Gastric glomus tumors (GGTs) are benign tumors that typically occur in the submucosa of the gastric wall. Glomus tumors typically occur in the subungual region of the finger and rarely manifest in the stomach. Diagnosis is challenging as these tumors lack specific clinical features, radiographic findings, and endoscopic findings. In prior cases, endoscopic ultrasound with fine-needle aspiration has been utilized to make a pre-operative diagnosis. In our case, pathology from general endoscopy was consistent with a GGT. Thus, our patient was accurately diagnosed by esophagogastroduodenoscopy (EGD) with conventional biopsy. Glomus tumors result from cells of the glomus body and are typically benign. When glomus tumors occur in the stomach , they typically occur in the submucosa of the gastric wall. Most patients are definitively diagnosed post-operatively or have endoscopic ultrasound as these tumors lack specific clinical, radiographic, and endoscopic features. Herein, we present a case of a 44-year-old female with lower abdominal pain who was diagnosed with a mesenchymal neoplasm favoring gastric glomus tumor on biopsy specimen following esophagogastroduodenoscopy (EGD) and it was later confirmed as glomus tumor on subtotal gastrectomy specimen following laparoscopic partial gastrectomy specimen.A 44-year-old female with a past medical history of multiple sclerosis, chronic constipation, and depression presents to gastroenterology clinic for the evaluation of abdominal pain. She developed abdominal pain of the bilateral lower quadrants over the course of three months associated with intermittent nausea. She had no history of gastrointestinal bleeding. Her past surgical history is significant for a laparoscopic cholecystectomy. Her medications include fingolimod, escitalopram, and famotidine. Family history did not include a history of gastrointestinal malignancy. Physical examination showed a soft and non-tender abdomen with no other significant findings. She was started on fiber and laxatives to alleviate any component of constipation-related pain. However, in light of no improvement with these measures, the decision was made to proceed with EGD.Her EGD revealed a normal esophagus and a 1.5-centimeter umbilicated gastric tumor located in the greater curvature of the stomach with a shallow ulcer on top of it that was oozing blood. The bleeding was treated with bipolar cautery, and hemostasis was achieved  and blood in the stool (25%) and that 14% of patients were asymptomatic . Lower aWhile diagnosis by conventional endoscopic biopsies is possible, it is difficult. This is due in part to the intramural location of these lesions impeding sufficient specimen collection . Most arHowever, our patient’s endoscopy with conventional biopsy was suggestive of gastric glomus tumor, thus, EUS was not necessary in our case. Furthermore, CT scan demonstrated that the mass was contained to the stomach without any evidence of metastatic disease. Cases of gastric glomus tumor reported are managed by laparoscopic gastrectomy, which is the surgical modality chosen for our patient . FindingOur case highlights two important points. First, our patient was accurately diagnosed by EGD with conventional biopsy. This was likely due in part to the growth pattern of this patient’s tumor into the gastric cavity. For this reason, EUS with FNA was deemed unnecessary and the patient was spared from another procedure. Second, the ulcerated and umbilicated appearance of tumor also emphasizes the variety of ways glomus tumor may manifest on endoscopy.In conclusion, we presented a case of a 44-year-old woman with abdominal pain who was diagnosed with gastric glomus tumor by endoscopic biopsies and underwent laparoscopic resection. Maintaining a high index of suspicion for such tumors during endoscopy will help in achieving adequate sampling. Pre-operative diagnosis is difficult for gastric glomus tumors but is important in that it allows for more conservative workup and surgical planning.


Pulmonary manifestations of benign metastasizing leiomyoma (BML) usually include multiple well-defined, round, bilateral nodules. Low-grade endometrial stromal sarcoma (LG-ESS) is a rare uterine tumor. A 70-year-old woman visited the clinic complaining of acute cough and dyspnea in April 2017. Chest computed tomography (CT) revealed pneumothorax and multiple pulmonary nodules. She had a history of hysterectomy for uterine leiomyoma 23 years ago. Biopsy revealed that the pulmonary masses were consistent with BML. However, the patient had two subsequent episodes of acute, recurrent respiratory distress, accompanied by massive pleural effusions and hydropneumothorax over the next two years. A chest CT performed for acute dyspnea revealed large and multiple hydropneumothoraces. The size and distribution of pulmonary masses were aggravated along with cystic changes and bilateral pleural effusions. Given this aggressive feature, additional immunohistochemical findings and gynecologic pathologist review confirmed the correct diagnosis to be LG-ESS. After initiating anti-estrogen therapy, the patient achieved a partial response, without recurrence of symptoms, for 28 months. Metastatic LG-ESS responds well to anti-hormonal therapy. If the clinical pattern of a disease is different than expected, the possibility of a correction in the diagnosis should be considered. Benign metastasizing leiomyoma (BML) is a very rare condition that usually affects women of reproductive age with a history of uterine leiomyoma (LM) resection or hysterectomy ,2. It isLow-grade endometrial stromal sarcoma (LG-ESS), a subtype of endometrial stromal tumors, is a very rare tumor of low malignant potential and is characterized by the proliferation of short spindle cells with low nuclear atypia and low mitotic index . LG-ESS A 70-year-old woman visited the clinic complaining of acute cough and dyspnea in April 2017. A chest X-ray and chest computed tomography (CT) revealed pneumothorax in the left chest and multiple nodules in both the lungs .2 . She has not received any type of estrogens such as hormonal therapy. No other special medical history or medication was recorded. Video-assisted thoracoscopic surgery was performed for the treatment of pneumothorax, and tissue biopsy was performed to confirm the diagnosis of lung nodules. Based on the patient’s medical history and serial review of radiological findings, the histological diagnosis was BML. Abdominal CT, which was performed to determine the extent of the disease, revealed other masses in the pelvic cavity. However, the pelvic mass was asymptomatic. Excisional biopsy of the pelvic mass was also performed after stabilization of the pneumothorax. Similar to the pulmonary masses, the pelvic mass was also diagnosed as BML. Immunohistochemical staining was positive for estrogen receptor (ER) and progesterone receptor (PR) at both tissue sites. Symptoms improved after resolution of pneumothorax, leading to the decision to regularly follow-up the patient without further treatment.The patient had been diagnosed with bilateral lung nodules in 2002 (15 years prior) at another hospital and was aware of the lung lesions. The patient was closely followed up without treatment since diagnosis, as no active symptoms were noted. However, regular follow-up appointments were discontinued by the patient 7 years ago. She had undergone bilateral salpingo-oophorectomy with hysterectomy due to uterine myoma in 1994 (23 years prior). Comparison of previous chest CT performed outside the hospital between 2002 and 2008 revealed that the size and number of pulmonary nodules had slowly increased, although the patient did not complain of any symptoms during this period. The body mass index of the patient was 20.9 kg/mSubsequently, the patient experienced two more episodes of recurrent dyspnea owing to increased pleural effusion within the two years following the initial onset of symptoms. A chest CT performed at the time of the third hospitalization for acute dyspnea in June 2019 revealed large and multiple hydropneumothoraces and bullae with massive bilateral pleural effusions .The size and distribution of the pulmonary masses were aggravated along with cystic changes. Considering the rapid growth in a relatively short time and associated distressing symptoms, the decision was made to initiate active antitumor treatment instead of continuing with conservative management and close observation. The patient had previously undergone bilateral salpingo-oophorectomy and was menopausal. Therefore, letrozole, an aromatase inhibitor, was initiated at 2.5 mg once daily. At this time, considering the patient’s aggressive and rapid clinical progression, which was not considered benign, the possibility of malignancy, rather than BML, was raised. Therefore, it was decided to review the surgical specimens of the lung and pelvic masses from 2017. Microscopic examination revealed that the metastatic lung nodules were small, uniform, characterized by bland tumor cells with spindled nuclei and scant cytoplasm, in the background of rich small arterioles or capillary networks . MitoticJAZF1 translocation, molecular alterations could not be evaluated.Immunohistochemical (IHC) staining showed that desmin was expressed in some tumor cells. The tumor cells showed patchy cytoplasmic immunoreactivity with CD10, while additional immunohistochemical staining revealed that caldesmon was diffusely positive in the tumor cells. Diffuse nuclear positivity of tumor cells with Wilms’ tumor-1 (WT-1) was also noted . Based oAfter initiating hormonal therapy, the size and number of lung masses decreased on subsequent chest CT, and bilateral pleural effusions disappeared completely. The size of the pelvic masses also decreased slightly but not to the extent observed in lung lesions. Although tumors were still unresectable, patient condition has been stable without significant toxicity from the treatment or recurrence of symptoms for 28 months . Her treThe most common site for BML is the lungs . Since BThe reasons for misdiagnosis of BML in this case can be summarized as follows: (1) Pulmonary BML was initially suggested based on patient’s gynecological history. Review of old medical records from another hospital (from 27 years ago) indicated that the reason for the patient’s hysterectomy was bulky uterine LM; (2) Since the discovery of lung masses in 2002, the patient had no symptoms for more than 15 years and had a very indolent course, thus excluding the possibility of malignancy; (3) Histology obtained from both lung and pelvic masses indicated BML diagnosis. Correct diagnosis would benefit from re-review of surgical specimens from the hysterectomy performed 23 years ago. Unfortunately, this was impossible due to specimens being obtained too long ago, and the patient underwent the operation in another hospital. It is possible that the hysterectomy specimens of the patient would be consistent with LG-ESS, if they could be re-reviewed. It has already been reported that the histological diagnosis of the primary lesion was changed to LG-ESS retrospectively based on pulmonary metastatic lesions after several decades . In contBecause of these complexities, the clinician’s rational suspicion for the diagnosis, and expert pathological evaluation by an experienced gynecologic pathologist were essential for the accurate diagnosis of LG-ESS . From a JAZF1-SUZ12, JAZF1-PHF1; for HG-ESS, fusions of YWHAE-NUTM2, ZC3H7B-BCOR); hence, it would be helpful to conduct a molecular test, if possible [Because none of the above immunohistochemical markers are specific, and their expression patterns vary , several cases would be difficult to evaluate by IHC staining alone. Our case also showed patchy positivity for desmin, diffuse positivity for h-caldesmon, patchy positivity for CD10, and diffuse positivity for WT-1. Ultimately, the key criterion to differential diagnosis between LM and LG-ESS is morphology . Typicalpossible ,27,28.No standard treatment has yet been established for LG-ESS. Radiotherapy and surgical excision can be considered even when metastatic lesions are resectable .Since proliferation and differentiation of endometrial stromal cells are regulated by estrogen and progesterone, hormonal therapy has been a mainstay for recurrent or metastatic tumors. ER and PR were expressed in up to 80% and 90% of LG-ESS cases, respectively . ProgestInterestingly, in the case of metastatic and unresectable BML and LG-ESS, hormonal therapy can be considered as both tumors are hormone sensitive and show estrogen and PR expression . In the Because of the rarity of LG-ESS, the clinical course of the disease has not been clearly characterized. It has been known that the period from initial curative surgery to recurrence varies widely and may even exceed 20 years . AlthougThis patient’s metastatic LG-ESS responded well to hormone therapy and showed a very indolent course for a considerable period of more than 15 years, even without any treatment. In this case, it was possible to correct the diagnosis based on the clinician’s recommendation. Therefore, when a clinical pattern different from that already known is encountered, the possibility of diagnosis re-evaluation should be considered, especially in rare diseases.


