrical concentric wall thickening with homogeneous contrast enhancement are the most common findings , while hIn patients with acute complications of abdominal MTB, evidence of pulmonary MTB infection on chest X-rays may be absent. Varying rates have been reported, with pulmonary findings in 39–80% , 14.Aside from clinical and radiological difficulties, microbiological confirmation of diagnosis poses an additional challenge. MTB culture is considered the gold standard due to possible false-negative results of microscopy and PCR. However, abdominal MTB is usually a paucibacillary infection, so it can take several weeks to get a positive culture result. In the current case, the first intra-abdominal MTB culture was positive after 5 weeks of incubation, but MTB treatment had been commenced on suspicion.Hence, a histological result of granulomatous inflammation, radiology, and the migratory background are decisive in establishing the correct diagnosis in a timely manner when microbiology is still pending.M. tuberculosis might lead to complications as presented in this case such as ileus or perforation, as well as malabsorption requiring parenteral administration of anti-tuberculosis therapy. A combined approach of surgery and tuberculostatic therapy led to complete cure of this highly unique complicated case.Bowel wall perforations due to intestinal MTB are associated with high mortality, thus requiring rapid diagnosis and therapy. However, diagnosis of abdominal MTB is challenging due to nonspecific clinical and radiological signs and its paucibacillarity, which reduces the sensitivity of microbiological methods. Impaired bowel function by


Rhabdomyosarcoma (RMS) is a rare soft tissue tumor originating from skeletal muscle that is mostly reported in children. The most common sites of involvement are the head, neck, and extremities. The 2020 WHO classification divide RMS into four types: embryonal, alveolar, pleomorphic, and spindle cell/sclerosing. Reports of RMS with primary lung origin are rare. We present a case of RMS in a 16-month-old boy who presented with a lung mass and microscopic examination with fluorescence in situ hybridization confirmed the diagnosis of alveolar RMS. In conclusion, RMS should be considered in the differential diagnosis of any lung mass with small round blue cell morphology in the microscopic evaluation and should be distinguished from metastatic RMS of other sites, pleuropulmonary blastoma, lymphoma, neuroblastoma, primitive neuroectodermal tumor (PNET)/EWING, and malignant peripheral nerve sheet tumors (MPNST). Rhabdomyosarcoma (RMS) is a malignant soft tissue neoplasm having skeletal muscle differentiation . It is tWe report a case of a 16-month-old baby boy who presented clinically with shortness of breath and radiologically with a lung mass. The clinical presentation, radiological findings with pathology report, and fluorescence in situ hybridization (FISH) are compatible with primary alveolar RMS.A 16-month-old baby boy with known G6PD deficiency and club foot presented with progressive shortness of breath. His mother reported that the shortness of breath was associated with fever and decreased appetite. The baby had been delivered normally at full-term.2 saturation, 89%. The chest examination revealed decreased breath sounds in the right chest. The remainder of the systemic review was unremarkable.Physical examination revealed that the patient appeared ill and distressed. The vital signs were as follows: blood pressure, 100/70 mmHg; heart rate, 108 bpm; respiratory rate, 45 breaths/min; and ORadiological studies, including computerized tomography (CT) and magnetic resonance imaging (MRI), were performed. The studies revealed a lobulated mass (7.3 x 6.4 x 4.4 cm) in the base of the right lung that involved the diaphragm, mediastinal pleura, and right pericardial space; the mass encased the esophagus and extended to the interlobular fissure. Three other pleural-based nodules were identified in the right upper lobe Figures , 1B. BasA pathological examination revealed six cores of lesioned tissue composed of nests of small round blue cell tumors, with some cells having little cytoplasm. The nuclei were round with euchromatin and focal cytoplasmic striation was noted. Necrosis was rare Figures , 2B. An Based on the clinical history of no other primary in other sites of body and radiology in addition to microscopic features, immunohistochemistry, and the FISH study, the final diagnosis was primary pulmonary RMS, alveolar type. The patient received chemotherapy and radiotherapy for 10 months, demonstrating improvement at a follow-up imaging study. The patient showed complete remission at one-year post-treatment follow-up.RMS is a primitive mesenchymal tumor with skeletal muscle differentiation. RMS is common in children and has a poor prognosis. Alveolar RMS has the worst prognosis due to its unique PAX3-FOXO1 fusion gene molecular phenotype .RMS is associated with a congenital cystic adenomatoid malformation (CCAM) but may also occur in a healthy lung. The etiology of primary pulmonary RMS is still unknown, but there are two main hypotheses for its origin: first, the tumor may arise from heterotopic islets of striated muscle, which could explain the frequent association of RMS with pulmonary malformations such as cystic adenomatosis; and second, the tumor may arise from metaplastic changes in uncommitted mesenchymal cells in the absence of congenital abnormalities . Like otThe main differential diagnosis is pleuropulmonary blastoma, lymphoma, neuroblastoma, primitive neuroectodermal tumor (PNET)/EWING, and malignant peripheral nerve sheet tumors (MPNST). Pleuropulmonary blastoma has blastema, anaplastic and epithelial components that are not present in RMS. The nuclear positivity for MyoD1 and myogenin is specific for RMS among other differential diagnoses.An extensive search of English research literature  identified 32 cases reported as primary pulmonary RMS in the pediatric age group Table  8-32]. -32. 8-32Primary pulmonary RMS is a rare disease that exhibits aggressive behavior. RMS should be included in the differential diagnosis of any lung mass with small round blue cell morphology. Clinical and radiological assessment is necessary to exclude metastatic RMS from other sites. In addition to RMS, other differential diagnoses that should be considered for a lung mass are pleuropulmonary blastoma, lymphoma, neuroblastoma, PNET/EWING, and MPNST.


