Female reproductive organ angiomas are rarely reported and are accidentally found during surgery. Angiomas arising from infundibulopelvic vessels presenting as adnexal masses are even rarer, and a few doctors have experience in their management.Herein, we report the case of a 40-year-old woman who was admitted after a physical examination revealed an ovarian mass. The physical examination revealed a palpable adnexal mass in the right pelvic cavity. Ultrasound showed a 4.5 × 4.0 × 5.0 cm space-occupying lesion close to the right ovary, which had many echogenic lines and calcifications in its cystic cavity.Right adnexal mass.Laparoscopic surgery was performed in all the patients. During the surgery, the mass was found to be a retroperitoneal hemangioma with distorted and dilated vessels. We separated the right infundibulopelvic vessels and performed tumor resection with minimal blood loss.The patient recovered well, and no abnormalities were observed during the following 2 years. Pathological results showed that this adnexal mass was a type of cavernous hemangioma arising from the infundibulopelvic vessels.Surgical removal of the affected tissues is an aggressive treatment of choice for cavernous hemangiomas. Laparoscopic resection of infundibulopelvic hemangioma is feasible, and gynecologists are qualified for this operation, as long as damage to the iliac vessels is avoided. They are found in many organs, including the skin, mucosa, liver, and brain. However, benign vascular tumors of the female reproductive organs are uncommon. Hemangiomas arising from the ovaries are relatively common. Hemangiomas arising from the infundibulopelvic vessels are extremely rare. To our knowledge, only 2 cases have been reported.,4 Herein, we report a case of cavernous hemangioma, arising from the infundibulopelvic vessels in a woman who underwent surgery for an adnexal mass.Hemangiomas are composed of several vascular proliferations. This is a common soft tissue tumor that accounts for approximately 7% of all benign tumors.The patient was a 40-year-old woman who was admitted after physical examination revealed an ovarian mass. She had right lower abdominal pain during sexual intercourse for a month. Additionally, she had no other subjective symptoms or remarkable medical history. Physical examination revealed a palpable adnexal mass in the right pelvic cavity. Ultrasonography revealed a 4.5 × 4.0 × 5.0 cm space-occupying lesion close to the right ovary, which had many echogenic lines and calcification in the cystic cavity Fig. . Thus, tThe patient underwent laparoscopic surgery on 20/8/2018, and the mass was a retroperitoneal hemangioma with dilated and distorted blood vessels. The mass was then carefully dissected through a peritoneal incision. When we attempted to locate the origin of the dominant vascular supply of the lesion during the dissection process, we found that it was connected to the right ovary and right infundibulopelvic vessels Fig. , 4.The operation time was 90 minutes, and the overall blood loss was 50 mL. The patient made an uneventful recovery to normal health and was discharged on postoperative day 4. Pathological examination results demonstrated that the mass was a type of cavernous hemangioma, consisting of calcified nodules in homogeneously dilated and blood-filled vessels , and racemosum hemangioma. The incidence of cavernous hemangiomas is lower than that of capillary hemangiomas. Clinically, cavernous hemangiomas differ from capillary hemangiomas in several essential features. Cavernous hemangiomas are usually larger and less restricted; therefore, they may infiltrate deep tissue structures more frequently. They usually do not tend to recede and may even be locally destructive by exerting pressure on adjacent tissue structures. Therefore, a large proportion of cavernous hemangiomas frequently require operative resection in contrast to capillary hemangiomas. Because of slow blood flow, dystrophic mineralization in an organizing thrombus leads to the formation of phleboliths in the mass. Cavernous hemangiomas have been recorded in a variety of organs, including the liver, spleen, colon, adrenal glands, bone, mediastinum, central nervous system, and other soft tissues. Genetic investigations have indicated that cavernous hemangiomas from the brain and retina are of autosomal dominant inheritance. Furthermore, the mutation in the KR1T1/CCM1 gene may lead to premature protein termination, which may facilitate the occurrence of retinal and cerebral cavernous hemangiomas. In the female reproductive system, cavernous hemangiomas are mostly found in the ovaries, or sometimes in the uterus, cervix, and fallopian tubes.In our case, the tumor was a cavernous hemangioma with thin vessel walls and diluted cavities, which implicated both infundibulopelvic and fallopian vessels. Cavernous hemangiomas are congenital defects derived from the mesoderm and consist of dilated blood vessels, including huge blood-filled spaces, which are caused by the expansion and thickening of capillary walls. According to literature report, lymphangiomas usually do not have calcifications, and angiosarcomas do not have fatty hyperplasia, but they often show more infiltrative and invasive features in the surrounding tissues. Generally, gastrointestinal stromal tumors and fibromas usually have well-defined and smooth boundaries, which are homogeneous solid hypoechoic masses on ultrasound. They are different from this case.According to the imaging findings of this case, the differential diagnosis should include mature cystic teratoma of the ovary, vascular tumors , and other soft tissue tumors . Our ultrasonic imaging results indicated the possibility of a mature cystic teratoma; therefore, we initially considered a teratoma of the ovary. If possible, an additional contrast-enhanced computerized tomography may help to differentiate the hemangioma from the teratoma.Cavernous hemangiomas of the infundibulopelvic vessels are rarely diagnosed and are often discovered incidentally during health examination or abdominal surgery. Surgical removal of the affected tissues is an aggressive treatment of choice. Based on our operative process and literature review, we believe that retroperitoneal hemangiomas derived from the infundibulopelvic vessels can be resected successfully with low bleeding and minimal invasion by gynecologists qualified for this surgery. Further studies are needed to evaluate the long-term effectiveness of surgery.Conceptualization: Xin Tan, Hongwei Ma.Data curation: Huiyun Tang, Qian Chen.Visualization: Wen Zheng.Writing – original draft: Hongwei Ma.Writing – review and editing: Hongwei Ma.We thank Prof. Gang Shi and Prof. Yuedong He for their assistance with the operation. We would also like to thank Ms. Yiwen Yang for her help with English language editing.


Surgery for dumbbell-type posterior mediastinal tumors (D-PMTs) is difficult because surgeons should confirm the tumor’s extension into the spinal cord and pay attention to the Adamkiewicz artery. We describe two patients of D-PMTs who underwent lateral- or prone-position video-assisted thoracic surgery (VATS). In patient 1 (a 70-year-old woman), the tumor extended to the spinal canal through the fourth thoracic intervertebral foramen. After hemi-laminectomies, she was moved to the lateral position, and the tumor was resected. In patient 2 (a 16-year-old boy), the tumor extended to the spinal canal through the seventh thoracic intervertebral foramen. Additionally, 320-row high-resolution computed tomography showed Adamkiewicz arteries running through the sixth and eighth thoracic intervertebral foramina. After laminectomy, the tumor was resected without repositioning. Prone-position VATS is a useful approach for D-PMTs because it provides a better view of the vertebrae compared with the lateral position. We discuss the advantages and disadvantages of both approaches.The online version contains supplementary material available at 10.1007/s12055-022-01343-0. Among mediastinal tumors, dumbbell-type posterior mediastinal tumors (D-PMTs) are difficult to treat surgically. There are three reasons for this difficulty. First, surgeons must confirm the tumor’s extension into the spinal cavity. Second, the surgical field is always deep around the vertebral body, and the aorta and lung often interfere with the visual field and forceps manipulation. Third, surgeons must pay attention to the Adamkiewicz artery (AKA). We describe two patients with D-PMTs that were resected by lateral- or prone-position video-assisted thoracic surgery (VATS) after orthopedic laminectomy, and we discuss the advantages and disadvantages of each approach.Patient 1: A 70-year-old Japanese woman had a tumor in the left posterior mediastinum that extended to the spinal canal through the fourth thoracic (Th4) intervertebral foramen on computed tomography (CT) and magnetic resonance imaging (MRI) Fig. . Hemi-laPatient 2: A 16-year-old Japanese boy had a tumor in the left posterior mediastinum that extended to the spinal canal through the Th7 intervertebral foramen on CT and MRI Fig. . High-reA larger part of D-PMTs is located on the vertebral side than on the descending aorta side, and maintaining a good surgical field is difficult. McKenna et al. first reported the use of VATS to treat D-PMT in the prone position. This procedure is unpopular probably because of the technical difficulties of VATS in the prone position . HoweverWe described two patients who underwent resection of D-PMTs by lateral- or prone-position VATS with orthopedic laminectomy. Prone-position VATS is considered a safe and superior approach for D-PMTs.ESM 1(MP4 52.4 mb)