Primary sternal lymphoma represents a rare entity which must be evoked in front of a sternal mass especially as its treatment is different from that of sarcomas, the principal etiology of sternal masses. Primary sternal lymphoma represents a rare entity which must be evoked in front of a sternal mass especially as its treatment is different from that of sarcomas, the principal etiology of sternal masses. The patient firstly consulted in November 2019. Systemic symptoms as fever, night sweating, or weight loss were absent. The clinical examination revealed a firm painful mass of the manubrium. There were no inflammatory signs of the skin. A first chest computed tomography (CT) revealed a poorly limited osteolytic lesion of the manubrium measuring 20 × 13 × 40 mm with multifocal interruption of the anterior and posterior bony cortex. There was a deep extension to the mediastinal tissue as well as to superficial layers (Figure Postoperative course was uneventful. On macroscopy, manubrium was enlarged and the cut surface was white, homogeneous. The cortical bone was deformed with focal rupture. The posterior tissue contained lymph nodes measuring 5 mm‐3 cm. Histological examination revealed sternal and lymph nodes infiltration by sheets of large round cells with scanty cytoplasm and round nuclei containing two or three nucleoli; mitoses were numerous. There was no chondroid differentiation. Immuno‐histochemical staining showed high and diffuse positivity for CD20 and CD79a Figure . Margins3Primary tumors of the sternum are rare, accounting less than 1% of all primary bone tumors.The absence of specific signs of sternal lymphomas makes the diagnostic difficult. In fact, clinical signs are usually a firm sternal painful swelling, progressing since several weeks.Taking into consideration the frequency of malignant nature of sternal tumors, a histopathological confirmation is often necessary before any treatment, especially that in some cases, sternal resection with a curative oncological intent may be large with a complex reparation.The diagnostic of DLBCL is based on histological examination with immunohistochemical testing. Referred to World Health Organization classification of soft tissue and bone tumors, the group of a single skeletal site with or without regional lymph node involvement is considered primary lymphoma of bone. Expression of CD20 represents a therapeutic target. Indeed, anthracycline‐containing chemotherapy coupled to Rituximab is considered currently as the first‐line treatment of CD20‐positive DLBCLs.4The diagnosis and treatment of sternal tumors may represent a real challenge. Even if chondrosarcomas are the most common, rare tumors such as DLBCLs must be kept in mind, especially that treatment strategies are different.None declared.WA and AH: collected data, research, and manuscript writing. GBH, MR, and AL: collected data and research. NG: collected data and correction of the manuscript. IF: involved in correction of the manuscript.Published with written consent of the patient.


Pilomatrixcarcinoma is a very rare follicular neoplasm that shows matrical differentiation. The majority of these lesions originate de novo, while only a few cases of transformation of pilomatricoma  have been described in the literature. The neoplasm affects mostly middle-aged males with a male-to-female ratio of 3–4:1. The most common localizations are the face, head, trunk and extremites, though there are a few reports of pilomatrixcarcinoma of the eyelid, eyebrow, axilla and clitorid. Here, we describe the first case of a pilomatrixcarcinoma on the anterolateral surface of the first toe of the left foot of an 83-year-old patient, which developed in less than six months and led to amputation of the distal phalanx. We report a brief review of the current literature with particular emphasis on histopathological features useful for diagnosis. An 83-year-old man was referred to our hospital due to the onset of a grayish nodule that appeared a few months earlier on the anterolateral surface of the first toe of the left foot in the perionichial area. The patient had no significant history of skin cancer and was undergoing therapy for essential arterial hypertension. The laboratory tests showed only a slight increase in the Erythrocyte sedimentation rate (VES), with all other parameters completely normal. The dermoscopic study of the lesion revealed a solitary nodule, about 3.0 cm in diameter, and on palpation, it appeared as a firm nodule. After a standard radiograph was performed, it was decided to subject the patient to an incisional biopsy to ascertain the nature of the lesion. The diagnosis of adnexal-type carcinoma was made, even if the intrinsic characteristics of the biopsy did not allow a nosographic diagnosis of certainty. The patient then underwent a distal phalangectomy with grafting of a skin flap to close the skin break.Gross examination of the sample confirmed the presence of an exophytic-polypoid lesion that seemed to infiltrate the deep plane A. A sectGross specimen: an exophytic lesion is obvious on the anterolateral surface of the first toe (*) A; the suAfter sampling, processing, paraffin-embedding and microtome-cutting, five-micron-thick sections were obtained and stained with routine staining (Hematoxylin-Eosin). Histologically, lesions appeared as a poorly circumscribed and asymmetric neoplasm, without ulceration of overlying epidermis C. NeoplaTo ensure that it was an adnexal lesion, an immunohistochemical reaction was carried out for Beta-catenin, which was found to be positive mainly at the level of the membrane of the matrix cells but also weakly present at the level of the cytoplasm D. Diagnosis of Pilomatrixcarcinoma was made.About 135 cases of Pilomatrixcarcinoma were been published in the English language literature ,3,4,5,6.The clinical suspicion was squamous carcinoma, although this was not completely in accordance with the rapid timing of onset, more typical of malignant adnexal neoplasms ,6. HistoSome authors have described ,7 nucleaWe briefly described a new onset site of pilomatric carcinoma of the first toe of an elderly patient, with no apparent signs of immunocompromise. A careful histopathological evaluation and integration of clinical-anamnestic data, together with the knowledge of this entity, are fundamental prerequisites for a better outcome for the patient.


Pleuropulmonary malakoplakia is a rare granulomatous inflammatory condition characterized by the accumulation of histiocytes that contain basophilic inclusions called Michaelis-Gutmann bodies . It is usually reported in patients with acquired immunodeficiency syndrome. We present clinical, radiological, pathological features and management of a rare case of pulmonary malakoplakia in an immunocompetent male patient with a past history of empyema treated with surgical decortication. Clinically, the patient presented with shortness of breath, productive cough and lethargy. On imaging, Computed Tomography of Thorax showed multiple nodular lung masses and nodular pleural thickening with marked Fluorodeoxyglucose Positron Emission Tomography avidity raising suspicion of advanced pulmonary malignancy. Characteristic Michaelis-Gutmann bodies were identified on histopathology, confirming the diagnosis of malakoplakia. The patient was medically managed with a long course of antibiotics. On follow-up, there was a significant clinical and radiological improvement. Pulmonary malakoplakia is a rare entity, with very few cases reported worldwide, and even fewer in immunocompetent individuals. A 72-year old male was referred to the pleural clinic for right-sided empyema diagnosed on CT Thorax a and b. Few months later, the patient presented with breathlessness, lethargy, productive mucoid cough with small volume haemoptysis and weight loss over 6 kg. The patient was upgraded to an urgent cancer pathway and further investigations such as chest x-ray, CT scan of thorax a and b aAn ultrasound-guided biopsy of right-sided pleural thickening was performed .Fig. 4UlThe core biopsies were largely replaced by fibrosis. Within the fibrosis, dense lymphoplasmacytic infiltrate and Von Hansemann histiocytes containing granular eosinophilic cytoplasm were seen. Von Hansemann histocytes are known to destroy alveoli leaving fibrotic interstitium behind. Many of these granular histocytes contained concentrically layered targetoid basophilic inclusions typical of Michaelis-Gutmann calcific bodies .Fig. 5 granular cytoplasmic staining, confirming the presence of PAS+ bacteria within the von Hansemann histocytes. The MGB were positive for Von Kossa stain, a staining method used to highlight calcium deposits (Image 7c and 7d). Grocott stain, a staining method for highlighting the carbohydrate wall of fungi, was negative for fungal elements, and no granulomas were identified. Differential diagnoses based on morphological features using hematoxylin and eosin (H&E) included:Pulmonary malakoplakia was diagnosed based on the presence of MGBs confirmed with Von Kossa stain.A decision was made to step down from the cancer pathway and continue treatment with a long 10-week course of ciprofloxacin and carbocisteine. The patient improved clinically, and interim CT showed regression of soft tissue masses and nodularity in the right hemi thorax on follow-up .Fig. 6CTPerforming image-guided biopsy completely changed the diagnosis from advanced lung malignancy on imaging to a potentially curable inflammatory condition.Pleuropulmonary malakoplakia is a rare granulomatous inflammatory condition characterized by the accumulation of granulomatous masses mimicking malignancy. It is essentially a histopathological diagnosis characterized by the accumulation of macrophages containing characteristic intracellular or extracellular inclusions referred to as MGB. The term malakoplakia is derived from Greek word ‘malakos’ meaning soft, and the word ‘plakos’ meaning plaque. The condition was initially described by Michaelis and Gutmann in 1902 Pathogenesis is uncertain but believed to be due to defective lysosomal activity leading to defective phagocytosis and accumulation of intra-cytoplasmic deposition of fragments from bacteria, iron, and calcium, which would form the MGB •Rhodococci equi•Proteus mirabilis•Pseudomonas aeruginosa•Yersinia•Staphylococcus aureus•Fungal infectionsGenitourinary tract is the most common site representing 58%-80% of cases, with most cases reported in females and associated with infection by gram-negative bacteria such as Escherichia coli and Klebsiella sp. Gastrointestinal tract and retroperitoneal sites are the second most common sites, contributing to 12%-15% of cases. Other rare sites include lung, liver, bone, skin and uterus. Other organisms associated with malakoplakia are:Most patients have some form of immunosuppression, including solid organ transplant, autoimmune disease requiring steroid use, or chemotherapy. Alcoholism, chronic systemic disease, poorly controlled diabetes and malignancy can also play a role.Pulmonary malakoplakia is a rare diagnosis with very few cases reported worldwide, the first case reported by Gupta et al. in 1972 Clinically and radiologically, pulmonary malakoplakia can mimic tumors, abscesses or infections such as tuberculosis Histologically, there is a collection of foamy histiocytes or von Hansemann cells containing basophilic inclusion with clear halos called MGB. These inclusions are phagolysosomes containing undigested bacterial fragments. Biopsy is diagnostic.The treatment is mostly conservative and consists of a course of antibiotic depending on the organism isolated in culture.Malakoplakia most commonly affects the genitourinary system in female patients with chronic bladder infection.Clinical, radiological and histopathological correlation is essential for diagnosing pulmonary malakoplakia to prevent unnecessary surgical intervention. Treatment of malakoplakia is usually conservative by a long course of antibiotics.Although rare, pulmonary malakoplakia should be considered in unusual infections occurring at unusual sites, especially in immunocompromised hosts.Written informed consent taken for publication of case report.A written informed consent for the publication of this case has been taken from the patient. A consent form can be attached if required.