Intracranial yolk sac tumors (YSTs) are rare malignancies with limited treatment options and a dismal prognosis. They are usually managed with surgical resection and chemoradiotherapy.Here, we report a patient with primary YST in the pineal region who achieved long term survival. Despite undergoing treatment, he experienced several recurrences over a 15-year period.Brain magnetic resonance imaging (MRI) demonstrated the presence of space-occupying lesions in the pineal region and the medial tail of the left lateral ventricle. The tumors were excised, and the histological diagnosis suggested an intracranial YST.The patient achieved long term survival after combined modality therapy including surgery, stereotactic radiosurgery (SRS)/intensity modulated radiation therapy (IMRT), chemotherapy, and targeted therapy.The disease remained stable. However, the patient gave up treatment and passed away in October 2020, with a total survival of about 15 years.To the best of our knowledge, this patient with intracranial YST had received a longer survival compared with other published reports. We summarize previously published reports of intracranial YST and discuss the importance of multidisciplinary treatment. SRS may have a role, as a focal boost to residual tumor after resection or in case of recurrence after conventional radiotherapy, in the multimodality management of intracranial YSTs. Intracranial YST that is commonly localized in the pineal region, saddle and third ventricle, always develop rapidly, and are prone to recurrence and metastasis. It has a poor prognosis, with the 3-year survival of 27.3%. The present study reports the case of a male adult patient with primary YST in the pineal region who survived for up to 15 years after the multimodality treatment approach including surgery, stereotactic radiosurgery (SRS)/intensity modulated radiation therapy (IMRT), chemotherapy, and targeted therapy. To the best of our knowledge, this patient had a longer overall survival after combined modality therapy compared with other published reports.Yolk sac tumors (YST) is a rare kind of malignant germ cell tumor that mostly occur in children and adolescents.22.1Informed consent for publication of the case details and accompanying images has been obtained from the patient's next of kin.2.2A 20-year-old man was admitted to the hospital because of headache in 2005, and then diagnosed as the pineal YST. Following SRS, the patient's symptom was relieved. In late 2013, he presented with symptoms of headache, polydipsia, and polyuria. Brain magnetic resonance imaging (MRI) demonstrated the presence of a mass in the medial tail of the left lateral ventricle, which was confirmed to be a YST by the postoperative pathology. SRS was subsequently performed after tumor resection. In January 2018, the patient experienced headache again and numbness in hands. MRI was performed and showed space-occupying lesions in the pineal region. The tumor was excised, and the histological diagnosis suggested an intracranial YST, therefore recurrence was considered. One month after the operation, serum alpha-fetoprotein (AFP) was 1230 ng/mL, and MRI showed irregular masses in the left medial temporal lobe, the left parietal lobe, and the trigone and the medial side of left lateral ventricle. Considering the presence of residual lesion and cytological examination of cerebrospinal fluid (CSF) remaining negative, whole-brain radiotherapy (36 Gy/18f) and boost to a total dose of 58 Gy were given  years old  divided intracranial germ cell tumors (IGCTs) into 2 fundamental types according to tissue subtypes: germinomas and non-germinomatous germ cell tumors (NGGCTs). NGGCTs include embryonal cancer, yolk sac tumor, choriocarcinoma, and teratoma. Complete surgical resection is the key to treatment, and postoperative chemoradiotherapy is given if tumor is residual. The efficacy of platinum-based chemotherapy (carboplatin or cisplatin) in the treatment of IGCTs has been well established.–25 And substituting cisplatin for carboplatin may contribute to a better survival in patients with intracranial NGGCT, which is based on the observation that the latter was less effective than the former at equivalent doses in 2-drug and 3-drug treatment protocols in patients with non-CNS germ cell tumors. At present, conventional 3D conformal radiotherapy/IMRT is mostly used for postoperative radiotherapy, and there are few reports on the treatment of YSTs by SRS.Without relevant guidelines currently, the treatment of YST is similar to the treatment of NGGCTs, for which a combination of surgical resection, chemotherapy, and radiotherapy is typically used. Therefore, it is increasingly used as primary or adjuvant therapy for pineal tumors. In the case of tumor recurrence in situ and failure to perform conventional radiotherapy, SRS has obvious advantages.Thanks to the technical characteristic of large dose in targeted area and low dose to the surrounding area, SRS can precisely kill the tumor and reduce the damage to the surrounding normal brain tissues. With the development of radiotherapy equipment and technology, researchers are also exploring new forms of radiation, such as proton radiation.The patient received whole-brain radiotherapy and focal radiotherapy and 4 SRS over a 15-year period. Nine years after the first SRS performed in 2005, no tumor recurrence was observed. After recurrence, administering surgery combined with SRS, the local control duration was up to 4 years. The patient received SRS for 3 times in the left lateral ventricle, especially after recurrence in 2019. Considering the patient's tolerance and important adjacent structures, staged SRS was adopted to reduce the radiation damage to the surrounding normal tissues on the basis of ensuring the implementation of an effective and enough biological dose. It can not only achieve local control, but also reduce postoperative adverse events. Studies have shown that serum AFP >1000 ng/mL at the time of diagnosis is a risk factor for subsequent recurrence, and it is recommended that patients receive intensive chemotherapy. In our case, the serum AFP level dropped constantly to the normal range during the 8 cycles of EP chemotherapy  can improve clinical outcomes. MDT has been considered necessary for patients with cancer. In the course of this patient's management, we chose more effective pattern and drugs through MDT approach, closely monitored as well as timely adjusted therapeutic regimens, which may contribute to improving local control and survival of the patient.Conceptualization: Ming Zhang.Data curation: Bao-Shuan Fang, Wen-Hao Zhao, Chen Li, Shuai Xu.Formal analysis: Zhen-Ning Xu, Xiang-Yong Yue, Xiao-Ci Cao, Ya-Dong Liu, Ming Zhang.Funding acquisition: Ming Zhang.Investigation: Zhen-Ning Xu, Xiang-Yong Yue, Xiao-Ci Cao.Methodology: Zhen-Ning Xu, Xiang-Yong Yue, Xiao-Ci Cao, Ming Zhang.Validation: Bao-Shuan Fang, Wen-Hao Zhao, Ming Zhang.Visualization: Zhen-Ning Xu, Ya-Dong Liu, Ming Zhang.Writing – original draft: Zhen-Ning Xu, Xiang-Yong Yue, Ming Zhang.Writing – review & editing: Zhen-Ning Xu, Xiang-Yong Yue, Ming Zhang.