Hydatidosis, a common zoonotic disease, especially in countries which are poorly developed, is not only capable of affecting a huge number of humans but also animals.A 40-year-old female presented to our hospital complaining of the left flank and left upper quadrant pain increasing with exertion for three years. Physical findings revealed a firm lump in the left upper quadrant area extending to the left flank about (15cmx14.5 cm) in size. Abdominal CT scan reported a well defined low attenuating fluid density consistent with thick walled cystic lesion in the left upper quadrant, which is not separable from the lower pole of left kidney as well as pancreatic tail, showing significant mass effect over the left renal pelvis resulting in moderate dilatation of left pelvi-calyceal system superiorly. Our case was managed with the removal of laminated membrane of the cyst and followed by Mebendazole therapy.The disease is commonly caused by Echinococcosis granulosus, the parasite mostly takes place in the liver (70 %) and in the lungs (25 %). In 13 % of cases the primary hepatic cyst raptures causing the formation of intraperitoneal cyst, however the primary intraperitoneal hydatid cyst (2 %) and the primary mesenteric hydatid cysts are very rare. Considering the possibility of hydatid cyst especially in the endemic regions is highly recommended because in these regions there are many diversities in the presentation. As surgical excision with subsequent Mebendazole therapy for four months is the proper treatment for these cases.Primary hydatid cyst of the mesentery is rare even in the endemic regions. Thus, it's important to differentiate hydatid disease of abdomen from the other cystic lesions, occured in the abdominal cavity, specially in the endemic regions. •Primary hydatid cyst of mesentery is rare even in the endemic regions•Surgery is the treatment of choice•Peritoneal cystic mass must be consider in differential diagnosis. In 13 % of cases the primary hepatic cyst raptures causing the formation of intraperitoneal hydatid cyst, however the primary intraperitoneal hydatid cyst (2 %) and the primary mesenteric hydatid cysts are very rare. In this article, the author presents a case of primary mesenteric hydatid cyst with chronic pain in left flank and left upper quadrant of abdomen 2A 40-year-old female presented to the hospital complaining of the left flank and left upper quadrant pain increasing with exertion since three years. The patient is married, with no remarkable past medical, allergic, drug and medication history. Physical findings consist of a firm lump in the left upper quadrant area extending in the left flank with the size of (15 cm × 14.5 cm). The mass was mildly tender on palpation and dull on percussion as well. Blood exam results turned out with HB11g%, TLC-8000, Differential Leukocyte count- P64, L30, E5, M1, and B0. Liver and Kidney function tests were normal. Ultrasonography demonstrated a well-defined large cystic lesion in the left upper quadrant of abdomen which had close attachment with inferior pole of the left kidney; minimal hydronephrosis with hydroureter were also observed during ultrasonography. It was not determined whether the mass was neoplastic or other abdominal cystic mass. Liver, Pancreas, Spleen and other organs were found normal. Intravenous Urography has revealed large cyst involving lower pole of the left kidney associated with displacement of collecting system and mild hydronephrosis. Abdominal CT scan reported well defined low attenuating fluid density thick walled cystic lesion in the left upper quadrant which is not separable from the lower pole of left kidney as well as pancreatic tail and the lesion shows significant mass effect over left renal pelvis resulting in moderate dilatation of left pelvi-calyceal system superiorly. The first imaging hypothesis could be infected hydatid cyst; considering the mesenteric cyst the differential diagnosis , Fig. 6.We prepared the patient for Laparotomy with Albendazole twice daily for 1 month. The operation was performed in Ali-Abad Teaching Hospital. On exploration a cystic mass with the size of (14.5 cm × 15 cm × 15 cm) in the mesentery jejunum strictly adhesive with the adjacent organ; liver, pancreas, spleen and other organs were normal. After instillation of sodium chloride hypertonic 20 % inside cyst it was completely excised. However, due to low economic resource, we could not able to perform the histopathologic and serological tests.The operation was successful and the patient was advised to take Albendazole twice daily for one month. During three years of follow-up with multiple visits at Ali-Abad Teaching Hospital the patient didn't complain of any symptoms.3The larvae of the tapeworm Echinococcosis infest as hydatid disease. Humans are mostly infected by Echinococcosis Granulosus species. The Sheep farming and Cattle farming areas such as Mediterranean Sea, Asia North and East Africa, South America, Australia and the Middle East are the regions in which most cases of this parasite are found There are two ways of acquiring this parasite by humans such as direct contact by infected dog and ingestion of the infected food. Embryos reach the liver in 60 %–70 % cases when they migrate through intestinal mucosa and traveling through intestinal lymphatics and venules. The embryos can be carried by blood stream to any organ if they bypass the liver Even though a few primary cases of peritoneal hydatid cyst have been detected, almost all of the peritoneal hydatid cysts are secondary to hepatic cysts. 13 % of abdominal hydatid cyst resides in the peritoneum. The rapture of primary hepatic and splenic cysts (either spontaneous or traumatic and iatrogenic) results in the formation of intraperitoneal hydatid cyst. 2 % of all the abdominal cases of hydatid cysts are consisted from primary intraperitoneal cyst which are very rare. Balik et al. had a retrospective review of 27 surgically treated extra hepatic cysts which took place between 1982 and 1999. Among them 19 patient had coexistent hepatic cysts (70.4 %) eight had only extra hepatic cysts (20.6 %) affecting the spleen (three patients), pancreas (two patients), adrenal glands (four patients), mesocolon (five patients), mesentery of the small intestine (one patient), ovaries (one patient), retroperitonem (four patients) and the omentum (two patients). When the hydatid embryo reaches to the mesentery by means of blood or lymph, it forms a solitary primary mesenteric cyst and no other cysts are present in this case. Mesenteric hydatid cyst can remain asymptomatic for many years and it becomes apparent when it grows causing mass effect on adjacent organs and making slowly growing mass in the abdomen The rarity of cases, lack of specific symptoms, and different appearance of imaging and quite resemblance to the organ's malignancy makes difficult reaching to a correct preoperative diagnosis. In differential diagnosis we should take in to account all the abdominal cystic lesions such us mesenteric, pancreatic, gastrointestinal duplication, ovarian cyst and lymphangia's Careful and complete surgical excision is the optimal treatment but sometimes in order to save other organs from being injured we can perform subtotal or partial cystectomy. To prevent from further spreading, anaphylaxis and to kill the daughter cyst, hypertonic saline or hydrogen peroxide can be used before opening the cavities. To prevent the recurrence Mebendazole and the Albendazole can be used as adjuvant therapy. In the cases in which there are disease recurrence or multiple sites are involved routinely usage of chemotherapy is preferred The preoperative diagnosis has significant importance in preventing the spread of the cysts and seeding of the surgical field. Deaths have also been reported commonly as a result of anaphylactic shock which not only is caused from spillage during surgery but also by taking biopsy mistakenly diagnosed as an intraperitonem tumor 4Primary hydatid cyst of mesentery is rare even in the endemic regions. Thus, it's important to differentiate hydatid disease of abdomen from the other cystic lesions, occured in the abdominal cavity, specially in the endemic regions. Surgery is the treatment of choice however, it should be done with cautions not to spread the daughter cysts throughout the peritoneum and not to cause anaphylactic shock due to dissemination. In all cases of cystic masses in peritoneal cavity hydatid cysts should be considered in differential diagnosis.Not commissioned; externally peer-reviewed.No financial support was provided for this study.The manuscript has got an ethical review exemption from the Ethical Review Committee (ERC) of our institution, as case reports are exempted from review according to the institutional ethical review committee's policy.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.MAA convinced the idea. MAA and SHK operated the patient. MAA and RS was involved in literature review and drafted the manuscript. RS and MAA helped to collect clinical and follow-up data of the cases. RS and KW participated in reviewing the drafted manuscript. MAA participated with the corresponding, editing the drafted manuscript as per journal policy, and submission of the article. All authors read and approved the final manuscript.Not applicable.The corresponding author is the guarantor of article.The authors declare that their work is not funded by any institution, organ, or government and they have no financial support.


Congenital megalourethra is a urogenital anomaly characterized by a cystic dilatation and elongation of the penile urethra resulting from the absence and hypoplasia of the corpus spongiosum and corpus cavernosum, or anterior urethral valve. There are two clinical types: scaphoid and fusiform. Generally, the etiology is unknown, but it is thought to be a defect in mesodermal development. Fewer than 100 cases have been reported in the literature, and the exact incidence is unclear. In most cases, the surgical procedure is challenging and requires extensive reconstructive and/or replacement surgery.We present a 6-month-old boy suffering from a cystic dilatation of the penile urethra along with urine dribbling during micturition since birth. The patient was diagnosed with the scaphoid type of megalourethra and was operated on using reduction urethroplasty. On the 21st post-operative day, we removed the Foley catheter and followed the patient on two occasions (the 45th post-operative day and the 6th post-operative month) with excellent results.The anagement of megalourethra depends on the clinical type. Meticulous surgical technique, the use of fine suture materials with careful handling, and fixation of the vascularized flap are the main principles of an acceptable result. Observation of erectile function and fertility require long-term follow-up. •Megalourethra is a rare urogenital anomaly involving the formation of the anterior urethra.•The etiology is unknown, but it is believed to be a mesodermal developmental defect.•It has two clinical types: scaphoid and fusiform.•The treatment of the scaphoid clinical type is reduction urethroplasty, and the treatment of the fusiform clinical type ranges from sex reassignment to major phallic reconstruction. The c2fr silicon foley catheter as a urethral stent and 6-0 Vicryl suture. In the first stage, a subcuticular running suture was done starting from distal to proximal; in the second stage, a suture was inverted over the first plan (as reinforcement layer)  B; and int layer) C. Followt layer) A&B. On t3Megalourethra is a clinical condition in which penile mesodermal tissues are congenitally deficient due to faulty migration, differentiation, or development of the erectile tissue . IncomplMegalourethra may be associated with other genitourinary tract anomalies. Common associated anomalies are kidney dysplasia-hypoplasia, hydronephrosis, hydroureter, vesicoureteric reflux, prune-belly syndrome, urethral duplication, megacystis, hypospadias, posterior urethral valves, and cryptorchidism. Common anomalies, including VATER  have also been described . The worOur case was a scaphoid type of megalourethra with no associated anomalies. The diagnosis was made upon delivery in the maternity hospital, and presentation for surgical repair was at the age of 6 month. Our surgical technique was reduction urethroplasty using vascularized subdartos flap (VSF) with an acceptable result at the 6th month of follow-up. Meticulous surgery along with fine suture materials and careful tissue handling (vascularized flap) are the mainstays of successful surgical result.N/A.None.The entire process of the article from conceptualization to publication  was conducted and observed by Turyalai Hakimi.Written informed consent was obtained from the patient parents 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.1.Name of the registry: N/A.2.Unique Identifying number or registration ID: N/A.3.Hyperlink to your specific registration (must be publicly accessible and will be checked): N/A.Dr. Turyalai Hakimi.Not commissioned, externally peer-reviewed.The author declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Generalized peritonitis with sepsis is a common general surgery emergency. The most likely implicated structure for generalized peritonitis with pneumoperitoneum is the gastrointestinal tract with urgent explorative laparotomy being the most definitive treatment. In this particular case, perforated diverticulitis was suspected and upon an exploration of the abdomen, frank pus in the setting of normal colon was noted. Some common differential diagnoses for frank pus in the abdomen include viscus perforation, pancreatic necrosis, gangrenous cholecystitis, or penetrating abdominal trauma. Here, we report a rare occurrence of peritonitis secondary to uterine rupture from pyometra. Pyometra is defined as the accumulation of pus within the uterine cavity secondary to the inability to adequately drain the uterine cavity and accounts for only 0.038% of gynecologic-related hospital admissions . A PubMeOur case reports an 80-year-old female with a history of type 2 diabetes mellitus who presented to the emergency department with abdominal pain, vomiting, diarrhea, and fever for one day. Per the family, the patient had also been complaining of generalized weakness and falls in the preceding week. She was hypotensive on presentation, which responded to fluid resuscitation. Her abdominal exam revealed diffuse tenderness to palpation with distention. She had a leukocytosis of 13,000, bandemia of 30%, and lactic acidosis of 4 mmol/L. She underwent computed tomography (CT) of the abdomen and pelvis, which revealed pneumoperitoneum. Figures Bacteroides fragilis and Escherichia coli. A perforation was found at the posterior wall of the uterus, which was leaking frank pus (Figure She was immediately taken to the operating room for an exploratory laparotomy, which revealed purulent peritonitis and normal appearing bowel. Intraoperative cultures were obtained which grew s Figure . The uteEscherichia coli, Bacteroides, Streptococcus, and other anaerobes [Bacteroides fragilis and Escherichia coli, which is consistent with expected organisms from perforated pyometra.Any gross disruption of the cervical canal may inhibit the ability of the uterus to properly clear its secretions. This leads to uterine infections and may culminate in frank perforation. Although more common in post-menopausal women, the spontaneous rupture of the uterus in the setting of pyometra is still very rare ,5. Ruptunaerobes ,5. In thPresentation of a ruptured uterus may be nonspecific such as in our case, with patients presenting only with nonspecific abdominal findings. Typical presentation includes purulent vaginal discharge, postmenopausal bleeding, and generalized abdominal pain . Other nThough correct preoperative diagnosis is always optimal, in the setting of pneumoperitoneum with hemodynamic instability, the definitive treatment is emergent exploratory laparotomy. In the presence of uterine pyometra, intraoperative gynecologic consultation should be obtained. Timely treatment with gynecologic surgery, early administration of broad spectrum antibiotics, abdominal washout, and ICU admission remain the mainstay of treatment. Keeping a broad differential but having a high level of suspicion while closely reviewing abdominal imaging makes the diagnosis more attainable. Clinicians should be aware that, although rare, perforated pyometra is a potential source for pneumoperitoneum and purulent peritonitis.