Introduction Brachial plexus lipomas are extremely rare benign tumors that may cause slow progression of neurological deficits leading to thoracic outlet syndrome. Up to now, surgery remains challenging. The aim of this study is to present our surgical treatment regime and long-term neurological outcome in three cases of giant brachial plexus lipomas and to show results of systematic review.Patients and Methods Retrospective analysis of our database “peripheral nerve lesion” to identify patients suffering from brachial plexus lipomas between January 1, 2012, and December 31, 2019. Systematic review was performed for literature published until March 31, 2020, analyzing PubMed, Google Scholar, Scopus, and the Cochrane Collaboration Library independently by two authors.Results Over the past years, three patients suffering from giant brachial plexus lipomas attended to our neurosurgical department. All patients underwent preoperative magnetic resonance imaging (MRI), ultrasound examinations, and electrophysiological testing. Tumors were removed microsurgically via anterior/posterior, supraclavicular/infraclavicular, and combined approaches. The patients were accessed postoperatively by MRI and clinical follow-up. Systematic review of the literature revealed 22 cases, which were analyzed in regard to demographics, surgical treatment, and neurological outcome.Conclusion Brachial plexus lipomas are an extremely rare cause for brachial plexus compression. Total microsurgical removal with intraoperative electrophysiological monitoring is the treatment of choice with excellent long-term MRI and clinical outcome. Brachial plexus tumors are relatively rare, and treatment is often challenging due to the complex anatomical location with adjacent nervous and vascular structures. In the majority of the cases, lipomas are benign asymptomatic soft tissue tumors showing only slow progression. Nevertheless, in very rare cases, deep-seated lipomas can grow to gigantic size measuring more than 10 cm of lengthThis report presents our microsurgical treatment regime of brachial plexus lipomas with intraoperative electrophysiological monitoring and ultrasound assistance. Furthermore, systematic review was performed.Retrospective analysis of our database “peripheral nerve lesion” revealed three cases of large brachial plexus lipomas all causing neurogenic TOS (nTOS). We analyzed medical records and preoperative/postoperative magnetic resonance imaging (MRI) and performed follow-up examinations to evaluate the long-term outcome.The study was approved by the Institutional Review Board .Systematic review was performed for literature published until March 31, 2020, analyzing PubMed, Google Scholar, Scopus, and the Cochrane Collaboration Library independently by two authors. Search keywords comprised “lipoma,” “brachial plexus, brachial plexus neuropathies or brachial plexus neuropathy.” Inclusion criteria were articles published in English presenting the clinical course, peripheral nerve location, and the treatment regime.Furthermore, the reference lists of included articles were reviewed to identify and include additional eligible articles. Those studies were meticulously cross-referenced to ensure that patients were not included in multiple articles . The syA 62-year-old male patient presented with a pectoral subcutaneous mass lesion. The tumor showed progressive and visible growth over a period of more than 7 years, finally causing atrophy and a severe paresis of the triceps brachii muscle, the biceps brachii muscle, the deltoid muscle, and the supraspinatus muscle. Electrophysiological testing revealed an impairment of the left brachial plexus and MRI showed a large lipomatous tumor extending from the area of the triceps brachii muscle toward the supraspinatus muscle, the clavicle, and the brachial plexus on the left side (8 × 7 × 6 cm). Total piecemeal tumor resection via a two-portal supraclavicular and infraclavicular approach and neurolysis finally led to a slight improvement of the paresis on the follow-up examination 12 months after surgery .A 61-year-old male patient presented with a 10-year history of right-sided TOS causing hypoesthesia of digitus IV and V, a severe paresis of the triceps brachii muscle, the biceps brachii muscle, and the dorsal and palmar interossei muscles. Ultrasound and MRI of the neck depicted a large lipomatous mass (10 × 7 × 5 cm) compressing the right brachial plexus. Electrophysiological testing showed impairment of the axillary nerve. Total tumor resection via a dorsal suprascapular, infraclavicular approach and neurolysis finally led to improvement of the hypoesthesia 4 weeks after surgery. The severe paresis did not improve until the first neurological follow-up 15 months after surgery .A 56-year-old female patient presented with a progressive swelling of the left neck and shoulder over a period of around 2 years. Preoperative MRI revealed a left-sided brachial plexus lipoma with contact to the brachial plexus. Total tumor resection finally led to long-term relief of the symptoms. Follow-up examination 9 months after surgery revealed no neurological deficit.The patient was positioned in supine position and ultrasonography showed the supra- and infraclavicular lipomas under the pectoral muscle. Skin incision along the pectoral muscle to the axilla was followed by subcutaneous preparation toward the fascia of the muscle. Further preparation in the infraclavicular fossa visualized the lipoma beneath the clavicula. The capsule of the lipoma was then mobilized microsurgically. Further preparation was achieved via a second skin incision above the clavicula. Bipolar electrical stimulation  was performed at the medial parts of the lipoma to test each nerve structure proximally and distally with voltages from 2 to 5 mA showing a vivid motor response. Mobilization of the tumor capsule was followed by piecemeal removal of the lipoma toward the brachial plexus using the Sonoca 300  after nerve stimulation. A hemostasis procedure and subsequent removal of the lesion were followed, using bipolar coagulation. At the end, total tumor resection was achieved, and electrophysiological nerve stimulation showed that the displaced brachial plexus was not harmed .Database search revealed 450 articles. Total 382 articles were excluded after analyzing the title and the abstract. The full text of the remaining 68 articles was reviewed and 58 articles were excluded afterward. In total, 10 articles were included,Three variants  of TOS have been described depending on the underlying pathophysiology.An extremely rare cause for nTOS is large lipoma adjacent to the brachial plexus, usually presenting as a subcutaneous mass and upper limb or shoulder pain. Lipomas are benign, slow-growing soft tissue tumors and the most common mesenchymal tumor with an estimated incidence of 10%.They can arise adipose tissue in any part of the body. Lipomas are commonly located in the back, thigh, forearm, chest, and the posterior neckLipomas should be differentiated from other brachial plexus tumors. Most common benign brachial plexus tumors are schwannomas and neurofibromas.Nonoperative and surgical approaches have been described as therapy of TOS.Lipomas adjacent to major nerves and vessels should be removed by microsurgical excision with electrophysiological neuromonitoring to prevent neurological deficits. Blind aspiration may injure these structures, resulting in a major bleeding or neuromuscular dysfunction with paralysis.Although advances in surgical strategies including peripheral nerve microsurgery have improved the outcome, there is still a risk of causing intraoperative damage. Preserving the neurological function while trying to achieve gross total resection should be the principle treatment goal. Therefore, intraoperative neurophysiological monitoring combined with intraoperative high-resolution ultrasound represents an effective technique for identifying and monitoring functional integrity of both the spinal cord and the nerve roots in real time. The benefit of intraoperative neurophysiological monitoring for preserving neuronal structures and achieving an optimal postoperative functional outcome was proven in several studies.In our opinion, microsurgical resection with intraoperative electrophysiological monitoring should be performed to remove the tumor in total and to avoid nerve injuries.Brachial plexus lipomas are an extremely rare cause for TOS and are typically diagnosed several months delay after the initial symptoms. Microsurgical removal under permanent intraoperative electrophysiological monitoring should be the treatment of choice as it is safe and has a favorable outcome.


Ascaris in urinary bladder is an extremely rare phenomenon. It may occur after fistula formation between urinary and gastrointestinal tract or by retrograde migration of adult worm, and is associated with complications.A 47-year-old Amhara woman from rural northwest Ethiopia presented with a complaint of difficulty to fully evacuate her bladder of 1 year duration. Ultrasonography showed thickened bladder wall with echo debris. There were also thickened bowel and fluid-filled loops of intestine adjacent to urinary bladder. On cystoscopy examination, there was live ascaris swimming inside the bladder. Enterovesical fistula was entertained and explorative laparotomy performed. Findings confirmed presence of iliovesical fistula. The fistula was divided and the continuity of the intestine restored. The inflammatory mass was subjected to histopathology study and turned out to be benign inflammatory reaction. She was also given antihelminthics. Postoperatively, her course was uneventful, and she was discharged cured.Though it is extremely rare to have urinary symptoms from ascariasis, it is important to have a high index of suspicion for all possibilities. Soil-transmitted helminth (STH) infections like ascariasis are a public health problem in developing countries where adequate method of disposal of human excreta is not available and affect more than one billion people , 2.People infected with ascaris are often asymptomatic. When it becomes symptomatic, ascariasis presents with myriad of clinical pictures depending on intensity of the infection, the nutritional and immunologic status of the host, and the possible complications that may arise. The sites of involvement are mainly lung during larval migration and intestine after full growth of the helminth. Invasion of the biliary ducts and the liver parenchyma may occur. The adult worm has been reported also in pleural cavity, pancreas, peritoneal cavity, lacrimal duct, middle ear, and femoral artery , 4.Urinary complications of ascaris are extremely rare , 6. TherA 47-year-old para five  Amhara woman from rural northwest Ethiopia without remarkable past medical history presented with a complaint of difficulty to fully evacuate her bladder of 1 year duration associated with protruding mass per vagina. Later, she reported voiding was only possible after reduction of the prolapsed organs. She also reported frequent treatment for urinary tract infection with ciprofloxacillin and norfloxacillin in the last 1 year at a nearby health facility. She has no history of smoking or alcohol consumption. She is a farmer living with her husband and five of her children, and is socially active.On examination at admission, she was chronically sick looking with normal blood pressure (110/70 mmHg), pulse rate (88 beats per minute), and temperature (36.5 ℃). She had pink conjunctiva, nonicteric sclera, no anterior neck mass, clear and resonant chest, quiet precordium, S1 and S2 heart sound well heard, no murmur or gallop, and flat abdomen without tenderness or palpable mass. On genitourinary examination, she had protruded mass per vagina with uterine cervix as the leading point 6 cm below the hymenal ring. Otherwise, there were no pertinent positive findings on other parts of her body. On neurologic examination, she had intact sensory and motor function.On her laboratory tests, her hematocrit was 38% with normal renal  and liver functions  = 22, serum glutamic pyruvic transaminase (SGPT) = 37); human immunodeficiency virus (HIV) test was negative; urine test showed white blood cell (WBC) count more than 10/high-power field (HPF) and there were no ova or parasites on stool examination. On ultrasonography, there was thickened bladder wall with echo debris. There were also thickened bowel and fluid-filled loops of intestine adjacent to urinary bladder  is an extremely rare phenomenon , 6. UA iThough it is extremely rare to have urinary symptoms from ascariasis, it is important to have a high index of suspicion for all possibilities, particularly when other possibilities are absent and the patient is not responding to treatments. This case report demonstrated the consequence of ascariasis, emphasizing the need for regular deworming for vulnerable sections of the community, such as farmers.