Abdominal wall endometriosis has an incidence of 0.3–1% of extrapelvic disease. Α 48-year-old female appeared in the emergency department with cellulitis in a lower midline incision. She had an endometrioma of the anterior abdominal wall removed 2 years ago. After 5 months, she underwent an open repair of an incisional hernia with a propylene mesh, which was unfortunately infected and removed 1 month later. Finally, in July 2019, she had her incisional hernia repaired with a biological mesh. Imaging modalities revealed a large mass below the umbilicus. Mass was punctured under ultrasound guidance. Cytology reported the recurrence of endometriosis. Pain and abdominal mass associating with menses were the two most typical symptoms. Wide local excision of the mass with at least 1 cm negative margins is the preferred treatment. Surgeons should maintain a high suspicion of the disease in reproductive women with circular pain, palpable abdominal mass and history of uterine-relating surgery. Endometriosis is a common condition where endometrial cells, both glands and stroma, are found outside the womb . Most ofA 48-year-old female patient visited the emergency department due to cellulitis in a lower midline incision. She had a tumor of the anterior abdominal wall removed at 2017, which turned out to be an endometrioma in the histological report. Six months later, she underwent an open repair of an incisional hernia with a polypropylene mesh. The mesh was placed on lay. One month after the surgery, the mesh was removed owing to infection. On July 2019, her incisional hernia was repaired with a biological mesh. From obstetric history, she had a caesarian delivery 18 years ago.Abdominal examination disclosed a palpable hard mass below the umbilicus. The patient was admitted to the surgical department for observation, and antibiotics were commenced, particularly vancomycin. A computed tomography (CT) of the abdomen was obtained, which demonstrated a large oval mass 10.7 × 5.7 × 7.8 cm with rim enhancement and dense content, which was located below the umbilicus.On the same day, percutaneous drainage of the mass was carried out. Macroscopically, the fluid seemed to be blood. Then, a small drainage catheter was left in place to drain the hematoma.Inflammation of the anterior abdominal wall was subsided on Day 2, while the percutaneous drainage catheter was removed on Day 3. The culture was sterile, and the patient was discharged on Day 8 without complications. Cytology report evinced the diagnosis of AWE: the presence of endometrial glands and stroma.Endometriosis is the presence of endometrial mucosa, both glands and stroma, outside the uterus . Its incAWE was first reported by Meyer in 1903 . It is tThe most frequent appearance is a cyclic pain associated with menstruation. Other symptoms include skin discoloration, bleeding, dysmenorrheal, dyspareunia and bowel or bladder symptoms, whereas some patients have no symptoms. Clinical examination reveals a palpable abdominal mass, which is usually immobile and painful. Even though pain, skin discoloration, bleeding and an increase in the size of the mass are linked with menses, only 57% of the patients exhibit cyclic symptoms [Abdominal ultrasound is regarded as the first-line imaging modality for masses and mass-like lesions in the abdominal wall. AWE is depicted as a heterogeneous hypoechoic mass with irregular shape and indistinct margins. It is usually solid, though sometimes has a cystic appearance. Occasionally, vascularity can be seen on color Doppler imaging , 9.CT and magnetic resonance imaging (MRI) of the abdomen provide useful information for choosing the best method for closing the fascia defect during operation, as they reveal the extent of the disease and the involvement of the fascia of the rectus muscle. The imaging findings on CT encompass a solid soft-tissue heterogeneous mass with mild-to-moderate enhancement after the administration of intravenous contrast material. On MRI, it is portrayed as a hyperintense or isointense heterogeneous lesion on both T1- and T2-weighted images. Feeding vessels can be observed on occasion on both imaging modalities , 9.Fine needle aspiration under ultrasound guidance is an easy, inexpensive and accurate procedure to confirm the diagnosis of AWE. Caution should be taken to avoid the introduction of new implants at the puncture sites. In case of a limited amount of sample material, an additional biopsy may be necessary , 8.AWE needs to be distinguished preoperatively from hernias, abscesses, lipomas, desmoids tumors and malignancies. It is worth noting that the malignant transformation of endometriosis is rare, with an incidence of 1% of cases .The treatment of choice for AWE is wide local excision of the mass with at least 1 cm negative margins , 10. MesPain and abdominal mass associating with menses are the two most typical symptoms of AWE. Abdominal ultrasound is the first-line modality for the diagnosis of AWE, while CT and MRI disclose the extent of the disease and the involvement of rectus muscle. Wide local excision with negative margins of 1 cm at least is the preferred treatment. Surgeons should maintain a high suspicion of the disease in reproductive women with circular pain, palpable abdominal mass and history of uterine-relating surgery.None declared.None.Written informed consent was obtained from the patient prior to publication.