A healthy 12-year-old presented with wheezing and progressive dyspnea over a 10-month period. He had several general physician consultations and emergency visits during this time and was treated as an asthma exacerbation with no clinical response. He was referred to the pediatric pulmonologist and a tracheal deviation in his previous two chest X-rays was noted, therefore further studies were performed. A severe extrinsic tracheal compression due to a mediastinal mass was documented. He was taken into surgery where a partial resection of the tumor was made. The biopsy of the tumor reported an inflammatory myofibroblastic tumor (IMT), a rare tumor with an atypical presentation, which made this case a diagnostic challenge. Inflammatory myofibroblastic tumors (IMT) are rare and their diagnosis is based on the histopathological finding of inflammatory cells, fibroblasts, and myofibroblasts -2. They This article was previously presented as a meeting abstract at the 2021 International Congress on Pediatric Pulmonology "CIPP 2021".A previously healthy 12-year-old, with a family history of asthma, presented with a sudden onset of wheezing and progressive dyspnea over a 10-month period. He had several consultations and emergency visits during this time where he was treated with bronchodilators and started on inhaled steroids with no clinical response.Due to his persistent symptoms, he was referred to a pediatric pulmonologist where a tracheal deviation in his previous chest X-rays was noted Figure .Further studies were performed, and a bronchoscopy documented severe extrinsic tracheal compression due to a mediastinal mass Figure .On a chest computerized tomography (CT), a 16x22x30mm heterogenous mediastinal mass was documented at the right posterolateral level of the trachea, which generated an extrinsic compression of 90% of the tracheal lumen  . These aIts etiology is multifactorial and has been associated with trauma, inflammatory conditions, and infections ,3. RearrIMTs are most often found in the lung, abdomen, and pelvis, but they can also appear in the mediastinum and tracheobronchial three ,5,6. AmoHistologically, it is defined as a lesion composed of tangles of myofibroblastic cells accompanied by an inflammatory infiltrate of plasma cells, lymphocytes, and eosinophils ,11. ThesThe treatment reported in the literature is mostly surgical resection -3. Our pInflammatory myofibroblastic tumors are infrequent and their location at the mediastinum is uncommon. When there is airway compression, the diagnosis of nonspecific symptoms, such as dyspnea, can be challenging for the clinician. This case highlights the importance of an adequate differential diagnosis process and a multidisciplinary approach when a patient presents atypically and does not respond to the usual treatment.


Herein, we report the case of a 12-year-old boy diagnosed with multiple aneurysmal bone cysts (ABCs) who had previously undergone surgery on the proximal left tibia, proximal left femur, and distal tibia. During follow-up after the surgery, he developed another lesion on the proximal left humerus. Although rare, the pathological diagnosis was multiple ABCs. Lichtenstein and Jaffe first used the term aneurysmal bone cysts (ABCs) indicating a distention of the affected bone with a gross appearance of a cavity containing fluid and blood . ABCs arPatients with ABCs usually present with pain, a palpable mass, pathological fracture, or a combination of these presentations. In a study of 238 patients with ABCs, the most common anatomical presentations were on the long bones, spine, or flat bones . RadiogrTreatment mainly involves surgery. It includes excision and occasionally embolization of the feeding vessels. Curettage is the most commonly used modality of treatment. An en-bloc resection is an option when there is an active lesion or a recurrence. Selective embolization is used in surgically difficult anatomical locations or as an adjuvant . AlthougA 12-year-old boy with a diagnosis of multiple ABCs previously underwent surgery at another center on the distal left tibia and proximal left femur. He presented to our institute with a lesion on his left proximal tibia. After almost a year, he developed another lesion on his proximal left humerus. He had a history of three surgeries, with two being performed at another hospital.The first lesion started at the age of eight on the left distal tibia. It was diagnosed as an ABC based on a pathological report at another health institution. The patient was treated with curettage and bone graft. He was followed up and no recurrence was noted. Approximately six months later, the patient had a pathological fracture of the left femur neck, which was managed by open reduction and internal fixation Figure .Pathology specimens indicated fibrous tissues admixed with solid areas, new bone formation, giant cell reaction, and bloody spaces corroborating with the features of ABC Figure . The patTwo years later, the patient presented with severe pain in the left leg, which was tender on examination. An X-ray showed a large cyst on the left upper tibia Figure , suggestA year later, during the latest admission, the patient presented with pain and swelling of the left upper arm. An X-ray indicated a well-defined expansile lytic lesion on the proximal third of the left humeral shaft Figure , which wABCs indicate a distention of the affected bone with a gross appearance of a cavity containing fluid and blood  Imaging Our patient was considered to have metachronous (multiple primaries) ABCs along with a recurrent ABC on a site other than the main site. This was supported by the bone scan findings as described. According to the best of our knowledge, this term has appeared only four times in the literature. A minimum of two ABCs are required for the diagnosis of “metachronous and multiple ABCs.” Our patient had four bone lesions; three were confirmed as ABCs and one giant cell tumor. It is known that giant cell tumors are the precursor lesions of ABCs, and they are sometimes mistakenly diagnosed as ABCs . In ABC,Our case is interesting because of the metachronous and multiple ABCs that are rarely found in the literature. All the primary lesions were located on the left side. No lesion was identified on the contralateral side. Similar scenarios were reported by Donigan and Sundaram .The first of the four cases described in the literature was reported in 1997. Sundaram et al. described a case of ABC in a nine-year-old boy with a diametaphyseal osteolytic lesion on the left tibia. The lesion was curetted and packed with bone fragments. After 15 months, the patient returned with a new ABC on the left pubic region along with a recurrence of the ABC on the left tibia. Both the lesions had identical histological features. He was followed up for three years with no recurrence .In 2003, Donigan et al. described a case of ABC on the left proximal humerus in a 17-year-old patient, which was treated by curettage. At the age of 32 years, he presented with a pathological compression fracture involving the left side of the eighth thoracic vertebrae (T8). An open biopsy confirmed the diagnosis of ABC, which was managed with an en-bloc resection at T7 and T8 along with reconstruction using a femoral allograft .In 2004, Scheil-Bertram et al. described a case of a two-year-old boy with a history of congenital heart defects. He presented with a pathological fracture of the proximal humerus, which was diagnosed as ABC. Later, he developed another ABC affecting the right lateral clavicle, both distal radii, and right ulna. No genetic abnormalities were detected by cytogenetics .In 2012, Amer et al. reported a case of a nine-year-old patient with a history of mild developmental speech delay and intermittent functional constipation since early childhood. The patient presented with a right scapular ABC, which was treated by percutaneous intralesional injection of doxycycline under fluoroscopic guidance. He had a second ABC affecting the left proximal tibial metaphysis 30 months later, which was treated with percutaneous intralesional chemoablation with a bone graft substitute .Multiple ABCs, although benign, have sequelae that could be debilitating to the patient. Here, we emphasize the importance of early diagnosis, appropriate treatment, and adequate follow-up of these lesions. For clinicians, it is important to consider multiple ABCs in the differential diagnoses in patients presenting repeatedly with swollen limbs and/or chronic bone pain.