The incidence of lymphoma is constantly increasing worldwide. The reasons for this increase are unclear and likely multiple. B cell lymphomas represent the majority of non-Hodgkin lymphomas. Primary orbital localization remains a rare entity to think about in order to avoid missing a therapeutic emergency. In this article, we report the case of a 52-year-old man who has been treated for five years for an inflammatory orbitopathy with steroids, but the worsening of the clinical condition and the installation of exophthalmia led to push investigations and the outcome was a primary orbital lymphoma marginal zone type. The patient was treated by systemic chemotherapy with immunotherapy (RCHOP protocol) with a very good evolution and complete disappearance of the lesion after chemotherapy. Lymphoma is a heterogeneous group of several subtypes of lymphoproliferative malignancies that are usually classified into two categories: Hodgkin lymphoma, and all other lymphomas into non-Hodgkin lymphoma (NHL). Primary ophthalmic malignancies are usually Non-Hodgkin’s lymphoma, with a rate of 1-2% of all NHL [Ocular adnexal NHL can arise from the conjunctiva, lachrymal gland, orbit, or eyelid. Extra-nodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type is the most common histologic type of primary ocular NHL . The ratWe report the case of a 52-year-old man with a long history of tobacco use who was treated over the course of five years for an inflammatory orbitopathy with corticosteroids without improvement. It's evolution was marked by the appearance of exophthalmia with decreased visual acuity.Physical examination found a painless eyelid swelling on the right eye’s internal angle with an important exophthalmia and excessive lachrymal non-purulent secretion. No inflammatory signs were found next to the tumor Figure . DecreasOphthalmological examination revealed a papillary edema of the right eye. Given the progressive nature of the disease, the patient benefited from an orbital magnetic resonance imaging (MRI) that revealed a right exophthalmia secondary to an extra-ocular intra-orbital lesion process that had infiltrated orbital muscles and encompassed the optic nerve Figure . A biopsThoraco-abdominal-pelvic computed tomography (CT) scan, bone marrow biopsy, cerebral MRI, and lumbar puncture had eliminated a secondary localization of lymphoma. Thus, the disease was classified as a stage IEA according to Ann Arbor classification and T3N0M0 according to TNM  classification. Given the long-term evolution, the possibility of metastasis masked by corticotherapy and difficulty to access to PET scan (positron emission tomography) in our context, the patient was treated with systemic chemotherapy following the R-CHOP protocol every 21 days for six cycles  scan, bone marrow biopsy, and cerebrospinal fluid in high grade of malignancy . It may The modified classification of Ann Arbor is typically used to classify orbital lymphoma. However, it has multiple weaknesses as it does not take into consideration the following criteria: laterality, the contiguity or lack thereof in the orbital annexes sites and the involvement of extra nodal sites such as the parotid or sub mandibular galls. Therefore, the TNM  classification was developed by the American Joint Committee on Cancer (AJCC) in 2009 to overcome these weaknesses and provide better precision of extension assessment .Optimal treatment of the early stage orbital adnexal lymphoma is unclear because of the rare cases of early-stage case reports, incomplete staging, or pseudo tumors. A few studies, mostly retrospective, demonstrate that for low-grade lymphoma, radiotherapy alone may provide excellent results with a five-year progression-free survival of 100%. For patients with aggressive lymphoma, chemotherapy with or without radiotherapy has shown better results compared to radiotherapy alone. The combination of chemotherapy and radiotherapy has yielded better results than chemotherapy alone in terms of progression-free survival. Although studies on chemotherapy benefits in early-stage orbital lymphoma are rare, the R-CHOP regimen has proven efficiency in the treatment of extra-nodal marginal zone lymphoma among other chemotherapy associations with anti-CD20 antibody molecules .Orbital adnexal marginal zone lymphoma is a rare affliction. Biopsy with immunohistochemical study should be practiced in the etiological assessment of inflammatory orbitopathy. While the Ann Arbor classification has multiple weaknesses, the TNM classification is better adapted to classify orbital lymphoma. There is no treatment consensus concerning early-stage orbital lymphoma.


Cyst of the canal of Nuck is a rare abnormality of the female inguinal canal that can present similarly to a hernia. If incompletely obliterated, the patent canal of Nuck may predispose to an inguinal hernia or hydrocele due to direct communication with the abdominal cavity. Such defects are normally detected and repaired in early childhood but can also present later in adult life. We report the case of a 44-year-old woman who presents with a fluctuant, mobile and irreducible left-sided groin mass. Ultrasound of the groin identified a cystic structure in the canal of Nuck. The patient underwent successful open herniorrhaphy with excision of the cyst and mesh repair of the inguinal canal. Subsequent histopathological examination also revealed concurrent endometriosis of the canal of Nuck. A systematic approach to differential diagnoses for a female groin mass, further investigations and management are discussed. A groin mass, referring to swellings located in the inguinofemoral region at the junction of the upper leg and lower abdomen, is a very common presentation. The clinical features of a groin mass vary in size, shape, tenderness and consistency, reflecting various possible underlying pathological processes, including hernias, infection, neoplasms, vascular or congenital abnormalities . While aA 44-year-old female presented to her general practitioner with a 1-month history of a left-sided groin mass. The mass was occasionally painful and was more prominent when standing and straining. It was not associated with any abdominal or pelvic pain, vomiting, constipation, dysuria or vaginal discharge. She was otherwise in good health with a background history of stage 3 cervical intraepithelial neoplasia, which was treated with large loop excision of the transformation zone. Her surgical history included two cesarean sections. On examination, the mass was lateral to the left pubic tubercle and measured ~2 cm in diameter. It was mobile, fluctuant and irreducible. Although it was more prominent upon standing, there was no cough impulse. The overlying skin was not erythematous and there was no associated local lymphadenopathy. The abdominal and vaginal examinations were unremarkable.The patient was referred for an ultrasound (US) of the left groin, which showed a contained cyst in the inguinal canal consistent with a CCN . She wasGroin masses in females are less widely encountered than in males due to key anatomic variations of the inguinal canal between sexes. Notably, males have a larger and more prominent inguinal canal, containing the spermatic cord and obliterated processus vaginalis, which accompanied the descent of the testes into the scrotum. This descent may leave an opening in the abdominal wall through which males are more susceptible to an indirect inguinal hernia . On the Clinically, CCN presents as a palpable, fluctuant, reducible or irreducible swelling in the inguinolabial region, which can be either painless or moderately painful . OmentalThe inconsistent clinical presentation of the more unusual groin mass differentials poses a diagnostic challenge; therefore, ultrasonography is recommended as the first-line imaging modality as it can accurately differentiate between cystic or solid lesions. US appearance typically shows an oval thin-walled cystic lesion with smooth borders and without internal vascularity , 9 Fig.. CT and Surgery is often recommended even for an asymptomatic mass due to the strong association between CCN and inguinal hernias . ReferraIn conclusion, a female inguinofemoral mass is a common presentation with a wide variety of differential diagnoses. CCN should be considered due to its similar presentation and close correlation with inguinal hernias. Endometriosis of the canal of Nuck or inguinal canal is also possible and is confirmed upon histology. Ultrasonography is the first-line imaging modality in distinguishing between solid and cystic groin masses before referring for surgical management.


Sjögren’s syndrome (SS) is a systemic chronic autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands, as well as oral and ocular dryness. Among the late complications, malignant lymphoma is the most serious complication of SS. The risk of lymphoma in patients with SS has been estimated to be approximately 7–19 times higher than that in a generally healthy population. Although various histologic subtypes of lymphoma can occur in patients with SS, mucosa-associated lymphoid tissue (MALT) lymphoma accounts for 48–75% of malignant lymphomas that are frequently located in the parotid gland. However, MALT lymphoma affecting the tongue in patients with SS is extremely rare. Here, we share our experience with a unique case of MALT lymphoma of the tongue, originating from the minor salivary gland tissue in a patient with SS. Through this case report, we emphasize that MALT lymphoma should be considered in the differential diagnosis of a tongue mass in patients with SS. Sjögren’s syndrome (SS) is an autoimmune disease characterized by lymphocytic infiltration of the exocrine glands, such as the salivary and lacrimal glands. In addition, immune abnormalities, such as the production of various autoantibodies, including anti-SS-A and SS-B antibodies, and increased levels of polyclonal immunoglobulin are also observed. As the exocrine glands are destroyed, the production of saliva and lacrimal fluid is reduced, causing dry eyes and mouth. This condition is clinically diagnosed when specific serum autoantibodies are detected. Patient prognosis is affected by complications, and malignant lymphoma is one of the most severe complications . The risThis was an observational case study that did not alter the patient’s management and clinical outcomes. Thus, ethical approval was not required for this case report, and patient consent was waived due to the retrospective nature of the study.9/L). Computed tomography (CT) was performed using a dual-layer detector CT unit  to evaluate the tongue mass, but it was difficult to identify the lesion because of metallic dental artifacts  to diagnose SS .In terms of significant findings other than these classification criteria, most of the radiological findings of SS-associated MALT lymphomas have been observed in the parotid gland, such as (1) the solid-cystic form is more common than the solid form on CT and MRI, and the lesion may show calcification and clear or unclear boundaries and may occur solitarily or in multiples, and (2) the parotid gland may show diffuse swelling with a honeycomb-like appearance or multiple solid cystic changes in the parenchyma . In contPatients with MALT lymphoma generally have a good prognosis, and when diagnosed, they can be cured with surgical excision only. Furthermore, chemotherapy and radiotherapy can be considered when there are limitations to the surgical treatment.In conclusion, we described an extremely rare case of MALT lymphoma in SS patient, presenting as a painless tongue mass, with clinical, radiological, and histopathological findings. In clinical practice, the radiological and clinical findings of MALT lymphoma can be nonspecific, as shown in our case, and the rarity of SS-associated MALT lymphoma in the minor salivary gland can lead to an even more challenging diagnosis. Therefore, throughout this case report, we highlight that a meticulous radiological review with awareness of the pathophysiological association between SS and lymphoma may be greatly helpful in establishing an accurate diagnosis.