Incidentalomas are commonly encountered adrenal lesions. However, adrenocortical carcinoma (ACC) represents a rare etiology of adrenal incidentalomas (AI). The diagnosis of AI is generally based on laboratory data and imaging results, Fine needle aspiration (FNA) is not usually indicated in the workup of incidentaloma. In this report, we present a case of AI in which two FNA procedures failed to make the correct diagnosis of ACC. Adrenal incidentaloma (AI) is a common endocrine condition, and it is defined as an adrenal mass of greater than 1 cm in diameter detected incidentally when performing radiological studies to evaluate a non-adrenal condition or disease. A multidisciplinary workup with a careful laboratory and radiological analysis is required to make a correct diagnosis of the condition and ensure its effective management . While AAdrenocortical carcinoma (ACC) is a serious medical condition and is found in around 2% of all cases of AI . FunctioACC is a rare and aggressive malignant tumor, and it is associated with two different peaks of incidence: before the age of five and between 40-60 years of age; however, it can also occur in people of any age . Most caIn this report, we present the case of a patient with AI in whom two fine needle aspiration (FNA) procedures failed to make the correct diagnosis of ACC.A 61-year-old Caucasian male presented to the hospital with a complaint of sudden shortness of breath. CT scan of his lungs was diagnostic for pulmonary emboli and a small lung nodule of 0.5 cm, and incidentally revealed a left adrenal mass of 9 cm. The patient was treated with anticoagulation for pulmonary emboli. He did not show any symptoms of hyper or hypoadrenalism, but serum metanephrine and cortisol were done routinely to determine the secretory status of the adrenal adenoma, and both of them were within normal limits. Biopsy of the left adrenal nodule was ordered by a general practitioner and was performed one month after the discharge, and it was found to be non-diagnostic. However, a repeat biopsy done three weeks after the first one revealed adrenal cortical tissue, raising concerns related to adrenal hyperplasia, adenoma, and unrepresentative biopsy material. The patient was referred to endocrinology three months later. Evaluation by the endocrinologist did not reveal any history of weight gain, weakness, or insomnia. The patient had not observed any change in his libido or hair distribution. He had a history of hypertension for more than 10 years, which was being controlled with two medications. Physical exam showed normal vital signs, no stigmata of Cushing’s syndrome, and normal body mass index (BMI). Urine analysis for catecholamines and cortisol were within normal limits, and so were serum aldosterone-to-renin activity, electrolytes, and dehydroepiandrosterone sulfate (DHEA-S) levels. A repeat CT scan of the abdomen done four months after the first one revealed a bi-lobed heterogeneous mass in the left adrenal gland measuring 9 x 5.5 cm with a central low density likely indicating necrosis  presented with distant metastasis; the primary extra-adrenal organ involved was the lungs  [Even though ACC is a rare condition, it should be suspected in patients with AIs that show certain characteristics on imaging. FNA is not recommended as part of the evaluation and can be misleading. Current guidelines recommend the removal of lesions of >4 cm.


Retroperitoneal liposarcomas (RPL) are rare mesenchymal tumours with an annual incidence of 2.7 cases per million. Well-differentiated liposarcomas (WDLs) and dedifferentiated liposarcomas (DDLs) are the most common subtype. WDLs are widely known to be low-grade tumours that are less likely to metastasise and easily resected. In contrast, DDLs are high-grade aggressive metastatic tumours with mortality rates between 50% and 70%.We present an unusual case of a 47-year-old male with a background of hypertension presenting with cardiac-sounding chest pain. Initially managed as an acute coronary syndrome (ACS), he eventually underwent a CT scan which revealed a 20x18x17cm retroperitoneal complex mass with possible infiltrates to the posterior wall of the greater curvature of the stomach. Ultrasound-guided biopsy and subsequent histopathology analysis revealed DDL consistent with MDM2 amplification.This case highlights how RPL can present with diagnostic difficulties. Multidisciplinary input from haematology, surgery and specialist teams is vital to optimise patient management. Retroperitoneal liposarcomas (RPL) are rare tumours that contribute to 10%-15% of sarcomas with an annual incidence of 2.7 cases per million . TherefoA previously fit and well 47-year-old lorry driver presented with a three-hour history of central burning chest pain with radiation to the left side of his chest which was associated with one episode of vomiting. His past medical history consisted of hypertension, a body mass index of 40.09, non-alcoholic fatty liver disease and hypercholesterolaemia. He was a non-smoker and drank between three and six units of alcohol per day. There was no relevant family history.On examination, there was evidence of diaphoresis and raised blood pressure (172/119mmHg); however, all other observations were unremarkable. Despite his ECG showing sinus rhythm with no ischaemic changes, he was started on acute coronary syndrome (ACS) treatment with dual antiplatelets, enoxaparin and glyceryl trinitrate (GTN) spray due to what initially looked like a cardiac clinical presentation; however, the former medications only partially improved symptoms (mainly the GTN spray).On admission, his blood results were unremarkable and his troponin levels were unconcerning . A thorough review by the Cardiology team ruled out any cardiac cause of his chest pain and the ACS protocol was stopped. Omeprazole was commenced due to the possibility of gastroesophageal reflux as a cause of chest pain, as he was experiencing burning retrosternal discomfort. His chest x-ray was normal with no signs of consolidation or collapse.Despite normal liver function tests and amylase the patient was still experiencing ongoing