Lung cancer has become a leading cause of cancer‐related deaths. With the conventional use of low‐dose spiral computed tomography (CT) in physical examinations, an increasing number of small pulmonary nodules are screened. However, primary pulmonary meningiomas (PPMs) are rarely reported. Here, we report the case of a 64‐year‐old woman who had a CT scan during physical examination, which revealed three ground‐glass‐like opacity pulmonary nodules in both lungs. The patient underwent video‐assisted thoracoscopic wedge resection of the right upper and lower lobes. Paraffin sections revealed pulmonary meningothelial‐like and collagenous nodules in the right upper and lower lobes which stained as follows: EMA+, VIM+, SMA‐, S‐100‐, CD34‐, STAT6‐, Ki‐67+ (2%), and CgA‐. Primary pulmonary meningiomas (PPMs) were finally diagnosed. PPM is a kind of rare and benign tumor. Surgery can provide a precise pathological examination, and patients can achieve an excellent prognosis after surgical resection. Multiple ground‐glass nodules were dectected in both lungs by chest computed tomography. The two nodules in the right lung were wedge resected by thoracoscopic surgery, and were confirmed as primary pulmonary meningioma by HE staining and immunohistochemistry. Lung cancer has become a leading cause of cancer‐related deaths. With the conventional use of low‐dose spiral computed tomography (CT) scanning in physical examinations, an increasing number of small pulmonary nodules are screened. However, primary pulmonary meningiomas (PPMs) are rarely reported.A 64‐year‐old woman was referred to our department because of pulmonary nodules in both lungs which had previously been identified during a physical examination 2 years previously. The patient had an 8 month history of hypertension, but no history of smoking. The patient's younger brother and daughter had suffered from lung cancer and adenocarcinoma in situ, respectively. A computed tomography (CT) scan revealed three ground‐glass nodules in both lungs (right upper/right lower/left lower lobes), which were similar to multicentric early‐stage adenocarcinoma Figure . Both heIntraoperative pathological examination of the snap‐frozen sections revealed benign pulmonary lesions. Postoperative paraffin sections revealed pulmonary meningothelial‐like and collagenous nodules in the right upper and lower lobe, which stained as follows: EMA+, VIM+, SMA‐, S‐100‐, CD34‐, STAT6‐, Ki‐67+ (2%), and CgA‐ Figure . FinallyMeningiomas are relatively common tumors of the central nervous system. The incidence of an ectopic meningioma is 1%–2% of meningiomas, and the lungs are an uncommon site.PPM mostly manifests as a single solitary pulmonary nodule.Because of the morphological PPM diversity on CT images, clinical diagnosis is extremely challenging. Early lesions can manifest as ground glass‐like changes when they are small, which can easily be confused with early‐stage lung cancers. As the lesions grow, it becomes difficult to distinguish them from other benign lung tumors, such as pulmonary hamartoma, special infections  and lipomas. It is also difficult to distinguish PPMs with aggressive growth or multiple metastases from advanced lung cancers. Meanwhile, CT imaging cannot solely guide a patient's treatment as it provides no specificity. Moreover, previously reported cases have indicated that positron emission tomography‐computed tomography (PET‐CT) use during examination also provides no advantage in the diagnosis of PPM, so that the necessity of a pathological examination after surgery in our case was the best choice.The majority of PPM lesions are benign and have an excellent prognosis after surgical resection, and Spinelli et al. reported a PPM case with an 8‐year nonrecurrence after a pulmonary wedge resection.In conclusion, PPM is a kind of rare and benign tumor, but only five cases of malignant PPMs have previously been reported. The diagnosis of PPM relies on pathological examination, and surgery can provide a precise diagnosis and excellent prognosis.The authors confirm that there are no conflicts of interest.


Atypical choroid plexus papilloma (aCPP) is very rarely seen in adults. Here, we present the case of a 47-year-old male with several months of headache, nausea, dizziness, and imbalance who was found to have an enhancing mass of the fourth ventricle with imaging findings suggestive of likely ependymoma. The patient underwent suboccipital craniotomy with C1 laminectomy and telovelar approach for gross-total resection of the lesion, with final pathology demonstrating WHO grade II aCPP. Subsequent genomic analysis showed a biologically relevant TERT mutation, as well as several variants of unknown significance. We conclude that aCPP is a rare, benign entity diagnosed by tissue sample that is potentially curative with surgical resection and may harbor targetable genetic mutations. Choroid plexus papilloma (CPP) is a rare benign neoplasm of the choroid plexus, accounting for less than 1% of all intracranial neoplasms in adults. Depending on location, the clinical presentation of CPP may include signs/symptoms of obstructive hydrocephalus, vertigo, diplopia, lateral gaze palsies, and visual field defects . MaximalHere, we present the case of a fourth ventricular aCPP in an adult patient. We discuss the pertinent clinical, operative, and histopathological findings, as well as the results and implications of associated next-generation sequencing (NGS).A 47-year-old male presented with a 2-month history of head pressure, nausea, dizziness, and tandem gait imbalance. The review of symptoms was negative for diplopia, sensory abnormalities, and limb weakness. Magnetic resonance imaging (MRI) demonstrated a 2.6 cm well-circumscribed contrast-enhancing mass of the fourth ventricle with extension into the right foramen of Luschka without radiographic evidence of hydrocephalus Figure . Spinal The patient underwent suboccipital craniotomy and C1 laminectomy with subsequent telovelar approach to the fourth ventricle for tumor resection. The right-eccentric tumor was dissected off the floor of the fourth ventricle, cerebellar peduncle, and the tela. The tumor was debulked and followed laterally all the way to the foramen of Luschka. The cerebellopontine angle with cranial nerve IX was visualized at the end of the resection through the expanded foramen of Luschka. The tumor was quite vascular and had significant areas of attachment to the lateral border of the brainstem, tela, and right cerebellar peduncle. The frozen section returned as likely ependymoma.Postoperative imaging showed complete resection of the tumor Figure . ImmediaHistopathologyHistopathology on permanent sections was discordant with intraoperative pathology. The lesion showed true papillae with entrapped psammoma bodies characteristic of CPP Figure . In addiTempus NGS revealed a biologically relevant TERT promoter mutation (c.-124C>T) with a tumor mutational burden in the 37th percentile and stable microsatellites. Mutational variants of unknown significance included KMT2D, UGP2, FCGR2A, and ZFHX3.The patient remains recurrence-free as of his last one-year postoperative follow-up visit. He is able to ambulate normally and is back to work full time. His diplopia has also completely resolved. He continues to have right-sided hearing loss.Surgical approachFourth ventricular tumors like this reported aCPP are typically accessed via a suboccipital craniotomy and either transvermian or telovelar approaches. In addition, certain case studies  report the usage of transcortical approaches . TurkoglHistologyAccording to the WHO, CPPs are graded from I to III based on specific histological criteria, with benign CPPs classified as grade I and malignant choroid plexus carcinomas (CPCs) as grade III. Atypical CPPs, first recognized as a distinct entity in 2007 and classified as grade II, are intermediary tumors that exhibit characteristics of both benign CPPs and CPCs . HistoloGenetic analysisThe Tempus xT assay is an oncological testing panel that utilizes NGS to detect genomic alterations in 648 genes and aid in the selection of targeted therapies. It reveals both genetic variations of biological relevance, which produce functionally significant genetic alterations, and variants of unknown significance, whose alterations have an unclear effect on oncogenesis. Our patient’s assay revealed five mutations of unknown significance, namely KMT2D, UGP2, FCGR2A, and two mutations of ZFHX3 in a splice region. In addition, there was one biologically relevant mutation in TERT.Understanding the function of these genes allows for extrapolation regarding their potential contribution to features of our patient’s tumor. The growth of the aCPP might, in part, be attributed to a mutation in the KMT2D gene, which encodes a histone methyltransferase that is part of a protein complex regulating the transcription of estrogen receptor genes. KMT2D has been reported as an essential mutation for cancer cell survival, as its depletion improves chemotherapeutic sensitivity . UGP2 coMutation in the promoter region of the TERT gene leads to overexpression of telomerase in 85-90% of human malignancies . ActivatBeyond personalized treatment strategies, other newer treatment paradigms exist which may be considered in patients with aCPPs. Immunotherapeutic agents, in particular immune checkpoint inhibitors, now play an integral role in the medical management of a variety of different cancers including lung cancer, renal cell carcinoma, and melanoma, and their potential benefit in CNS malignancies is being widely studied . This isThis work presents a 47-year-old male patient presenting with a history of head pressure, nausea, dizziness, and tandem gait imbalance. Preoperative imaging demonstrated a 2.6 cm mass of the fourth ventricle with hydrocephalus, which was characterized as an atypical CPP on histological analysis and a TERT mutation on Tempus NGS. The patient underwent suboccipital craniotomy with C1 laminectomy, followed by a telovelar approach to the fourth ventricle to achieve GTR. Minimal postoperative complications were noted and compared to traditional approaches such as transvermian, strengthening the potential utility of the telovelar surgical approach.This case report also demonstrates the use of next-generation DNA sequencing to better understand the tumor’s genetic profile. Doing so allows for targeted molecular therapies to be used and improve precision-based approaches to intracranial tumor management. Finally, this report also exemplifies the importance of comprehensive histopathological examination of tissue specimens for accurate diagnosis.