Aneurysmal bone cysts are rare lesions, comprising one to six percent of primary bone tumors. Despite benign, those may be locally aggressive. We report a pediatric case with an atypical presentation. The patient was a seven-year-old boy, admitted to an emergency room due to right inguinal pain, without a history of trauma. The symptoms had acute onset and worsened gradually for five days. Radiographs revealed a cystic lesion on the proximal right femur and two longitudinal fractures. After further diagnostic work-up and given the probable diagnosis of an aneurysmal bone cyst, surgical treatment was performed. The diagnosis was then confirmed by histopathological analysis. After surgery, the patient maintained severe pain, having an important range of motion (ROM) and muscular strength reduction on the affected limb. As so, the patient engaged in a daily tailored Physical Medicine and Rehabilitation (PMR) program, for four months. After concluding the treatment plan, the patient was asymptomatic: recovery of both ROM and muscular strength was achieved, as well as the ability to return to previous daily-life activities. This is a paradigmatic case in which a rare condition with a rare presentation was displayed after several others were ruled out, requiring a multidisciplinary approach. Althoe trauma . Despite having a benign nature, aneurysmal bone cysts can be locally aggressive. Recurrence rates of up to 70% have been reported, generally in children with open growth plates, and within the first two years after surgical removal ,2. Epidemiologically, aneurysmal bone cysts usually develop during the first two decades of life, with no clear gender preference, most often on the metaphysis of long bones -6. TheseClinical symptoms are usually indolent, but possibly rapidly progressive. Pain is the most common symptom, usually insidious, progressing from several weeks to months. Nonetheless, a minority of patients present with a sudden onset of pain . Swelling, stiffness, deformity and decreased range of motion (ROM) can also be reported .Radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) are suitable diagnostic methods; nevertheless, MRI is the most appropriate method to define fluid areas and to rule out other diagnoses. Pathologic features consist of blood-filled spaces, separated by osteoid tissue ,6. USP6 Therapeutic options are variable and dependent on the location and size of the lesion, but the standard of care is surgical resection . SeveralPhysical Medicine and Rehabilitation (PMR) programs have a significant role after surgical intervention, targeting pain control, scar desensitization, ROM recovery, muscular strengthening, functional limb reeducation, and balance and gait training . We report a pediatric case of an unusual presentation of a large aneurysmal bone cyst, in which a multidisciplinary approach was adopted.A 7-year-old boy, without any relevant background and/or a history of trauma, was admitted to the emergency room due to right inguinal pain that extended to all right inferior limb (RIL). The symptoms had acute onset, worsened gradually for five days, and were refractory to anti-inflammatory/analgesic drugs. A giving-away feeling and gait claudication were also reported. Physical examination revealed severe pain on active and passive RIL mobilization, predominantly on internal and external hip rotation, and the patient was unable to walk. Radiographs revealed a cystic lesion on the proximal right femur, with thin sclerotic margins (“eggshell”), nearby the great trochanter, and two longitudinal fractures in its anterior and superior strand Figure . A CT hiPMR evaluation was performed on the sixth postoperative day. The pain was graduated by the Numeric Scale of Pain (NSP) which ranges from 0 to 10 ; ROM wasAfter discharge on the following day, a daily PMR outpatient program was started. The goals of the rehabilitation program were pain control, scar desensitization, hip and knee ROM increase, RIL muscular strengthening, balance and gait training, and autonomy and participation recovery. The sessions included a combination of manual therapy, play-based neuromuscular reeducation, proprioceptive and gait training. Manual therapy was performed for scar mobilization and desensitization, ROM recovery, and isometric strength training of the quadriceps, external hip rotators, abductors and extensors, progressing to isotonic muscle strengthening. Gait training encompassed progressive load on the affected limb: partial weight-bearing and subsequent full weight-bearing after three weeks and six weeks, respectively. The patient was monthly evaluated and the PMR program was adjusted according to the clinical evolution, lasting for four months. A significant improvement in pain, scar characteristics, hip and knee ROM, muscular strength, and gait ability was found Table . On the We report a pediatric case of an aneurysmal bone cyst that presented with sudden onset of pain due to a pathological fracture. Despite infrequent, PMR doctors should be aware of this entity, especially due to its challenging clinical presentation, differential diagnosis, and specific therapeutic needs.Regarding the differential diagnosis of aneurysmal bone cysts, namely malignant bone tumors, both imagiological and histological findings are important to rule out a variety of lesions, specifically fibrous dysplasia, eosinophilic granuloma, giant cell tumor, non-ossifying fibroma, osteoblastoma, myeloma, chondroblastoma, and telangiectatic osteosarcoma ,7. In thConcerning the surgical treatment approach, the patient was submitted to bone curettage of the lesion followed by bone grafting, which is the standard of care . Also, cAneurysmal bone cysts are a rare entity that may lead to significant clinical and functional impairments. We reported a pediatric case of this entity that had a sudden presentation with pain due to a pathological fracture, in which surgical and rehabilitation treatment were performed with full recovery. PMR program was of utmost importance, both for clinical and functional improvements, so we provide an insight into our tailored treatment plan and its outcomes. Indeed, this is a paradigmatic case in which a rare condition with a rare presentation was displayed after several others were ruled out, requiring a multidisciplinary approach.


Myxomas are benign mesenchymal neoplasms which arise mainly in the heart. The laryngeal localization is very rare. We aim to describe the clinical, histological and therapeutic features of this condition. We report two cases of laryngeal myxomas occurred in male and female patients, presenting with a history of prolonged hoarseness. Laryngoscopy revealed a polypoid mass on the true vocal folds. The lesions were excised with cold instruments. One patient presented a recurrence 4 years after the first surgery. Laryngeal myxoma should be considered in case of a benign looking vocal fold lesion, especially a vocal cord polyp. Histologic exam is the only tool to confirm the diagnosis. It is treated by surgical resection. In the literature, recurrence is rare in laryngeal site, but patients need to be kept on close follow-up.  Myxoma is a rare myxoid tumor. It interests mostly the heart and occurs rarely in the head and neck region . The larCase 1A 59-year-old man with no past medical history was referred to our outpatient clinic with a 2-year history of intermittent hoarseness. He was a smoker with no history of voice abuse. On laryngoscopic examination, there was a polypoidal lesion located in the anterior half of the right true vocal fold with preserved mobility . The lesCase 2A 48-year-old woman with no past medical history presented with hoarseness of 20-year duration. She was a smoker with history of voice abuse. Laryngoscopic examination showed a polypoidal mass located in the anterior half of the two true vocal folds. Rest of the vocal cords was edematous. Vocal cord mobility was normal. She had also a thyroid nodule (size: 2 cm / EUTIRADS (European Thyroid Imaging Reporting and Data System) 5). She underwent right lobo-isthmectomy and direct laryngoscopy with excision of the laryngeal lesion by cold instruments. Histological findings were the same as the first case but the lesion was poorly vascularized in this case: a subepithelial paucicellular lesion, which formed by regular spindle to stellate fibroblast cells within an abundant and hypovascular myxoid stroma. No histological signs of malignancy were found. The lesion was lined by a normal stratified squamous epithelium . The diaMyxoma is a myxoid benign neoplasm of mesenchymal origin -3. It maClinical presentation is similar to common benign fold disorders  . HoarsenMyxoma lacks a fibrous capsule, so it tends to infiltrate the surrounding tissue ,3,5. TheThe main differential diagnosis includes some frequently encountered benign lesions, such as vocal cord polyps, but also several malignancies, such as myxoid liposarcoma, myxoid leiomyosarcoma, myxoid chondrosarcoma, rhabdomyosarcoma, myxoid neurofibroma, low-grade myxofibrosarcoma and low-grade fibromyxoid sarcoma ,7,8. TheMoreover, immunohistochemistry is very helpful in assisting diagnosis: Myxoma cells are negative for desmin, actin and S100 protein . ExcisioThe progression of myxomas is very slow ,5,6. DesNo malignant transformation of laryngeal myxoma has been reported.Although laryngeal myxoma is an infrequent condition, it should be considered in case of a benign looking vocal fold lesion, especially a vocal cord polyp, as in our two cases. Hoarseness is the most common presenting symptom. Histologic examination is an important tool to obtain final diagnosis and differentiation from other possibilities. Laryngeal myxoma is treated by surgical excision. Resection by cold instruments is the preferred approach. In our two cases, myxoma was excised with cold instruments. After surgery, the rate of recurrence is low comparing with myxomas originating outside the larynx. However, patients need to be kept on close follow-up to rule out recurrence. One of our two patients presented a recurrence 4 years after the first surgery.