right-sided lower chest pain and right upper quadrant pain. Therefore an abdominal ultrasound was requested to rule out any causes for this. This revealed a 15x11cm ill-defined heterogenous lesion that appeared to arise from the upper pole of the left kidney. The liver showed non-specific fatty changes with mild to moderate ascites.A subsequent computerised tomography (CT) scan of his renal tract showed a 24-cm retroperitoneal complex mass with probable infiltrates to the posterior wall of the greater curvature of the stomach. A further staging CT showed significant left-sided retroperitoneal changes encasing the kidney and vessels at the gastrosplenic ligament, extending into the omentum and peritoneal cavity with evidence of haemorrhage within the lesion. There was also a small volume haemoperitoneum within the pelvis, but no metastases Figure .Further investigations were performed to explore the cause of the retroperitoneal mass such as a haematological aetiology. Subsequent ultrasound-guided biopsy revealed dedifferentiated liposarcoma. Immunohistochemistry was positive for tumour markers CD56 and CD138. There was also patchy membranous positivity with CD99 marker Figure .Due to the size of the tumour at the presentation, it was inoperable. He was commenced on doxorubicin and ifosfamide chemotherapy.Prior to his second cycle of treatment, he was admitted to the hospital for pyrexia of unknown origin. During this admission he had a further CT scan, which showed that the tumour had increased in size, almost entirely encasing the left kidney as well as the splenic vein and artery. The mass effect caused by this rapid growth displaced the stomach, left adrenal gland, small bowel, coeliac axis and superior mesenteric artery. He is currently being followed up by the sarcoma team and after his third cycle of chemotherapy, imaging will be repeated to reassess for the possibility of surgical resection.Liposarcomas are classified into four histological groups: well-differentiated, dedifferentiated, myxoid/round cell and pleomorphic liposarcomas as per the World Health Organisation . DDLs arA distinguishing feature of WDL and DDL is evidence of a supernumerary ring and giant rod chromosomes that contain amplified oncogenes such as MDM2, CDK4, HMGA2 and TSPAN31 that play a key role in the tumorigenesis of liposarcomas ,10. And,Furthermore, poor prognosis has been associated with 1p32 and 6q23 chromosomal amplifications causing increased levels of JUN proto-oncogene and ASK1 which in turn are involved in the dedifferentiation of adipocytes . Other sThe approach to a retroperitoneal mass should begin with cross-sectional imaging and there are arguments for both multiple resonance imaging (MRI) and CT. It is generally accepted that the former is more suited for lesions in the extremities and the latter for chest, abdomen, pelvic and retroperitoneal masses. On imaging, DDL is characteristically identified as a retroperitoneal non-lipogenic mass surrounded by abnormal appearing fat. It is generally agreed that upon diagnosis the mass may be surgically removed. Core biopsy is only indicated in tumours that are unlikely to be completely resectable due to vascular involvement Extremity liposarcomas are commonly treated surgically via limb-sparing procedures; however, it is not as simple for RPLs due the higher rates of recurrence. Surgical resection of retroperitoneal tumours should be considered including resection of any involved adjacent organs; however, co-morbidities, age and asymptomatic DDL may negate the need to intervene surgically . A retroSystemic approaches to treating DDL have previously been limited to certain chemotherapeutic agents with doxorubicin, gemcitabine and docetaxel being amongst the most popular; however, it is widely accepted that the benefit from chemotherapy for DDL is reported to be minimal -15. AnthOther than the first-line chemotherapy options, there are other options that have been shown to have some benefits. For example, a phase II clinical trial involved treating patients with Palbociclib (a highly selective inhibitor of CDK4 and 6) demonstrated a progression-free survival rate of 66% in patients. However, another study using the same regimen  on a patient with DDL did not have a successful outcome and the patient subsequently developed new lung nodules. Therefore, it is widely accepted that the benefit from chemotherapy for DDL alone is reported to be minimal ,18.Recently, advances in molecular biology have led to the development of targeted MDM2 antagonists. One study looked at the use of such an agent (RG7112) in 14 patients with DDL MDM2-amplified liposarcomas, where they received three 28-day cycles of the treatment and found that only one patient had a confirmed partial response, with the remainder showing stable disease . AnotherAlthough surgical resection of WDL and DDL remains the first choice, it remains an unsuitable option for patients with unresectable, unstable and metastatic disease, especially in those with large liposarcomas due to poor outcomes. It is clear there is much development to be made in this area, and until then prognosis remains poor with almost 50% of patients eventually dying with the disease . In the RPL have insidious and clinically occult presentations and when they do manifest, can disguise themselves as other common clinical presentations. This in turn can lead to diagnostic difficulty. There are limited cases within literature where retroperitoneal liposarcomas initially present with primarily cardiac-sounding chest pain alone. This highlights an unusual presentation that may not have been previously considered. Surgical resection of both WDL and DDL remains the first-line approach in management. Combination chemotherapy regimes with ifosfamide and doxorubicin have shown to improve progression-free survival but have not enhanced overall survival, therefore early detection is crucial. Targeting oncogenes could provide new avenues of treatment. Due to their high recurrence rate, timely follow-up using a multidisciplinary team approach is significantly important in optimising patient outcomes.