Spontaneous rupture of testicular rhabdomyosarcoma is very rare. We report a case of spontaneous testicular rupture that was pathologically confirmed as rhabdomyosarcoma with unilateral blepharoptosis. The patient, a 19-year-old male, and his father had weakness of the left eyelid muscle. The patient was suspected to have a right inguinal hernia by a family doctor but was not treated further. 2 days later, there was skin itching in the right inguinal area, accompanied by redness, swelling and discomfort of the right scrotum, and the patient went to the local hospital again. Ultrasound examination showed that a contusion of the right testis may have been complicated with orchitis. Oral levofloxacin was ineffective. In addition, the swelling of scrotal increased significantly. He came to the emergency room of our hospital and also was treated with levofloxacin, but the pain was still not relieved. CT and ultrasound examination could not identify the cause of the disease. Exploration of the right scrotum was performed under general anesthesia and confirmed that the right testis had spontaneously ruptured. The pathological diagnosis was rhabdomyosarcoma of the right testis. Testicular rhabdomyosarcoma is clinically rare, and spontaneous rupture is even rarer. The pathogenesis of the disease needs to be further studied, and the diagnosis should be made on a case-by-case basis. Overall, the prognosis of testicular rhabdomyosarcoma is poor. As seen in this case, further study is required to determine whether there is some association between testicular rhabdomyosarcoma and ptosis. Unfortunately, the patient's family rejected a genetic examination because of financial difficulty. We only report a single case of this rare phenomenon here. Testicular tumors constitute <1% of all male cancers and occur especially between the ages of 15 and 35 years. Testicular germ cell tumor is the most common type of testicular malignancies . The remaining (5%) involves non-germ cell tumors such as sex-cord stromal tumors, testicular lymphomas, and paratesticular tumors [sarcoma ] . It is oBoth the patient, a 19-year-old male who was previously healthy, and his father had weakness of the left eyelid muscle , 2, althWe made a right groin incision and cut the skin subcutaneously and each layer of muscle in turn, exposing the spermatic cord. We observed hyperaemia and oedema of the spermatic cord blood vessels and surrounding tissue. We rotated the testis approximately 90 degrees, lifted the testis out of the scrotum, opened the testicular sheath, and observed a small amount of bloody fluid within. We opened the tunica albuginea, where we observed a large amount of bloody fluid and a fish-like tissue bulge. The whole testicular boundary was unclear, the epididymis was enlarged, and the tunica albuginea had a visible tear of approximately 1.5 cm in length . RadicalHaematoxylin-eosin staining . ImmunohRhabdomyosarcoma is a very rare malignant tumor derived from striated muscle cells and mesenchymal cells that have differentiated into rhabdomyosarcoma . For susAt present, the etiology of testicular rhabdomyosarcoma is unknown. Some scholars believe that it may be related to the excessive differentiation and growth of undifferentiated mesenchymal cells in the testis or primordial germ cells in a testicular teratoma . Other cUltrasound is the primary examination modality in the diagnosis of testicular tumors, characterized by non-invasiveness and high accuracy. However, rhabdomyosarcoma of the testis lacks specific ultrasound features , and it Testicular rhabdomyosarcoma has a high degree of malignancy and early metastasis. Postoperative chemotherapy can significantly improve the survival rate of patients . TesticuThe patient also had a special clinical manifestation, that is, unilateral congenital blepharoptosis, similar to his father. Blepharoptosis is often seen along with weakness of the eye muscles . This paTesticular rhabdomyosarcoma is clinically rare, and spontaneous rupture is rarer. Some information about the patient is limited. 3 months after the operation, the patient came to the clinic for follow-up once. It was suggested that the patient should have MDT discussion and gene testing or go to the oncology department. The family members of the patient refused due to economic reasons. Only one retroperitoneal ultrasound examination was performed, which suggested that the suspected lymph node was enlarged. Tumor markers were not be detected after the operation. As seen in this case, further study is needed to determine whether there is some association between testicular rhabdomyosarcoma and ptosis, This is where we are very interested in this case report. Both he and his father have unilateral ptosis. We suspect that this is a genetic manifestation. Whether there is an internal relationship between this genetic manifestation and the spontaneous rupture of testicular rhabdomyosarcoma has not been reported in the literature. It's also possible the relationship between ptosis and testicular rhabdomyosarcoma just a co-occurrence. Regardless of the relationship between them, there is no literature to report these two clinical manifestations at the same time and we will conduct further follow-up of the patient to obtain more disease-related information.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by Medical Ethics Committee of Second Affilliated Hospital of Army Medical University, PLA. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.RW, YS, SY, and WC were primarily responsible for the surgery. XL contributed to the primary nursing care. WF contributed to the pathological diagnosis. JZ contributed to the design and funding. All authors contributed to the article and approved the submitted version.This study was supported by the National Natural Science Foundation of China (No. 81900690).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objective: This study aims to assess the efficacy of diffusion-weighted (DW) and T1-weighted (T1W) magnetic resonance imaging (MRI) combined with high-resolution computed tomography (HRCT) (together as DW-T1W-CT) in the preoperative evaluation of the presence and extent of cholesteatoma, which helps determine whether a patient is suitable for transcanal endoscopic ear surgery (TEES). Methods: This retrospective study included 35 patients  aged from 2 to 81 years diagnosed with chronic otitis media with or without cholesteatoma, who had received surgical treatment and a preoperative MRI and HRCT during the period of December 2015 to December 2020 at Cathay General Hospital. We compared the preoperative DW-T1W-CT findings with the intraoperative findings and final pathologic diagnosis. The accurate predictive value was evaluated using the presence of cholesteatoma and its extent. Results: Regarding the efficacy of detecting cholesteatoma, we found a sensitivity of 92% (23/25 cases with cholesteatoma), a specificity of 90% (9/10 cases without cholesteatoma), and an overall accurate predictive value of 91.4% (32/35) by using combined DW-T1W-CT imaging. With regard to evaluating the extent of cholesteatoma, the combined DW-T1W-CT images obtained an accurate predictive value of 84% (21/25 cases of cholesteatoma). Conclusion: Combined DW-T1W-CT has been proven to be a reliable tool in detecting the presence of cholesteatoma. It is also useful in preoperatively depicting the extent of cholesteatoma, which is crucial for determining whether a patient is suitable for TEES, aiding in surgical planning and patient consultation. Mastoiditis with cholesteatoma is defined as a keratinized mass in the middle ear of a person with a history of head trauma, ear infection, or ear surgery. Cholesteatoma consists of keratinizing squamous epithelium. It can happen in the middle ear or mastoid cavity. Although cholesteatomas are not malignant tumors, they still can be invasive because of their erosive and expansible nature. Upper airway infection and otitis media could increase growth factors or matrix metalloproteinase, which make cholesteatoma more invasive. This can erode the surrounding bone in the middle ear and mastoid cavity, possibly furthering damage to the skull base or even to the brain ,2. CurreIn the endoscopic ear surgery (EES) era, surgeons can rely much more on a precise assessment and depiction of ear disease preoperatively than on microscopic surgery, while such preoperative assessments also help them to determine the surgical technique and approach route to be employed. Transcanal endoscopic ear surgery (TEES) has been increasingly adopted to treat diseases of the middle ear, including cholesteatoma. TEES has a number of advantages, compared to microscopic ear surgery, in dealing with chronic otitis media (COM) with or without cholesteatoma .In recent years, endoscopic ear surgery (EES) has been more broadly employed for managing COM with or without cholesteatoma. EES has many advantages, including a wider surgical view, more preservation of mastoid function, a smaller surgical wound, a shorter surgical time, and a shorter hospital stay compared to microscopic ear surgery . HoweverTraditionally, high-resolution computed tomography (HRCT) of the temporal bone is the preferred preoperative imaging study, in general, and in the diagnosis of cholesteatoma, in particular.HRCT can reveal the bony erosion caused by cholesteatoma with precise delineation of the soft tissue lesions in the temporal bone . NeverthFor years, diffusion-weighted (DW) magnetic resonance imaging (MRI) has been used to evaluate middle ear cholesteatoma, primarily for detecting residual or recurrent cholesteatoma during postoperative follow-up ,10,11,12Our current protocol for preoperative evaluation of acquired and congenital cholesteatoma consists of a combination of HRCT and MRI, primarily based on non-EP DW and T1-weighted (T1W) images.This retrospective study was conducted to evaluate the efficacy and accuracy of this combined DW-T1W-CT protocol in preoperatively assessing both the presence and extent of cholesteatoma.This retrospective study included 35 patients  aged from 2 to 81 years diagnosed with chronic otitis media with or without cholesteatoma, who had received surgical treatment and preoperative MRI and HRCT during the period of December 2015 to December 2020 at Cathay General Hospital. We excluded from this study those patients who underwent surgery but did not have complete preoperative MRI and HRCT imaging studies performed. This study was approved by the institutional review board (IRB number: CGH-P105012) and complied with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.Preoperative evaluations included detailed history taking, a physical examination, and a hearing survey. The HRCT of the temporal bone is essential for preoperative evaluation of cholesteatoma and identifying the bony erosion of such middle ear structures as ossicles, fallopian canal, semicircular canals, and scutum. To obtain more precise and specific lesion detection, MRI was also taken concomitantly for all ear surgery candidates as part of the preoperative survey. MRI, which is mostly based on non-echo planar imaging (non-EPI) diffusion-weighted (DW) MRI and T1-weighted (T1W) images, can be used to distinguish cholesteatoma from other inflammation tissue, such as granulation, fibrosis, secretions, or cholesterol granuloma. Combining MRI images with the anatomical features in HRCT can further help depict the accurate range of cholesteatoma extension.All the MRI and CT images were inspected and documented by experienced radiologists prior to surgery, who were blinded to the patients’ identities with regard to clinical and surgical findings.For the convenience of documentation and analysis, the estimated extent of cholesteatoma based on combined DW-T1W-CT was classified into five categories: (0) no cholesteatoma; (1) involving the tympanic cavity proper; (2) confined in the attic; (3) extended to mastoid antrum; and (4) extended beyond the antrum .In our department, the surgical approach for cholesteatoma primarily relies on the location and extent of the disease. For those cases w cholesteatoma that was confined within the tympanic cavity proper, attic, or mastoid antrum (categories 1 to 3), TEES is adopted, which includes transcanal, endoscopic tympanoplasty, atticotomy, or endoscopic open-cavity management of cholesteatoma, depending on the location and range of the cholesteatoma involved.For more advanced cholesteatoma that extends beyond the mastoid antrum and involves the peripheral mastoid air cell, or for such complicated cases as those involving semicircular canal fistula, dehiscence of dura mater, and small external auditory canal, TEES is insufficient. Therefore, the microscopic trans-mastoid approach or endoscope assisted microscopic ear surgery are adopted for such extensive cases (category 4).Intraoperative findings were recorded in detail, including the characteristic and involved region of the lesion, and the final diagnosis was confirmed by the pathological report.Assessing the presence of cholesteatomaFor all patients in the study group (35 cases), the preoperative DW-T1W-CT images were compared with intraoperative findings and pathologic diagnosis. We then assessed the sensitivity, specificity, and accurate predictive value with regard to predicting the presence of cholesteatoma. Assessing the extent of cholesteatomaFor those cases proven to be cholesteatoma after surgery (25 cholesteatoma cases), the preoperative DW-T1W-CT images and documents were reviewed and compared with intraoperative findings to evaluate the acute predictive value, with regard to determining the extent of cholesteatoma.In this study, IMPAX Image Processing Software is applied to analyze CT and MRI image of patients with chronic otitis media. Validity statistical analysis is applied in analysis of image data.Of the 35 patients included in this study, 24 patients were diagnosed preoperatively as having otitis media with cholesteatoma, and 11 patients were diagnosed as having mastoiditis without cholesteatoma by using the combined DW-T1W-CT image study. Among those patients diagnosed as cholesteatoma, only one case was proven to be merely mastoiditis with granulation, but not cholesteatoma, after surgery.Among those diagnosed with mastoiditis, two of them were actually found to be cholesteatoma cases after surgical and pathological inspection. One case was diagnosed as cholesterol granuloma, which is a special type of middle ear granulation tissue, as a presentation of mastoiditis .In predicting the presence of cholesteatoma, our study reveals a sensitivity of 92% (23/25 cases with cholesteatoma), specificity of 90% (9/10 cases without cholesteatoma), false positive of 4% , false negative of 18%  and an overall accurate predictive value of 91.4% (32/35 correct prediction), by way of preoperative combined DW-T1W-CT examination . The falIn this image series, CT showed mass lesion in middle ear, DWI MRI revealed hyper intensity signal and T1 MRI expressed mild peripheral ring enhancement around middle ear lesion. According to these features, otitis media with cholesteatoma is suspected in the pre-operative image evaluation. However, in the real situation, no cholesteatoma was found during the surgery or proved by the post-operative pathological diagnosis.In this image series, CT showed mass lesion in middle ear cavity, intermediate-intensity DWI MRI signal and hyper-intensity T1 MRI signal were expressed in middle ear cavity. No definite evidence of cholesteatoma was noted in the pre-operative image evaluation. However, the cholesteatoma was revealed during the surgery as well as post-operative pathological examination.In this image series, CT showed mass lesion in mastoid cavity, hypo-intensity DWI MRI signal and hyper-intensity T1 MRI signal were expressed in mastoid cavity lesion. No definite evidence of cholesteatoma was noted in the pre-operative image evaluation. However, the cholesteatoma was found during the surgery as well as post-operative pathological examination.Furthermore, for the 25 cholesteatoma cases , the surgical findings, including the location and invading range of cholesteatoma, were recorded and compared with the preoperative image studies. Our analysis reveals that the preoperative combined DW-T1W-CT image can have an accurate predictive value of 84% (21/25 correct prediction) regarding the extent of cholesteatoma .In our study, the high validity of DW-T1W-CT in the preoperative evaluation of cholesteatoma is proven. Our study reveals a sensitivity of 92%, specificity of 90%, and an overall accurate predictive value of 91.4%, by way of preoperative combined DW-T1W-CT examination .High-resolution computed tomography (CT) continues to play a pivotal role in the preoperative evaluation of COM with or without cholesteatoma. CT scans can depict the anatomy of the middle ear and mastoid, as well as accurately predict the involvement of the sinus tympani and facial recess in the case of cholesteatoma . FurtherModern MRI techniques have increasingly emerged as the imaging study of choice in the preoperative evaluation of cholesteatoma and its postoperative follow-up. Using non-EPI DW-MRI, cholesteatoma can be distinguished from other tissue and mucosal retractions in the middle ear and mastoid . The MRIWith all these characteristics, an MRI has traditionally been considered the primary non-invasive method for excluding residual or recurrent cholesteatoma during postoperative follow-up, thus avoiding unnecessary second-stage surgery in most cases, especially in the pediatric population ,18,19,20A non-echo planar-based diffusion-weighted sequence (non-EP- DWI) has recently been described for evaluating middle ear cholesteatoma. This sequence has a higher resolution and thinner slice thickness (2 mm) and can show cholesteatoma as small as 2 mm, prior to primary and second-look surgery. A prospective evaluation of this non-EP-DWI sequence revealed a high sensitivity for detecting congenital or acquired middle ear cholesteatoma ,12.In the preoperative stage, the combined use of CT and MRI allows for unambiguous confirmation of the diagnosis, the ability to show the extent of the cholesteatoma, and evaluation of the risk for peri-operative sensory hearing loss related to labyrinthine fistulas, all of which can facilitate planning the surgical approach accordingly and better counseling the patient  12]..12].Some limitations of DWI have been previously reported. Tiny congenital cholesteatoma, small retraction pockets, and evacuated cholesteatoma with an absence of keratin accumulation responsible for hyper intensity can be missed on an MRI ,10,12. FOur study reveals that the efficacy of detecting the presence of cholesteatoma using combined DW-T1W-CT image has a sensitivity of 92% (23/25 cases with cholesteatoma), a specificity of 90% (9/10 cases without cholesteatoma), and an overall accurate predictive value of 91.4% (32/35). Furthermore, comparing the preoperative assessments to the actual surgical findings demonstrated that the accurate predictive value of combined DW-T1W-CT images on the extent of cholesteatoma was 84% (21/25). Therefore, we believe that this tool is valuable for precisely predicting the presence and extent of cholesteatoma and can help determine the appropriate surgical procedure and plan for a patient’s best interests. Yet, our study also revealed a false positive rate of 4% and a false negative rate of 18% by using the combined DW-T1W-CT image method to detect cholesteatoma. Although this evaluating method is very accurate according to not only our study but also many other results from the studies mentioned above, preoperative discussion with patient including the thorough explanation of this minor uncertainty is crucial.HRCT is currently the most widely used imaging tool for preoperatively diagnosing and characterizing cholesteatoma. However, the role of an MRI has become increasingly important. The more reliable information the surgeon can obtain prior to an operation, the better the surgical planning can be. The surgical outcome will also be enhanced when the otologist is flexible in choosing among the available surgical techniques and tailoring them to a patient’s clinical and imaging findings.Combined DW-T1W-CT imaging has been proven to provide a reliable preoperative evaluation of diseases of the middle ear and can help precisely delineate the presence of cholesteatoma and its extension. It is a valuable tool for the otologic surgeon in determining the appropriate surgical technique and better planning, especially for candidates for transcanal endoscopic ear surgery.