Retroperitoneal Retrocecal hernias are a rare variety of internal hernias and represent an unusual cause of bowel obstruction. Early diagnosis is based on CT scan and requires knowledge of the pathology in order to avoid small bowel resection. We report a case of retrocecal hernia treated surgically and review the characteristics and treatment of retrocecal hernias in the literature.Our work is a retrospective case report with a descriptive aim concerning a patient operated for retrocecal hernia within the department of general surgery of CHU Ibn Rochd Casablanca.A 72-year-old man presented to the emergency department with abdominal pain and vomiting that have been evolving for 9 days complicated by an occlusive syndrome 36 hours before the admission. The patient was apyretic, and the abdominal examination noted abdominal meteorism predominantly in the right iliac fossa, absence of abdominal scarring, and free hernial orifices. The abdominal X-ray showed air-fluid levels and the abdominopelvic CT scan found clumping of the dilated small intestines posteriorly and below the cecum. The diagnosis of retrocecal hernia was suspected and the patient was taken to the operating room. The operation was performed by laparotomy through a midline incision. On exploration, the cecum and ascending colon were pushed forward and viable bowel loops were incarcerated in a fossa located posteriorly and below the cecum. The procedure consisted of a collapse of the retrocecal ligaments by right coloparietal collapse.A bowel obstruction in an apyretic patient without abdominal scarring or parietal hernia should suggest the diagnosis of internal hernia, which must be investigated. •Retrocecal hernias are a rare variety of internal hernias and represent an unusual cause of bowel obstruction.•Early diagnosis is based on CT scan and requires knowledge of the pathology.•The procedure consisted of a collapse of the retrocecal ligaments by right coloparietal collapse.•We report the case of a retrocecal hernia in an elderly man and describe the anatomy and the characteristic features of this pathology. Because the clinical diagnosis of these hernias is difficult, imaging studies such as computed tomography (CT) and small bowel follow through play an important role.Retrocecal hernia, a type of internal hernia, is rare. It results in strangulation ileus and, therefore, often requires emergency surgery. Early preoperative diagnosis of pericecal hernias is important to avoid small bowel resection. We report a case of retrocecal hernia treated surgically and review the characteristics and treatment of retrocecal hernias in the literature.the work has been reported in line with the SCARE criteria .2A 72-year-old man, with no pathological antecedent, presented to the emergency department with abdominal pain and vomiting that have been evolving for 9 days complicated by an occlusive syndrome 36 hours before the admission. The patient was apyretic, and the abdominal examination noted abdominal meteorism predominantly in the right iliac fossa, absence of abdominal scarring, and free hernial orifices.The abdominal X-ray showed air-fluid levels and the abdominopelvic CT scan found clumping of the dilated small intestines posteriorly and below the cecum , Fig. 2.The diagnosis of retrocecal hernia was suspected and the patient was taken to the operating room. The operation was performed by laparotomy through a midline incision. On exploration, the cecum and ascending colon were pushed forward and viable bowel loops were incarcerated in a fossa located posteriorly and below the cecum . The nec3Internal hernia is defined as the protrusion of a viscera, most commonly the small intestine, through a peritoneal or mesenteric opening, resulting in encapsulation in another compartment . InternaThere are several types of internal hernias, such as those described by Meyers according to their location, of which para-duodenal hernias are the most frequent . ClassicGenerally, these hernias are composed of the terminal ileum and can go up to the right kidney or to the duodenum, pushing forward the cecum or the right colon. They are therefore retroperitoneal hernias.Clinically, pericecal hernias are manifested by symptoms of acute bowel obstruction. Manifestations may range from nonspecific symptoms such as abdominal distension and nausea to acute abdomen and are proportional to the severity of the obstruction. Internal hernias are initially reducible in most cases and symptoms are usually intermittent, which may cause diagnostic delay leading to significant intestinal suffering ,5,6. ThuLarge recesses, such as the retrocecal recess, increase the risk of intra-hernial volvulus. The main differential diagnosis, in the presence of abdominal scarring, is occlusion by flange and/or adhesions .In front of the signs of small bowel obstruction, the volumetric CT scan remains the best way to make an early diagnosis of retrocecal hernias. It shows the agglutination of the ileal coils, often dilated, behind the cecum which is pushed forward. There is a closed loop occlusion aspect with sometimes several "Bird's beak signs", a modification of the vessels  with convergence of these towards the hernial neck ,7,8. Dil4Internal hernia is an increasingly common condition that may be diagnosed confidently with CT in most cases. The radiologist plays an important role in the diagnosis of these hernias and may sometimes be the first to suggest the diagnosis to clinicians but clinical suspicion is highly important to not to miss the diagnosis due to the rarity of this condition.A bowel obstruction in an apyretic patient without abdominal scarring or parietal hernia should suggest the diagnosis of internal hernia, which must be investigated.This work was carried out in collaboration among all authors. All authors contributed to the conduct of this work. They also declare that they have read and approved the final version of the manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.I declare on my honor that the ethical approval has been exempted by my establishmen.None.Not commissioned, externally peer-reviewed.None.Mounir bouali: writing the paper and operating surgeonFatine amine: Corresponding author writing the paper and operating surgeonAbdelilah elbakouri: writing the paperKhalid elhattabi: writing the paperFatimazahra bensardi: study concept.Abdelaziz fadil: correction of the paper.Dr fatine.The authors declare having no conflicts of interest for this article.


Intestinal obstruction is one of the most important cause of acute abdomen. An internal herniation is an uncommon yet relevant clinical entity causing an acute intestinal obstruction that can occur after major bowel surgery. Here, we describe a case of acute intestinal obstruction caused by internal herniation in a patient with muscle-invasive urinary bladder carcinoma who underwent robot-assisted radical cystectomy with an ileal conduit. We also discuss the management of adjuvant chemotherapy-induced leukopenia. Intestinal obstruction is a condition that occurs when the normal flow of bowel contents is interrupted. Mechanical bowel obstruction is responsible for four out of five cases of small bowel obstruction . It can A 39-year-old gentleman presented to the Emergency Department with complaints of abdominal distension with non-passage of flatus and feces for the past six days. He was a known case of muscle-invasive urinary bladder cancer who underwent robot-assisted radical cystectomy three months ago. The postoperative period was uneventful, and he was on adjuvant chemotherapy with gemcitabine and cisplatin and received the last cycle of chemotherapy one week before presentation to the hospital. His symptoms had gradually worsened over the period of past six days. He had average urine output from the ileal conduit. On examination, he had tachycardia (pulse rate: 110/minute) with a blood pressure of 110/70 mmHg. Abdominal examination revealed a distended abdomen with diffuse tenderness and exaggerated bowel sounds. Digital rectal examination showed collapsed rectum with no palpable mass. Clinically, he was diagnosed to have an acute intestinal obstruction.Investigation3 and hemoglobin of 12.2 g/dL.X-ray of the abdomen in the erect and supine position was done, which showed dilated small bowel loops with significant air-fluid levels Figure . BecauseTreatment3.Emergency exploratory laparotomy was performed. Dilated small bowel  was noted along with distal ileum herniating into the mesenteric defect. It had densely adhered to the defect and the right lateral pelvic wall Figure . Adhesio3. Because of immunosuppression, broad-spectrum intravenous (IV) antibiotics (meropenem 1 g IV eight hourly and teicoplanin 400 mg IV 12 hourly followed by IV once daily), antifungal (fluconazole 100 mg IV once daily), and antiviral (acyclovir 300 mg IV once daily) were started. The patient recovered gradually, and total counts increased to 5,000 cells/mm3 on the fourth post-operative day (POD); he was allowed oral intake from POD three and discharged from hospital on POD seven in stable condition.During the postoperative period, total counts decreased further to 200 cells/mmAn internal herniation is a relatively uncommon phenomenon yet a very important cause of acute intestinal obstruction. It is the protrusion of the bowel or other viscera through a normal or abnormal orifice in the peritoneum or mesentery. It can be associated with bowel strangulation or incarceration . InternaSymptoms of patients with internal herniation are non-specific; our patient presented with a typical feature of acute intestinal obstruction because of retro-ileal conduit small bowel herniation.The first case of internal herniation in literature causing intestinal obstruction was reported in 1997 by Kringsman et al. Their patient had a 30 cm gangrenous jejunum segment, which was resected . The secHaving a pre-operative diagnosis of internal herniation hastens the management of the condition. CT scan findings of internal hernias include evidence of small bowel obstruction and occurrence of closed-loop obstruction. Sac-like mass or cluster of dilated small bowel loops at an abnormal anatomic location in small bowel obstruction should alert the clinician of the possibility of internal herniation. Stretched, engorged, and displaced mesenteric vascular pedicle and convergence of vessels at the internal hernia  provide clues to the diagnosis ,10. HoweInternal hernias are a rare but important cause of mechanical bowel obstruction. History of surgery or trauma are pointers toward internal herniation. Contrast-enhanced CT scan of the abdomen may be the best available emergency pre-operative investigation available for the diagnosis of internal herniation. One must ensure to close the mesenteric defect during any bowel surgeries to prevent post-operative internal herniation. In our patient, chemotherapy-induced leukopenia responded well with GM-CSF and was continued till the total WBC counts were within normal limits.