Chylous ascites represents a relatively uncommon condition. In this paper, we present a case of chyloperitoneum associated with pancreatic ductal adenocarcinoma (PDAC) and a review of literature regarding chylous ascites. A 76-year-old male patient was admitted in emergency department with acute abdomen. A pancreatic cancer was suspected. Subtotal spleno-pancreatectomy, for a nodular mass infiltrating the mild and distal portion of the pancreas, was necessary. During surgical intervention in the peritoneal cavity, a moderate quantity of whitish and thick consistency fluid with milk-like appearance was observed to be accumulated. After examination of the fluid, chyloperitoneum was diagnosed. The histologic examination showed a PDAC, with multiple emboli in lymph vessels, with tumor cells with plasmacytoid morphology, diagnosed as lymphangiosis carcinomatosa. The patient died at 3 weeks after surgical intervention. In patients with pancreatic cancer and chylous ascites, suspicion of tumor-related blockage of the lymphatic flow should be suspected. Prognosis of PDAC should be evaluated not only based on the number of lymph node metastases, but also considering the number of lymph vessels with tumor emboli and the architecture of tumor cells. This is the first reported case of a PDAC with plasmacytoid morphology of lymphangiosis carcinomatosa. Chylous ascites, also known as chyloperitoneum or lymphorrhagia, is a rare lesion of adults, with a reported incidence of 1:20,500, which is defined by the presence of a milky and lipid-rich fluid in the peritoneal cavity.Lymphatic fluid is characterized by thick consistency, cell count >500/mL, with lymphocytic predominance, total protein level between 2.5 and 7.0 g/dL, with serum to ascites albumin gradient (SAAG) less than 1.1 g/dL, lactate dehydrogenase (LDH) between 110 and 200 IU/L, glucose level >100 mg/dL, and triglyceride level in ascetic fluid >110 mg/dL.In this paper, we present an unusual case of a ductal carcinoma of the pancreatic tail (PDAC) associated with chylous ascites, as result of tumor emboli-related blockage of the lymphatic flow. A review of literature was also done.A 76-year-old male was admitted to the general surgery department with 1-month history of abdominal pain, weight loss (5 kg in the last month), accusing nausea, and multiple episodes of emesis. He was a social drinker and he quitted smoking 2 years ago. He also related to be treated for arterial hypertension.At the present admission, the tenderness painful abdomen was diagnosed as acute abdomen. The ultrasound examination showed pancreatic enlargement and suspicion of a pancreatic cancer was done. The computed tomography (CT scan) with contrasting substance revealed that a pancreatic nodular mass, larger than 50 mm which infiltrate the pancreatic body and tail, was extended in the splenic hilum and associated multiple supra- and subdiaphragmatic adenopathy.Bilateral deep vein thrombosis of the femoral and popliteal veins were associated and interpreted as Trousseau's sign. Emergent laparotomy was decided.The signed informed consent for surgical intervention and publication of data was obtained before surgery.The exploratory laparotomy revealed an infiltrative tumor mass of the mild portion of the pancreas, penetrating the celiac trunk, inferior mesenteric vein, and spleno-portal confluent, with peripancreatic adenopathy. A moderate quantity of whitish and milky-like fluid was identified in the peritoneal cavity and was collected for biochemistry examination.Subtotal spleno-pancreatectomy was performed, with the suture of celiac trunk, inferior mesenteric, and portal vein. The surgical specimens were sent for histopathological examination.Laboratory examination of the peritoneal fluid revealed 295 mg/dL triglycerides, more than 500 cells/mL, with the majority of them being lymphocytes, a protein count of 5.4 g/dL, with SAAG of 0.94 and LDH of 187 IU/dL. The glucose level of the abdominal fluid was not quantified. With five out of six diagnostic criteria achieved, the diagnosis of chylous fluid was established.Macroscopic examination of the surgical specimens revealed a 50 × 40 × 40-mm white and infiltrative mass involving the middle and distal portion of the pancreas, with direct infiltration of the spleen hilum, free pancreatic lateral and posterior margin and crossing of the pancreatic anterior margin. Multiple tumor deposits were also identified in the peripancreatic tissue.Microscopically, the well-defined tubular structures, some of them being hugely dilated, alternated with poorly differentiated areas . The tuThe microscopic features, correlated with the immunoprofile of the tumor cells and clnicopathological characteristics, allowed the diagnosis of a pathologic tumor-node stage III (pT4N2) poorly differentiated PDAC with lymhangiosis carcinomatosa (carcinomatosis of lymph vessels) and chyloperitoneum.The postoperative evolution was unfavorable, the chylous ascites was persistent, despite persistent drainage, and patient died at 3 weeks after surgery.In children, congenital abnormalities and traumatic disruption of the lymph vessels are the commonest causes of chylous ascites. In adults, this is an extremely rare lesion, which can be related on tumor and nontumor lesions .In developed, western countries, abdominal tumors, cirrhosis, and iatrogenic lymph vessels disruption during surgery accounts for more than half of chylous ascites, while in developing countries, the most frequent etiologies responsible for this condition are infectious diseases like tuberculosis and filariasis.The main mechanisms of acquired chylous ascites are the following ones: traumatic disruption of thoracic duct, obstruction of lymphatic flow, caused by infectious agents or tumor cells, fibrosis of the lymph vessels wall, in patients with autoimmune diseases or after radiotherapy, or increased lymph fluid production, such in cirrhosis or cardiovascular diseases.Although rare, malignancies such as lymphomas , Kaposi sarcoma, leukemias, neuroendocrine tumors or adenocarcinomas of the gastrointestinal tract, and carcinomas of lung and endometrium were described to be the possible causes of chylous ascites.As regarding the pancreas, chylous ascites was reported as a rare complication of iatrogenic lesions of the lymphatic channels during cephalic duodenopancreatectomy with extensive lymphadenectomy.Even though it is not the most common cause of chylous ascites, PDAC can cause it via lymphangiosis carcinomatosa, respectively obstruction and disruption of lymphatic channels flow. Representing one of the most lethal tumors worldwide, PDAC is the 12th most common encountered cancer worldwide, with an incidence of 4.2 per 100,000 and over 330,400 deaths per year.As the lymph node metastasis is the most significant prognostic factor of PDAC, in a recent study, the possible prognostic role of the degree of lymphatic vessel invasion was emphasized.A grading system of lymphatic invasion (ly) was proposed by the Japan Pancreatic Society, which suggested to be used in daily diagnosis and classify cases based on the following four-tier code: ly0 (no evidence of invasion), ly1 (slight invasion), ly2 (moderate invasion), and ly3 (marked invasion).Besides the lymphangiosis carcinomatosa, another aggressive indicator was the histological aspect of the tumor cells. The primary tumor showed tubular structures, but plasmacytoid morphology was seen in the tumor emboli and lymph node metastases. Although rare, gastroenteropancreatic plasmacytoid carcinomas are considered high grade tumors, which aggressivity seems to be induced by the epithelial mesenchymal transition (EMT) phenomenon revealed by loss of E-cadherin and nuclear translocation of β-catenin due to alteration of the Wnt/β-catenin pathway.In pancreas, plasmacytoid morphology was described in cytologic specimens, in “lipid-rich variant of pancreatic endocrine tumors”99mTechnetium-labeled human albumin.Independently by localization, the plasmacytoid carcinomas are known to be predisposed to intraperitoneal spread and carcinomatous ascitesThe present case highlights the need for a more attentive preoperative evaluation of patients with PDAC and at the same time, the negative role of associated chylous ascites, in these patients.No data were published yet regarding the relation between the number of involved lymphatic vessels and risk of chylous ascites even about the minimum number of lymphatic vessels with tumor emboli that can be used as a negative prognostic factor, in patients with PDAC of the pancreatic tail.