The nasolabial cyst is an uncommon non-odontogenic cyst that develops in the lower region of the nasal ala; its pathogenesis is uncertain. This lesion grows slowly and measures between 1.5 and 3 cm; it is characterized clinically by a floating tumefaction in the nasolabial sulcus, which elevates the upper lip. The diagnosis is based on the clinical findings and, if necessary, image exams. This paper reports a case of a white 48-year-old Brazilian female patient that presented a firm tumor in the left ala of the nose; the clinical features suggested a nasolabial cyst. CT scans revealed an expanding tumor with soft tissue density located in the left ala of the nose. It measured 1.2 cm in diameter and had a clear and well-defined outline; its homogeneous density was about 50 HU. MR images revealed a circular lesion located in soft tissue; T1 and T2 weighted signals were hyperintense, as were images after fat suppression. The diagnosis was a nasolabial cyst, which was confirmed by histopathology after surgery. Zuckerkandl originally described Nasolabial cysts in 1882; the first case itself was reported by McBride in 1892. In 1989, Brown-KellyIn 1953, KlestadtThere is still much debate about the origin of nasolabial cysts. It is thought that its pathogenesis is related to a period between the 4th and 8th weeks of intra-uterine life; at this time the maxillary process of the second brachial arch forms the base of the nose and the nasal alae. Midline fusion between each maxillary lateral palatine process and the base of the septum forms the hard palate, at the same time initiating formation of the nasal fossa. Aberrant changes at any of these fusion points may give rise to a fissure cyst.12Signs and symptoms may include local pain, nasal block, and infection, which may cause tumefaction with significant inflammation and infection. This is clinically characterized by a floating mass in the nasolabial sulcus area that involves the nasal alae, extending to the ventralinferior portion of the pyriform margin, causing elevation of the lower lip.14Cysts may cause bulging on the lateral wall of the nasal fossa floor, which becomes evident on occlusal maxillary radiographs.The differential diagnosis is made with odontogenic lesions such as follicular, periodontal and residual cysts, and neoplasms;Brown-Kelly first described the histopathology of this lesion in 1898.The diagnosis of nasolabial cysts is essentially clinical. Bidigital palpation reveals a fluctuating tumefaction between the floor of the nasal vestibule and the gingivolabial sulcus, which helps to confirm the diagnosis.The purpose of this study was to report a nasolabial cyst case and to describe its features on CT and MRI exams.A white woman aged 48 years presented for dental treatment at a private dental clinic and complained of a hard mass in the left nasal ala area that had developed over the past two years. The patient had previously sought a dermatologist, who raised the possibility of a tumor and referred her to an oncologist. The oncologist requested CT, which revealed a well-defined expansive mass with homogeneous density (around 50 Uh), similar to soft tissue, with 1.2 cm diameter, located in the left nose . Bone stOther radiological exams were conventional dental radiographs , which did not reveal significant changes that might suggest any bone lesion  and 3B. Therapy consisted of intra-oral surgical enucleation of the lesion under general anesthesia. An incision was made along the gingivolabial sulcus between the central incisor and the left first upper molar for removing the lesion. The cyst measured about 1.5 cm and contained a yellowish secretion. Histopathology revealed a fibrous cystic wall lined with pseudostratified cylindrical epithelium enclosing mucous secreting and goblet cells. The patient was followed-up postoperatively during five months. There were no postoperative symptoms, and the lesion did not recur within this period.This study presents a case of a nasolabial cyst in which the clinical history shows the difficulty of diagnosing a lesion that does not involve bone; such patients frequently seek many health professionals. David & O’ConnelLOur case is not typical of the literature in terms of race; most of these lesions occur in black patients. Age and sex, however, were typical.The patient reported that the lesion developed within two years, and that there was no pain or discomfort and no esthetic effect. El-HamdEl-HamdCurrently, there are modern methods that support physicians in making a diagnosis. The diagnosis of nasolabial cysts is almost exclusively clinical.Pruna et al.Pruna et al.Our findings differ from those of Curvé, Osguthorpe & Van Tassel;The diagnosis in this study was based on clinical findings and image diagnosis, which described all of the findings of nasolabial cysts, and which were confirmed by histopathology.-CT and MRI are important exams for the diagnosis in suspected nasolabial cyst cases.-MRI revealed cyst contents more clearly than CT.-The diagnosis of nasolabial cysts should be based on clinical and imaging method findings.


Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign head and neck tumor. We report a rare case of JNA, provide a brief literature review, and treatment options, and emphasized the role of flutamide as pre-surgical medication for tumor regression. JNA primarily affects adolescent males aged 14 to 25 years. There are various theories explaining the formation of the tumor. However, sex hormones are found to play a crucial role in the etiology of the tumor. In recent years testosterone and dihydrotestosterone receptors have been identified on the tumor thus suggesting the strong influence of hormones. This permits the use of flutamide, an androgen receptor blocker, as adjuvant therapy for the treatment of JNA. This is a case of a 12-year-old boy who presented to the hospital with right-sided nasal obstruction, epistaxis, watery nasal discharge, and a mass in the right nasal cavity for two months. Diagnostic nasal endoscopy, ultrasonography, computed tomography, and magnetic resonance imaging were done. These investigations confirmed the diagnosis of JNA stage IV. The patient was started on treatment with flutamide for tumor regression. Epistaxis or bleeding from the nose is a common emergency that presents to primary care clinics, responsible for one in every 200 visits to the emergency department. Various factors that may precipitate epistaxis are trauma, metabolic disorders, autoimmune conditions, vascular abnormalities, neoplasia, and inflammatory and congenital disorders. Though traumatic causes like nose pricking are primarily responsible for epistaxis in children, it shouldn’t be undermined as it can be due to several underlying systemic disorders. Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign head and neck tumor that presents with epistaxis. It represents 0.05% and 0.5% of head and neck tumors and the incidence is between 1:6000 and 1:55000 with almost exclusive occurrence in male adolescents [We present a case of a 12-year-old boy who had an extraoral facial swelling diagnosed as JNA stage IV. We aim to focus on the literature review and widen the gaze of clinicians on this rare entity. We also emphasize the role of flutamide as a pre-surgical medication for tumor shrinkage.A 12-year-old boy was referred to us from a local private clinic for swelling on the right side of his face. The child presented with complaints of right-sided nasal obstruction, epistaxis, watery nasal discharge for two months, and a mass in the right nasal cavity. He frequently experienced painless epistaxis episodes that lasted 15 to 20 minutes each, resulting in blood loss of 30 to 40 ml. There was clear mouth breathing, especially during sleep. The patient did not express any headache complaints. History reveals no similar episodes of epistaxis two months ago. Upon extra oral examination, there was gross asymmetry of the face due to swelling over the right cheek. The swelling extended from the infraorbital margin superiorly to the lower border of the mandible inferiorly, from the ala of the nose and corner of the mouth anteriorly to the tragus of the ear and ramus of the mandible posteriorly. It was 7 cm × 6 cm in size, smooth with well-defined margins, and firm in consistency. It was tender, compressible, and pulsatile on palpation. Intraoral examination was normal. The patient showed no pallor, and the results of the routine hematological tests were within normal limits. Diagnostic nasal endoscopy revealed a congested right nasal cavity with the presence of a compressible mass that bled on touch. Fine needle aspiration revealed only blood. Ultrasound neck revealed a well-defined hypoechoic lesion of size 35 × 20 mm with internal vascularity in deep tissues of the cheek on the right side with proximity to the right maxilla. Computed tomography of paranasal sinuses showed a well-defined non-encapsulated soft tissue density mass lesion of size 69.5 ×56 × 30 mm epi centered in the right sphenopalatine foramen extending laterally into the pterygomaxillary fascia, infratemporal fossa causing anterior bowing of maxillary sinus posterior wall as seen in Figure Figure JNA is a relatively uncommon benign tumor that chiefly affects adolescent boys aged 14 to 25 years. The tumor originates near the sphenopalatine foramen and extends toward the surrounding structures . It appeJNA is a locally aggressive, slowly growing tumor with a high propensity to persistence and recurrence. Imaging is the sole method that can identify the lesion early, and it also plays a key role in deciding on surgical procedures and determining the prognosis. Flutamide is effective in the post-pubertal population and is used pre-operatively for the regression of the tumor. However, surgical excision is the main treatment modality that depends on tumor extension.


Urinary tract tuberculosis (UTTB) is a common form of extrapulmonary tuberculosis (TB) which can infrequently present as renal carcinoma, leading to serious errors in the diagnosis and treatment of UTTB.A 76-year-old Syrian man presented with gross hematuria as the main symptom. A urinary endoscopic examination and pelvic multi-slice computed tomography imaging increased the suspicion of a speared renal mass in the right urinary tract. The patient was treated for renal cancer. After nephrectomy and ureterctomy, the histopathology of the resected mass confirmed the diagnosis of UTTB and interstitial nephritis.This case should serve to increase the attention of clinicians to perform an accurate diagnosis step by step. This is especially important if they have a patient similar to the case described here who presents with a renal mass, to avoid serious results such as the loss of an essential organ system. Mycobacterium tuberculosis causes tuberculosis (TB). About one quarter of the world's population is infected with this bacillus, and it is the leading cause of death due to a single infectious agent and among the top ten causes of death worldwide [The bacillusorldwide . There aorldwide . UrogeniThe typical classical presentation of urinary tract TB (UTTB) involves the whole urinary collecting system . However, kidney parenchymal lesions are less common, including interstitial nephritis and glomerulonephritis . An atypHere we present an extremely rare case reported in the literature that revealed a significant medical mistake in the diagnosis of urogenital TB as RCC. Analysis of the case shows a combination of diffuse and interstitial TB in the same patient.A 76-year-old Syrian man was admitted to the emergency room with a complaint of frequency dysuria and gross hematuria lasting for 6 h. The medical history included hypertension and diabetes mellitus type 2 with no abnormalities. Other medical, family and psychosocial histories were clear. At presentation, the vital signs were stable, and clinical examination revealed that the other organs were normal. Initial hematology tests revealed elevated white blood cell counts (WBCs) , hemoglobin (HGB) (11 g/dL), mean corpuscular volume , and platelet counts , as well as moderate renal insufficiency . Abdominal echography revealed severe and mild hydronephrosis in the right and left kidney, respectively, with no renal stones or calculus. However, there was a significant thickness in the bladder wall (diameter: 1.5 cm).A cystoscopy was then performed to obtain a biopsy. The histopathology report showed pathological changes, possibly suggesting denuded cystitis, low-grade dysplasia, and severe interstitial cystitis. No invasive tumor was found in the specimen examined. Abdominal and pelvic contrast-enhancing multi-slice computed tomography (CT) revealed the presence of hydronephrosis in the right kidney with a filling defect in the pelvis; this was described as a non-enhancing hypodense area in the pelvis and inferior calyces Fig. . ThoraciA primary diagnosis of RCC was made based on the clinical presentation, the laboratory test results, and the imaging investigations. As a result, the patient underwent an open radical right nephrectomy and ureterectomy. The histopathology examination of specimens showed the existence of granulomatous pyelonephritis and necrotizing and caseous centers, which confirmed the correct diagnosis of urinary tract TB (UTTB). The granulomatous inflammation was extended to most of the ureter, pelvis, and calyces. In addition, patchy infiltrations were present in the renal parenchyma accompanied by focal segmental glomerulosclerosis. The final diagnosis was diffuse interstitial nephritis and UTTB Figs. , 3. TreaThe urogenital system is one of the most common sites of extrapulmonary TB. Urogenital TB is diagnosed in 1.1–1.5% of all TB cases and in 5–6% of cases of extrapulmonary TB . Thus, aThe differential diagnosis of enhancing renal mass is an abscess, primary renal tumor-like RCC, and lymphoma or secondary metastasis . Most ofIn the case described here, a 76-year-old man presented with complaints of frequency dysuria and gross hematuria. Laboratory tests showed elevated creatinine and urea levels. Based on multi-slice CT imaging of the abdomen and pelvis, we diagnosed RCC as the diffuse mass in the right urinary tract, so the treatment decided upon was open right nephrectomy and urethrotomy. However, based on the histopathology of the specimens taken after the open surgery, the diagnosis was diffuse interstitial nephritis and UTTT. This case is distinctive and rare due to the presence of two forms of diffuse and interstitial TB. This patient was treated with anti-TB therapy consisting of 6 months of isoniazid and rifampicin, supplemented with pyrazinamide and ethambutol in the first 2 months.Diagnosing UTTB as a malignant tumor and treating it with surgical removal is a reality due to TB appearing in the form of a mass. In addition, the detection of two types of TB, namely, diffuse and interstitial TB, in one case increases the rarity of the case. This case illustrates the care required of the radiologist and pathologist to accurately diagnose patients who present with a kidney mass and ensure that they receive standard anti-TB treatment and follow-up.


The head and neck is the most common site of the lymphangiomatous lesions. Most arise in the skin and subcutaneous tissues, but other sites include the larynx, parotid gland, mouth, and tongue. Benign tumors of the tonsils are rarely seen compared to malignanciesIn the literature less than 30 cases with lymphangiomatous polyp of the tonsils have been reported. The patients presented generally with dysphagia, sore throat or sensation of mass in the throat. The physical examination by indirect laringoscopy, unilateral tonsillary mass can be detected and these lesions are frequently misdiagnosed as malignancyHere we presented a case of pedunculated lymphangiomatous polyp on palatine tonsil.A 36-year-old woman who was referred the Otolaryngology Department of Yunus Emre General Hospital, in May 2009 with difficulty of swallowing and foreign body sensation in the throat. She had complaints of sneezing which started two years ago and she had history of allergies. Physical examination of her oral cavity revealed a pale peduculated mass extending from the left palatine tonsil. The rest of oral cavity, nasopharynx and larynx were normal. There was no evidence of cervical lymphadenopathy. The mass was suspected as a benign polyp and intra-oral tumor excision was performed under local anesthesia.The specimen was measured macroscopically 1,3 x 0,7 cm in diameter. The mass was firm and smooth, with a small pedunculated base. Histologically, its surface was covered with parakeratotic squamous epithelium and, its stroma was composed of loose fibrouse tissue included numerous dilated lymphatic space and aggregates lymphoid tissue . In the The head and neck is the most common site of the lymphangiomatous lesions. Most arise in the skin and subcutaneous tissues, but other sites include the larynx, parotid gland, mouth, and tongueLymphangiomatous polyp usually occurs in young adult and childrenThe history and the clinical examination are important for the diagnosis, but histological examination is needed to establish the diagnosis. Some authors maintain the assertion that these lesions are most likely hamartomatous, because of a haphazard proliferation of stromal elements that are normally found in the tonsilLymphangiomatous polyp should be considered in the differantial diagnosis of mass lesion in the tonsilLymphangiomatous polyps of the tonsil are unusual benign hamartomatous lesions, and they are treated with curative intent by simple surgical excisionWe think that lymphangiomatous polyps are more common than reported in the literature. However, the true incidence is not known because of different names are present in the literature. We believe that, our case is noteworthy to help the estimate of the true incidence in the future.