Cystic adrenal tumors are rare with an incidence of approximately 0.06% in the general population. Four main histological types are distinguished: Endothelial cysts of lymphangiomatous or angiomatous origin, pseudocysts, epithelial cysts and cysts of parasitic origin. Surgery is recommended for signs of complications, suspicion of malignancy and large size. In other cases, simple surveillance can be proposed.We report here a case of a lymphangiomatous endothelial cyst of the adrenal gland. The objective is to recall the clinical characteristics and to specify the diagnostic contribution of imaging as well as the therapeutic modalities of this entity. The clinical examination found a patient in good general condition, apyretic, with no palpable abdominal or lumbar mass and an unremarkable cardiovascular examination. Abdominal ultrasound showed the presence of a cystic tumor of the right adrenal gland measuring 35 mm in length.In view of the persistence of low back pain, an abdominal tomography scan was performed, showing a cystic, oval mass of the right adrenal gland, with regular contours, 45 mm long axis, spontaneous density 10 HU with a relative washout of less than 50% as shown in Hormonal exploration was in favor of a non-secreting tumor, with aldosterone, renin, methoxylated derivatives, and dexamethasone suppression test all normal.Given the increase in volume of the cystic mass, as well as the persistence of right lower back pain, the decision was to operate on the patient.A right adrenalectomy was performed by laparoscopic transperitoneal approach, which was performed without any intraoperative incidents and with simple postoperative follow-up and resolution of the clinical symptoms.Anatomopathological examination of the surgical specimen showed a lymphangiomatous endothelial cyst of the right adrenal gland without signs of malignancy, as illustrated in 3Adrenal cysts are rare (0.064–0.18% of autopsy series).The sensitivity of their detection is 100% on MRI, 80% on computed tomography (CT) and 66.7% on ultrasound.The great majority of these cysts are small, unilateral and clinically asymptomatic. On the other hand, cysts larger than 10 cm in diameter may cause sensations of abdominal pain or tension, low back pain, or even gastrointestinal disorders due to compression of the proximal organs. The largest of these are sometimes accessible to abdominal palpation.In our case, the cystic mass was 45 mm in long axis on CT scan and the patient complained of right low back pain.Histologically, four main types are distinguishedThe anatomopathological examination of the surgical specimen of our case concluded to a lymphangiomatous endothelial cyst without signs of malignancy.Radiological studies can be useful for the pre-surgical diagnosis of cystic lesions of the adrenal gland. Computed tomography (CT) has been shown to be very effective in recognizing cystic lesions, but current imaging modalities cannot clearly distinguish benign from malignant adrenal cysts.The histologic nature of the cystic adrenal lesion is often difficult to specify with simple imaging. Only the presence of parietal calcifications suggests an adrenal pseudocyst.In our case, the CT scan confirmed the cystic nature of the adrenal mass, which did not present signs of malignancy, but could not predict its histological nature.Careful analysis, both morphological and hormonal, is necessary in the face of any incidental finding of a cystic adrenal image. The diagnosis of pheochromocytoma necessarily leads to surgical removal of the tumor. In the absence of pheochromocytoma, surgery is recommended  in the presence of signs of complications, suspicion of malignancy and large size (greater than 5 cm). In other cases, simple clinical and CT surveillance can be proposed.In our patient, we opted for a surgical treatment consisting in a right adrenalectomy by laparoscopic transperitoneal approach, in view of the increase in size of the cystic mass and the persistence of low back pain in our patient. The evolution was favorable, with simple postoperative courses, and without signs of recurrence over a 5-year follow-up.4Cystic adrenal lesions are rare, covering a broad spectrum of primary adrenal tumors and may be associated with both benign and malignant adrenal tumors.Distinction between adrenal cysts and adrenal tumors with cystic changes should be made by extensive pathologic sampling of any macroscopically suspicious lesion.Surgery is recommended if there is evidence of complications, suspicion of malignancy, and large size (greater than 5 cm). In other cases, simple clinical and CT surveillance can be proposed.


Actinomyces species which can infrequently affect the large intestine. Disseminated actinomycosis is reported as a rare complication associated with intrauterine devices. We report a case of intra-abdominal actinomycosis mimicking a transverse colon malignancy.Actinomycosis is a rare inflammatory bacterial disease caused by A previously healthy 40-year-old Sinhalese woman was evaluated for intermittent colicky left-sided abdominal pain for 2 months’ duration. Computed tomography of the abdomen showed a circumferential thickening of the wall and narrowing of the lumen of the descending colon with evidence of extraluminal extension to the adjacent parietal peritoneum and abdominal wall suggestive of a stage IV neoplasm. An exploratory laparotomy with extended left hemicolectomy was performed. Macroscopic evaluation revealed a mass lesion with multiple abscesses attached to the transverse and descending colon. Histology was suggestive of actinomycosis with no evidence of malignancy.Abdominal actinomycosis should be considered in a young patient with chronic abdominal pain. It should be understood that the presentation may be vague and highly variable. Computed tomography-guided biopsy/fine needle aspiration or laparoscopy and biopsy may be useful in arriving at a diagnosis and can prevent unnecessary surgical intervention. Actinomyces species, which are anaerobic bacteria [Actinomyces requires the presence of an anaerobic microenvironment to proliferate, and therefore requires the concomitant presence of many other bacteria for this purpose [Actinomycosis is a rare inflammatory condition caused by bacteria . They ar purpose . Actinom purpose . Actinom purpose , 4.Clinical and radiological features of actinomycosis can mimic other benign and malignant abdominal diseases such as tuberculosis, diverticulitis, inflammatory bowel disease and malignancies. Therefore, the diagnosis is usually challenging and the disease is often detected histologically after surgery .In this case report, we present a rare occurrence of intra-abdominal actinomycosis mimicking a large intestinal tumor.A 40-year-old Sinhalese woman who was previous healthy presented with a history of intermittent colicky left-sided abdominal pain for 2 months’ duration. There were no other lower gastrointestinal symptoms, loss of weight or loss of appetite. She was hemodynamically stable. There was no palpable abdominal mass or evidence of peritonitis, and the rest of the history and examination were unremarkable. She did not have a significant family history of illnesses. She was unemployed. Basic biochemistry, which included complete blood count and renal and liver profile, was within normal parameters. Colonoscopy revealed a narrowing of the lumen of the descending colon a few centimeters distal to the splenic flexure. Biopsy showed evidence of resolving infective colitis, with no evidence of malignancy. Computed tomography of the abdomen and colonogram showed a circumferential thickening of the wall and narrowing of the lumen of the descending colon extending from 3 cm below the splenic flexure downwards, with evidence of extraluminal spread through the serosa and infiltration of adjacent parietal peritoneum and abdominal wall, suggestive of a stage IV neoplasm. There was no evidence of abdominal metastasis.Surgical exploration and excision of a probable malignancy was planned. Exploratory laparotomy revealed a mass lesion with multiple abscesses attached to the transverse and descending colon with a narrowed segment at the proximal descending colon. The mass was attached to the omentum and pericolic fat. Multiple enlarged lymph nodes along the inferior mesenteric artery were noted. The patient underwent extended left hemicolectomy with end-to-end colocolic anastomosis.The surgical specimen consisted of transverse colon and descending colon together measuring 370 mm in length and 50 mm in diameter. The lumen of the descending colon was narrowed in a region 130 mm from the proximal resection margin. A mass lesion with multiple abscesses measuring 90 x 70 x 45 mm was attached to the transverse and descending colon at the narrowed segment.Microscopic examination of sections of the mass lesion showed multiple abscesses surrounded by a fibroblastic reaction and a mixed inflammatory infiltrate with foreign body type giant cells. Occasional abscesses contained a few basophilic colonies suggestive of actinomycosis. The lymph nodes showed reactive changes. There was no evidence of tuberculosis, inflammatory bowel disease or malignancy Figs. , 2.Fig. The patient received intravenous penicillin treatment for 10 days followed by oral penicillin for 6 months after reviewing with histology. There were no complications related to surgery. Follow-up assessment after 1 year revealed that the patient was free of symptoms, with no clinical evidence of bowel obstruction.Actinomyces israelii is a filamentous gram-positive bacillus which is a commonly seen constituent of the microflora in the human body [man body . ActinomInvolvement of the abdominal organs was reported in up to 20% of all cases of actinomycosis. The clinical presentation may vary and is known to mimic malignant tumors, inflammatory bowel disease and tuberculosis .Actinomyces is a part of the normal flora in the gut and female genital tract. In the gut, it is normally found in the stagnated segments which are the cecum and sigmoid colon. It normally does not cause any disease. However, factors such as intestinal necrosis, previous abdominal surgeries, foreign bodies, appendicitis and perforation can predispose to infections. The exact mechanism is not known, and some authors postulate that neoplastic or inflammatory processes may contribute to actinomycosis development , 9. SimiActinomycosis is commonly known to occur in the terminal ileum, cecum and appendix and less commonly in the ascending colon. Obstruction secondary to actinomycosis is rare, as the typically affected region of the bowel contains liquid material and has a wider lumen. The involvement of the transverse and the descending colon is rare, which is the region of involvement in the reported case.Actinomycosis has a vast spectrum of presentations. It is known to present with bowel obstruction , multiplOften, actinomycosis is diagnosed postoperatively, although in certain instances histopathological assessment of endoscopically obtained specimens may help in the diagnosis. When actinomycosis presents as bowel obstruction or abdominal mass mimicking a malignancy, the diagnosis by imaging becomes difficult. However, contrast-enhanced computed tomography (CT) scan may sometimes reveal an intra- or extraluminal solid mass with focal areas of attenuation invading the nearby tissues , 18. OftFurthermore, a common finding includes a large mass adjacent to the involved bowel, which is seen in actinomycosis of the colon. In rectosigmoid regions, cystic masses are more commonly seen, while in transverse or ascending colon regions, pure solid masses are commonly noted. These features may help in arriving at a diagnosis . In lateActinomyces obtained from a surgical specimen or needle aspiration of a collection. Endoscopic biopsies usually result in a limited study and only demonstrate chronic inflammation without sulfur granules. This is because of the limited depth of tissue sampling. Sulfur granules represent colonies of Actinomyces. Although this is highly suggestive, it is not a pathognomonic feature of actinomycosis. Sulphur granules may be seen in nocardiosis, botryomycosis and Aspergillus infections [Histopathological and microbiological analyses are key to the diagnosis. A definitive diagnosis is achieved by the presence of sulfur granules and/or culture of fections . Therefofections . In retrHigh-dose intravenous penicillin administration followed by prolonged oral penicillin treatment for at least 6–12 months is the treatment of choice. Penicillin is known to decrease morbidity and unnecessary invasive procedures such as laparotomy . HoweverIn conclusion, colonic actinomycosis should be considered in a young patient presenting with chronic abdominal pain. It should be understood that the presentation may be highly variable, with vague symptoms. Therefore, a high degree of clinical suspicion is essential for diagnosis. CT-guided biopsy/FNA or laparoscopy and biopsy may be useful in arriving at a diagnosis that can prevent unnecessary invasive surgical interventions.