A 40-year-old woman presented erythematous patches that evolved with hyperchromia on her left forearm after contact with a myriapod . She comThe patient signed an informed consent form. Since this is a case report, ethics committee approval was not required.


Purpose: To review the current options in the management of Warthin tumors (WTs) and to propose a working management protocol. Methods: A systematic literature search was conducted using PubMed and ScienceDirect database. A total of 141 publications were selected and have been included in this review. Publications were selected based on relevance, scientific evidence, and actuality. Results: The importance of parotid WTs is increasing due to its rising incidence in many countries, becoming the most frequently encountered benign parotid tumor in certain parts of the world. In the past, all WTs were treated with surgery, but because of their slow growth rate, often minimal clinical symptoms, and the advanced age of many patients, active observation has gradually become more widely used. In order to decide on active surveillance, the diagnosis of WT must be reliable, and clinical, imaging, and cytological data should be concordant. There are four clear indications for upfront surgery: uncertain diagnosis; cosmetic problems; clinical complaints, such as pain, ulceration, or recurrent infection; and the patient’s wish to have the tumor removed. In the remaining cases, surgery can be elective. Active surveillance is often suggested as the first approach, with surgery being considered if the tumor progresses and/or causes clinical complaints. The extent of surgery is another controversial topic, and the current trend is to minimize the resection using partial parotidectomies and extracapsular dissections when possible. Recently, non-surgical options such as microwave ablation, radiofrequency ablation, and ultrasound-guided ethanol sclerotherapy have been proposed for selected cases. Conclusions: The management of WT is gradually shifting from superficial or total parotidectomy to more conservative approaches, with more limited resections, and to active surveillance in an increasing number of patients. Additionally, non-surgical treatments are emerging, but their role needs to be defined in future studies. The Warthin tumor (WT) has been identified as the second most frequent benign tumor of the parotid gland, following pleomorphic adenoma . WT is mWTs usually present as a slowly growing, painless, or mildly uncomfortable swelling or mass on the inferior pole of the parotid gland, which often feels soft. Around 15% of WTs are multifocal in the same gland and in approximately 10% of cases are present bilaterally . WTs havThe most common treatment has been a superficial or partial superficial parotidectomy. However, there still exist controversies on the extent of the surgery and in recent years extracapsular dissection is increasingly used. In fact, when a tumor is found during the follow-up, it is likely attributed to a second tumor rather than a true recurrence due to inadequate resection, given the fact that a WT may be multifocal . FurtherA scoping review of the current literature was conducted using PubMed and ScienceDirect databases from 1980 to 2021, with the last update on 18 May 2021, for English language publications using the following search criteria in the title or abstract: “parotid”, coupled with “Warthin’s tumor”, “Warthin tumor”, “Warthin’s tumor”, “Warthin tumor”, or “Cystadenolymphoma”. The search strategy aimed to identify publications that discuss treatment of WTs. When there was information in the abstract addressing WT treatment, the full-text article was reviewed. References from any full-text articles were cross-checked to ensure the inclusion of all relevant publications . The resThe preliminary literature search identified 581 publications. After sorting and removal of duplicates, 141 papers were retrieved and reviewed in detail. The highest evidence level reached was retrospective comparative studies (evidence-based medicine level III). However, most studies were retrospective case series (level IV). The 141 studies included a total of 8649 patients with WT of the parotid gland.Given the restraints in the number of references allowed by the journal, only 50 references are presented within the review. The 141 articles selected for the manuscript can be found in The diagnosis and, hence, the incidence of WTs has steadily increased since the original description of Aldred Scoot Warthin (USA) in 1929 . He wrotSo, the WT was rarely reported until at least 1929, but slowly has become the second most prevalent benign tumor and accounts for 4% to 25% of all salivary gland tumors [Recently, three studies from Germany described a rising incidence of WTs ,11,12. LDifferent explanations have been proposed for this rising incidence. The most common explanation is the increase of tobacco consumption. Smokers have eight times more risk of developing WTs compared with non-smokers. As tobacco use increased from 1920 to 1980 in Europe, this can probably explain part of the incidence growth in the period from Warthin′s original description. However, a retrospective study from Austria by Kadletz  demonstrAnother possible explanation is that due to the increasing use of imaging studies in daily practice in recent years  there are more diagnoses of WTs in asymptomatic patients that would not have been otherwise diagnosed . As a matter of fact, a significant number of WTs present as incidentalomas, especially in positron emission computed tomography . Due to In any case, the increase in its incidence in combination with a significant number of asymptomatic cases makes the debate on optimal management truly relevant.Three aspects must be evaluated as follows: (1) clinical data, (2) imaging, and (3) cytology.The most important clinical information includes age , smoking history, and location of the tumor . In addImaging is especially important and can certainly help in the diagnosis of a WT  identifying the triad of small oncocytic cells arranged in cohesive sheets or in papillary structures, numerous polymorphic lymphocytes, and a granular proteinaceous “dirty” background is used for the diagnostic . In contThe Milan System for Reporting Salivary Gland Cytopathology is gaining popularity and, following this reporting schema, WTs showing all these components fall within the diagnostic Category IV.A “Benign Neoplasm”, while oncocytic-predominant