Case Report. A 62-year-old female presented in emergency department with retention of urine for 12 hours with history of recurrent UTIs for last 1 year. She was also complaining of mild dull lower abdominal pain for last 6 months. She had no history of incontinence of urine and fever. On physical examination, hard mass was palpable on suprapubic region on palpation of abdomen. Urine culture shows Escherichia coli for which antibiotics was given. An X-ray kidney ureter bladder showed a radio-opacity in the pelvic region measuring 9 × 8 cm in size. Ultrasonography revealed bilateral mild hydronephrosis with a large bladder stone. Open cystolithotomy was performed, and the stone was taken out. Stone biochemical analysis showed predominantly urate crystals. Patient had uneventful postoperative course, and she was discharged on 4th postoperative day and was followed up for 1 months after operation.  Large urinary bladder stones are not common and even less common in females. We report a case of large bladder stone presented with acute retention of urine in a female patient.  Large urinary bladder stones are not common and even less common in females. Clinician should have think regarding large bladder stone as a cause of recurrent lower urinary tract symptoms like dysuria and should assess renal function for proper treatment. Open cystolithotomy is choice of operation in large bladder stone. Bladder stones (BS) comprised of 5% of all urinary tract stones. The aetiology of bladder stones is multifactorial. Bladder stones can be classified as primary, secondary, or migratory. Primary calculus are stones which passes from kidney or ureter and lodges in the urinary bladder while secondary calculus are formed inside the bladder . PrimaryOur patient who is from rural part of Nepal experienced recurrent dysuria without any additional workup and received empirical treatment despite of recurrent symptoms. Here, we report an unusual case of giant urinary bladder stone causing recurrent dysuria in a female patient.A 62-year-old female presented as an emergency patient with retention of urine for 12 hours. She had history of hesitancy at urination, increase frequency, interruption of urinary stream, urgency, and feeling of incomplete voiding for last 1 year. She was complaining of mild dull lower abdominal pain for last 6 months, intermittent in nature, no radiation, and aggravated while micturition. She had burning micturition on and off. She had no history of incontinence of urine and fever. She smoked cigarette 20 pack per year and left 10 years back. She denied any history of significant weight loss and hematuria. She is hypertensive under medication for 5 years and has chronic pulmonary obstructive disease for 2 years. On physical examination, her vital signs were stable. Hard mass was palpable on suprapubic region on palpation of abdomen. However, there was no renal angle tenderness present, and digital rectal examination was not done. Her blood investigation showed normal white blood cell count, blood urea nitrogen, and serum creatinine. Urine analysis indicated a very high white blood cell count and few red blood cells. Urine culture shows Escherichia coli for which antibiotics ciprofloxacin was given.An X-ray kidney ureter bladder showed a radio-opacity in the pelvic region measuring 9 × 8 cm in size . Ultrasoth postoperative day with suprapubic catheter and urethral catheter in situ. Suprapubic catheter was removed on 10th postoperative day, and urethral catheter was removed on 14th POD in outpatient department. She was followed up for 1 month after operation and no any residual stone seen and patient had normal urination.After optimization, open cystolithotomy was performed under spinal anesthesia. Patient had uneventful postoperative course, and she was discharged on 4Bladder stones are commonly contained with mixed composition. Struvite (ammonium magnesium phosphate) stone is the most common stone in presence of history of recurrent urinary tract infections with urea-splitting organisms such as Proteus, Klebsiella, Serratia, and Enterobacter species that produce alkaline urine . While cX-ray, ultrasound, computed tomography (CT) scan, or cystoscopy are common methods to make diagnosis of bladder stone .Nowadays, it is fact that open approach is being replaced by newer techniques aimed to be less invasive . There iLarge urinary bladder stones are not common and even less common in females. Clinician should have think regarding large bladder stone as a cause of recurrent lower urinary tract symptoms like dysuria and should assess renal function for proper treatment. Open cystolithotomy is choice of operation in large bladder stone.


Mandible can be the site of benign or malignant lesions of different origins, including odontogenic and non-odontogenic lesions. Cartilage-forming tumors have been rarely reported at this site. Chondrosarcoma is a rare malignant cartilage-producing neoplasm that is extremely rare in the mandible. The rarity of cartilage-forming tumor occurrence in the mandible can make diagnosis difficult for pathologists, as they do not expect this type of tumor at this anatomical site. Here we report a case of chondrosarcoma of mandibular angle.A 70-year-old Moroccan male patient consulted a dentist for wisdom tooth pain. Wisdom tooth extraction was conducted. After 6 months, the patient reported the recurrence of pain associated with swelling in the mandibular area and paresthesia along the path of the mandibular nerve. A panoramic radiograph demonstrated a mixed radiolucent–opaque lesion involving the mandibular angle. Computed tomography showed a large osteolytic spontaneously hypointense and multilobulated lesion. A biopsy was done. Histopathological examination revealed sheets and irregular lobules of atypical cells presenting cartilaginous differentiation. Tumor cells showed severe nuclear atypia and were located within a hyaline cartilage matrix. Some foci of necrosis were noted. Osteoid deposits were not found. The patient was diagnosed with grade III chondrosarcoma and underwent a right segmental mandibulectomy with submandibular lymph node dissection. Macroscopically, the tumor was localized in the mandibular angle with extension in the mandibular body. Histopathology confirmed the previous diagnosis of grade III chondrosarcoma and did not show any lymph node metastasis.Owing to many histological similarities, grade III chondrosarcoma must be distinguished from chondroblastic osteosarcoma and metastatic lesions. In addition, chondroblastic osteosarcoma of the jawbones has a worse prognosis than chondrosarcoma, making the distinction between these two malignant tumors the most important concern of the pathologist when dealing with a cartilage-forming tumor at this site. Surgery with wide excision margins remains the best therapeutic approach, while the role of radiotherapy is controversial. The management of mandibular chondrosarcoma requires a multidisciplinary approach involving maxillofacial surgeons, radiologists, pathologists, and oncologists. Mandible can be the site of various lesions that can be of odontogenic or non-odontogenic origin . The mosA 70-year-old Moroccan male patient with unremarkable personal and familial medical history consulted a dentist for wisdom tooth pain lasting for 2 months. A wisdom tooth extraction was conducted. After 6 months, the patient reported the recurrence of pain in the wisdom tooth area occurring at rest and while chewing associated with paresthesia along the path of the mandibular nerve. In addition, the patient complained of a swelling on the right side of the mandibular area. The patient was referred to the oral and maxillofacial surgery department of our hospital. Intraoral examination revealed a well-defined nodular mass located at the junction of the mandibular angle and the body of the mandible. The overlying mucosa showed no abnormalities. Extraoral examination showed multiple submandibular lymph nodes.A panoramic radiograph revealed a mixed radiolucent–opaque lesion involving the mandibular angle and associated with the displacement of tooth 18. Computed tomography (CT) demonstrated a large osteolytic spontaneously hypointense and multilobulated lesion associated with calcified areas measuring 47 mm in the largest diameter with extension to the masseter muscle and the anterior belly of digastric muscle (Fig. Thereafter, an incisional biopsy was done. On gross examination, the specimens were represented by five whitish tissue fragments firm in consistency, the largest of which measured 1.7 cm. Microscopically, the tumor was composed of sheets and irregular lobules of atypical cells presenting cartilaginous differentiation Fig. . Tumor cThe patient underwent surgery, which consisted of a right segmental mandibulectomy Fig. . The tumFour months later, the patient presented under the incision area a firm swelling. A CT was done and showed a jugulocarotid lymphadenopathy measuring 33 × 15 mm with a necrotic center Fig. . A surgiThe chondrosarcoma is a malignancy that produces cartilage matrix and occurs exceptionally in the bones of oral and maxillofacial region, accounting for 1–3% of all chondrosarcomas , 10. At Chondrosarcomas of the jaw tend to occur equally in both sexes . The mosRadiographically, the lesion appearance is not pathognomonic; nevertheless, it most commonly appears radiolucent with ill-defined outlines often associated with evidence of bone destruction . Other lOn gross examination, conventional intramedullary chondrosarcomas are large tumors often greater than 4 cm in size . The cutHistopathologically, the spectrum of chondrosarcoma varies widely from well-differentiated neoplasms that may be confused with benign cartilaginous tumors to locally aggressive high-grade tumors with metastatic potential . The graGrade I chondrosarcomas are characterized by a lobular histologic appearance, where lobules can show variation in size and shape . HyalineGrade II chondrosarcoma show increased cellularity with less chondroid matrix particularly at the periphery of tumor , 15. TheIn grade III chondrosarcoma, cellularity is high and lobules are composed of tumor cells displaying marked nuclear atypia and pleomorphism with at least at two mitoses found per 10 HPFs , 15. TheOther entities can simulate grade III chondrosarcoma, including chondroid chordoma . This tuAs for chondrosarcomas of other sites, surgical removal with wide surgical margin is considered the best therapeutic option for mandibular chondrosarcomas . RadiothThe diagnosis of mandibular chondrosarcoma is challenging for pathologists owing to the rarity of the mandibular location of chondrosarcomas and the multiple entities that can mimic it histologically . Early r


An accessory spleen is splenic tissue located separately from the anatomical location of the spleen and is a rare phenomenon. It can be found within the gastrointestinal tract. Clinically, accessory spleens are benign but can be misidentified as reactive lymph nodes or malignant gastrointestinal tumors. They are often diagnosed via endoscopy or imaging. We report the case of a woman presenting with iron deficiency anemia who was incidentally noted to have a gastric submucosal lesion with pathology significant for accessory spleen. As this case illustrates, when submucosal lesions are present in the stomach, especially in patients with a history of splenectomy, the endoscopic ultrasound (EUS) operator should consider the possible presence of an accessory spleen to minimize invasive removal procedures. The spleen lies in the left upper quadrant of the peritoneal cavity and is a vascular organ . The splAccessory spleens can arise from a congenital etiology or via splenosis ,3. The cA 54-year-old woman presented to her primary care physician for fatigue and was found to have iron deficiency anemia. Her past medical history was notable for stage 2 right breast cancer at age 24 , a splenectomy in her 30s for a large vascular mass, and a total abdominal hysterectomy at age 50 due to menorrhagia. Her family history was notable for her sister's death at age 26 due to splenic rupture of a vascular mass but was otherwise noncontributory. Immunization records were significant for pneumococcal, meningococcal, and Haemophilus influenza vaccinations two weeks prior to elective splenectomy. Her social history was negative for tobacco, alcohol, or drug use. Her laboratory evaluation revealed low hemoglobin, low mean corpuscular volume, low iron, low iron saturation, high total iron-binding capacity, high transferrin, and low ferritin Table .As part of her anemia evaluation, the patient underwent an esophagogastroduodenoscopy, significant for a 2-cm submucosal gastric fundic lesion Figure . Follow-Accessory spleens are additional splenic tissue located away from the anatomical site of the spleen and can have immunologic function . There aAccessory spleens are most commonly an incidental finding on imaging or endoscopy. They are often misdiagnosed and mistaken for malignant submucosal tumors . The CT Since accessory spleens are usually asymptomatic and of no clinical significance, resection is not recommended . CompensEUS-guided fine-needle aspiration may assist with the diagnosis of accessory spleens in cases of uncertainty to avoid invasive resections . The cytAccessory spleens are a rare occurrence and may have an immunological function. They are usually incidental findings with no clinical significance. However, they can resemble lymphadenopathy or malignant tumors and should be a differential diagnosis. When submucosal lesions are present in the stomach, especially in patients with a history of splenectomy, the EUS operator should consider the possible presence of an accessory spleen to minimize invasive removal procedures.