Each SBRT was performed on alternate days in a span of 14 days. The tumors gradually reduced in size with tolerable levels of toxicity. SBRT using CK could be a safe and effective adjuvant therapy for low-grade MFS.Myxofibrosarcoma (MFS) is one of the most common soft tissue sarcomas. Low-grade MFS has a high local recurrence rate, similar to that of high-grade MFS. Hence, appropriate adjuvant therapy is required to control low-grade MFS. In this report, we present a case in which recurrent low-grade MFS was successfully treated with stereotactic body radiation therapy (SBRT) using CyberKnife® (CK) . A 76-year-old man underwent SBRT using CK for recurrent low-grade MFS in the right posterior chest wall after undergoing resection and skin grafting four and three times, respectively. We planned CK treatment separately for each in two parts. For the lesion on the scapula side, the target volume was 109 cm Myxofibrosarcoma (MFS) is one of the most common soft tissue sarcomas affecting middle-aged and elderly people. The optimal treatment for MFS is radical surgical resection, including a wide margin of adjacent disease-free tissue. However, this treatment method may lead to a considerably reduced quality of life. Radiation therapy (RT) has been described as a definitive treatment for unresectable MFS. Furthermore, a novel advanced technique, stereotactic body radiation therapy (SBRT), allows for the delivery of a higher dose of radiation to the tumor while reducing the quantity of irradiation to the surrounding normal tissue. Herein we present a case in which postoperative recurrent low-grade MFS was successfully treated with SBRT using CyberKnife® (CK) .The patient was a 76-year-old man with a past history of ischemic heart disease (on antiplatelet drug), aortic regurgitation after bio-valve replacement, and pituitary dysfunction. His blood type was type AB, Rh (−). In 2012, he presented with an approximately one-year history of a gradually increasing painless mass (9 x 6 cm) in the right posterior chest wall. A dermatologist at the first hospital performed the initial surgery on him without sufficient preoperative evaluation by imaging. The initial pathological diagnosis was a solitary fibrous tumor. In total, he underwent resection and skin grafting four and three times, respectively, in order to treat a tumor on the right posterior chest wall -positron emission tomography (PET)/CT were performed as pretreatment examinations. CT and MRI revealed contrast-enhanced multiple nodules in the right posterior chest wall with irregular surfaces Figure .Enhanced MRI revealed a tail sign, i.e., a thick fascial enhancement extending from the tumor margin, in the right erector spinae muscle Figure . High FDNo other abnormal findings, such as suspected metastasis, were observed.3 and the total prescribed dose was 34.6 Gy, while the lesion on the spinal side had the PTV of 72 cm3 and a total prescribed dose of 36 Gy, both in five fractions  system with MultiPlan® (Accuray). The target lesions were tracked with the Xsight® (Accuray) spine tracking system. The gross tumor volume (GTV) was contoured using planning CT with MRI and FDG-PET/CT. We decided that the planning target volume (PTV) and GTV were the same. For the lesion on the scapula side, the PTV was 109 cmEach SBRT was performed on alternate days in a span of 14 days. The patient felt an improvement in his right upper limb as it got lighter during SBRT. There was no severe adverse event during and after SBRT. The tumor gradually decreased in size and the range of movement of his right upper limb expanded after SBRT. PET performed six and 12 months after SBRT showed a decrease in the uptake of FDG by the tumor Figure . CT and One year after SBRT, the patient continues to lead a normal life. We would like to perform additional treatment using CK when the residual tumor has increased in size.MFS is a fibroblast-derived soft tissue sarcoma that commonly occurs subcutaneously in the limbs of elderly people. MFS accounts for approximately 9% of all soft tissue malignant tumors . In geneComplete surgical resection at the time of primary tumor presentation remains the most effective therapy for MFS. It is generally believed that resection of at least 2 cm around the tumor is needed to ensure a negative surgical margin . The tumRT is a reasonable option for local treatment of tumors in situations where the effect of chemotherapy is uncertain. Sufficient doses of radiation may not be administered for the tumor of the trunk due to difficulty in surgery. Consequently, RT is mostly performed with a palliative aim, such as pain relief. Callegaro et al. have reported that RT was associated with a better local outcome, especially in myxoid liposarcoma, vascular sarcoma, and MFS, without being associated with survival . HoweverCK is an SBRT device with image guidance, and it consists of a robot arm, linear accelerator, and target tracking system. This system can irradiate a target with less damage to proximal organs by moving the robot arm, which has a wide range of motion. SBRT using CK is less invasive as compared with standard surgery and has a shorter treatment period and higher efficacy than CRT. Paik et al. have reported that SBRT using CK for soft tissue tumors yielded acceptable results with irradiation doses ranging from 20 to 48 Gy in one to five fractions . AdditioWe treated the two lesions by alternatively irradiating them every other day to reduce damage to the fragile skin. In the present case, CK radiotherapy was delivered at a prescribed dose of 33 Gy in five fractions, totaling 35-36 Gy over 14 days. Following the treatment, the tumor gradually reduced in size with tolerable levels of toxicity.Appropriate adjuvant therapy is needed to control low-grade MFS due to the high chances of frequent local recurrence. Our case report demonstrates that SBRT using CK might be safe and effective for managing unresectable low-grade MFS. Studies with longer follow-ups are required to further confirm the efficacy and safety of this treatment modality.


An ectopically located gallbladder is a rare entity. Here, we present a case of an ectopic gallbladder with left hepatic lobe agenesis. In this study, we describe the case of a 56-year-old male who was a known diabetic patient. He presented with abdominal pain, which started two weeks prior. Computed tomography (CT) abdomen with contrast was advised by the primary team, which showed an incidental ectopic gallbladder along the right posterior-inferior margins of the liver. Associated with it, there was complete agenesis of the left hepatic lobe, including absent segments II, III, and IV. Most of the commonly encountered ectopic positions include intrahepatic, transverse, retrohepatic, retroperitoneal, suprahepatic, falciform ligament, or under the left liver lobe. Ectopic gallbladders have clinical significance as they alter the clinical presentation of cholecystitis. They create technical challenges during cholecystectomy and other biliary operations and cause misdiagnosis in imaging. A thorough inspection of the biliary tract in patients undergoing surgery is suggested before electrocoagulation. A radiologist must always inform the clinician about the existence of an aberrant gallbladder. Rarely reported congenital liver anomalies include hypoplasia or agenesis of hepatic lobes, absent segment, and agenesis of gallbladder . AgenesiHere, we present a case of an ectopic gallbladder with left hepatic lobe agenesis. A 56-year-old male, who was a known diabetic patient, presented to the surgical outpatient department with a complaint of recurrent abdominal pain, which was persistent for the past two weeks. Contrast-enhanced CT abdomen and pelvis was acquired as a single-phase acquisition at approximately 60-90 seconds after intravenous contrast administration, which showed complete agenesis of the left hepatic lobe, including segments II, III, and IV Figure .The caudate lobe was normal. The main portal vein and its right branch were visualized, whereas the left portal vein was absent Figure . AtrophiWhile both middle and right hepatic veins were well-contrast filled, the hepatic artery was patent Figure .Liver attenuation and enhancement were normal with smooth margins. No hepatic focal lesion was seen. No intra- or extrahepatic biliary dilatation was reported. The ectopic gallbladder was found incidentally along the right posterior-inferior margins of the liver Figure .The patient did not have any history of abdominal surgery or trauma. Neither hepatic infection nor medication was reported in the medical history. Serum liver function tests were within the normal range. In the absence of known acquired causes of liver atrophy or presence of an associated visceral abnormality, the findings were attributed to be incidental and likely explain a congenital origin. Further dedicated ultrasound of liver and gallbladder was performed that confirmed the findings Figure . The patient's follow-up investigation did not reveal any abdominal nor pelvic pathology. He was clinically diagnosed with gastroesophageal reflux disease (GERD). The patient was called and inquired about the medical treatment provided to him, to which he showed a satisfactory response.Congenital liver anomalies are rarely reported. These include hypoplasia, deformed or agenesis of hepatic lobes, absent segment, and agenesis of the gallbladder . AgenesiTo the best of our knowledge and literature review, associated ectopic gallbladder with left hepatic lobe agenesis is rarely reported . It is fUnusual biliary symptoms require keen observation, where misinterpretation of imaging is crucial . The firRadiological imaging is helpful in knowing the presurgical anatomy. These may include computed tomography (CT), endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP). Alternative to invasive exploratory laparotomy or intraoperative cholangiography, radiological imaging has an added advantage of being non-invasive . MultimoLeft hepatic lobe agenesis with retrohepatic gallbladder is a rare anomaly. It is challenging for both radiologists and surgeons. Both should be aware of this condition in surgical planning and for better patient management.


Becker's nevus (BN) is one of the cutaneous hamartomatous lesions that often presents as an acquired, single unilateral pigmented hairy patch on the upper trunk, scapular region, or upper arm. Hereby we introduce a 13-year-old girl with the unusual manifestation of BN with multiple acquired, pigmented hairy patches for six months without any musculoskeletal or developmental involvements. After carefully reviewing the literature, to the best of our knowledge, this is the first case in this regard in Iran. Becker's nevus (BN) is one of the cutaneous hamartomatous lesions that often presents as a single unilateral pigmented patch on the upper trunk, scapular region, or upper arm that could be accompanied by hypertrichosis. Occasionally, BN, especially in multiple forms, may accompany some other cutaneous and musculoskeletal presentations such as pectoralis muscle hypoplasia, limb shortening, congenital adrenal hypoplasia, and pectus carinatum. BN is usually unilateral but few reports of bilateral presentation have been reported. BN affects males more than females (M/F: 5) and is acquired in most cases, but inheritance cases with an autosomal dominant pattern have been reported . The maiA 13-year-old girl with no significant past medical history was referred to our dermatology clinic with a complaint of two hairy pigmented patches on her back that developed six months ago with no precipitating factor. She was the third child of non-relative parents born by normal vaginal delivery after an uncomplicated perinatal period. Her first clinical examination at birth was normal. Her physical and mental developmental milestones were normal. Physical examination revealed two well-defined, irregular-shaped, dark-brown hairy patches on her back , including total body skin examination, gynecologic examination, and abdominal ultrasound study was done that did not reveal any non-cutaneous abnormalities. Evaluation of the patient’s family history did not show similar cutaneous lesions.BN is a cutaneous hamartomatous lesion that mostly presents as a single unilateral hyperpigmented patch. Sometimes, BN may be accompanied by hypertrichosis. The most common predilection sites are shoulder, anterior chest, scapula, and back. Most of the cases are acquired and present in childhood or adolescence. BN can present as an isolated lesion or as Becker's nevus syndrome, in combination with mammary hypoplasia, or any other skin or musculoskeletal presentations ,5. TreatAs mentioned, the most common form of BN is a single lesion, and it is significantly more common in males. Based on the literature review, only two female cases of BN have been reported ,11.Uncommon presentations such as bilateral BN in female subjects have rarely been reported Table .It's worth noting that despite observing cases of BN in Iran, this is the first case of multiple BN from this region. Considering the fact that BN is generally uncommon in females, presenting with multiple skin lesions with no skeletal and developmental disorders in a female is extremely rare. In two cases with multiple BN, it was accompanied by skeletal and developmental disorders ,16. If sBN is a cutaneous hamartomatous lesion that mostly presents as a single unilateral hyperpigmented patch that can present with associated hypertrichosis. In our patient, a 13-year-old girl presenting with two hairy pigmented patches for six months without any musculoskeletal or developmental involvements, microscopic examination showed epidermal papillomatosis, pigmentation of the basal layer, and elongation of rete-ridges. It is worth noting that this is the first case of multiple BN from Iran.