tumors might be classified as Category IV.B “Salivary Gland Neoplasm with Uncertain Malignant Potential (SUMP)” . A recenMacroscopically, a WT is an encapsulated, soft, and fluctuant, round to oval mass. Not uncommonly, lesions can be multiple. The cut surface is tan-brown, smooth, or lobulated with multiple cystic spaces containing a brown to green viscous fluid. Microscopically at scanning magnification, the tumors are well-circumscribed, exhibit variable papillary and cystic architecture, and show a combination of oncocytic epithelial elements and lymphoid stroma . Some leMAML2 gene rearrangement can solve the question, as a metaplastic WT does not harbor this molecular alteration [WTs can undergo infarction, either spontaneously or after a traumatic event such as FNAB, and when this phenomenon occurs, the term metaplastic WT is used . Microscteration .MAML2 rearrangement confirms the malignant diagnosis [On the other hand, a variant mucoepidermoid carcinoma—the so-called Warthin-like mucoepidermoid carcinoma—may be particularly problematic and must be distinguished from a WT . Histoloiagnosis ,25. Anotiagnosis ,27. NoneSurgery currently remains the primary recommended treatment of WTs. The extent of the surgery depends on the size and location of the tumor ,29. BaseSurgery is most frequently recommended when WT causes cosmetic concerns and objective clinical deformity is the patient′s primary complaint and concern . Other cExtent of resection, varying from minimal surgeries to reduce postoperative complications and sequelae, to more extensive surgical procedures to lower the possibility of recurrences or metachronous WTs, is still controversial. Attempts have been made at the classification of parotid tumors in terms of size and location to aid with determining the extent of surgical excision ,29, but Although in the past some authors  did recop = 0.004). Permanent facial palsy was significantly more common after total parotidectomy  than in multifocal extracapsular dissection  (p = 0.000). The authors concluded that the functional benefit of multifocal ECD was counterbalanced by the advantage of total parotidectomy in terms of second WTs.Even in the case of multiple WTs, Mantsopoulos et al.  comparedEven when multifocal ECD is possible, we believe this option must be employed only for selected patients and by dedicated surgeons with experience in multifocal ECD. The consensus  for multAs most WTs are lateral to the facial nerve, the most common strategy has been lateral  parotidectomy. Therefore, different authors presented it as the most common surgical approach performed in WTs ,36. AddiAs the majority of WTs are situated in the level II (parotid tail), parotidectomy II, or partial lateral  parotidectomy, is the most commonly performed less extensive surgical procedure instead of lateral parotidectomy. Leverstein et al.  stressedIn recent years, many authors have favored ECD in WTs. Witt el al.  reviewedHowever, ECD has generated some controversies, as it is a less standardized technique and long-term data are less extensive than with standard techniques. As mentioned, one must keep in mind that  the incoAn even more conservative surgical procedure than ECD for WTs has been proposed by Mantopoulos et al.  These auWTs usually occur in patients over 50 years of age, many WTs have been found incidentally, and they are often asymptomatic. The risk of malignant transformation is extremely low, and the growth rate can be slow. Thus, some authors propose AS as the first step for those tumors ,43,44. AThere is a trend to recommend 6 months of clinical follow-up with ultrasonographic evaluation to assess interval growth. The advantage of AS is to avoid surgery considering that some tumors remain asymptomatic over a long period of time, and some may even shrink. There have been reports of partial or complete resolution of a WT following fine needle aspiration cytology ,43,45.The standard advice for smokers should be smoking cessation. This will benefit this population because continued smoking increases the risk of metachronous WTs .The main drawback of AS is the potential variability in the behavior of a WT: some remain asymptomatic, whereas others may grow in a short period of time. Patients with tumors that grow progressively will eventually have to undergo more extensive surgeries. Schwalje et al. studied the growth rate of WTs  and founCurrently, the AS approach should be considered in all cases for which immediate surgery is not indicated .Experience with non-surgical options in the management of WTs is limited. Three recent studies described three potential new approaches: microwave ablation (MWA) , radiofrOne recent publication  presenteAnother recent publication  analyzedRecently, Mamidi et al.  publisheThese three non-surgical options may have good potential, as demonstrated in the management of other neoplasms, and may change the management of many of these tumors in the future. However, more evidence with long-term prospective outcome studies is needed to establish their proper role before widespread use.From this review, it appears that the incidence of WT diagnosis has progressively increased over the last decades in Europe, without a clear cause. In some countries, it has become the most frequent benign tumor of the parotid gland. This high incidence stresses the importance of discussing the controversies in its management. A reliable diagnosis is based on concordant clinical, imaging, and cytology data. In doubtful cases, surgical resection is advised to obtain a definitive histopathological diagnosis. If the diagnosis of a WT is proven, upfront surgery is indicated in cases of cosmetic or clinical complaints, or the patient′s wish, if medically reasonable. In the remaining cases, active observation is an option and should be offered to the patient.When the surgical option is chosen, the extent of surgery must be personalized. Category I or II (less than 3 cm) tumors probably are best treated with conservative resections. In larger tumors, most authors favor more extensive resections, including superficial parotidectomies or even total parotidectomies when the deep lobe is involved. In selected cases, alternative non-surgical treatments are emerging, i.e., microwave ablation or radiofrequency ablation and ultrasound-guided ethanol sclerotherapy, which may play an important role in the treatment of WTs in the future. More studies are needed to establish the role of these treatment modalities.