Primary pericardial mesothelioma (PPM) is a rare malignancy with a high prevalence of mortality. The diagnosis is usually challenging using a variety of imaging modalities and invasive procedures and is generally performed at the later stages of the disease or in autopsy. This case study points to an unconventional presentation of PPM and the challenges in diagnosing this rare mortal malignancy.This study presents a 44-year-old woman with no remarkable medical history with an initial diagnosis of effusive constrictive pericarditis at first hospitalization. Imaging evaluations, including transthoracic echocardiography and chest computed tomography scan, demonstrated visible thickened pericardium, pericardial effusion, and mass-like lesions in pericardium and mediastinum. The definite diagnosis of primary pericardial mesothelioma was established after pericardiectomy and histopathology examinations. Chemotherapy with pemetrexed and carboplatin was administrated to the patient, and she has been through four cycles of chemotherapy with no complications to date.Constrictive pericarditis is an uncommon presentation of PPM. Due to the high mortality rate and late presentation, difficulties and uncertainties in diagnosis, being aware of this rare malignant entity in different cardiac manifestations, particularly when there is no clear explanation or response to treatment in such conditions, is highly important.The online version contains supplementary material available at 10.1186/s13019-021-01684-8. Primary cardiac neoplasms are oncology rarities with the prevalence of 0.001–0.056% and account for 0.3 to 0.7% of all cardiac cancers. Only 25% of primary cardiac neoplasms are malignant . PPM is A 44-year-old woman introduced herself to the emergency department in November 2020, complaining of epigastric pain, progressive dyspnea, nausea, premature satiety, and anorexia. She also stated that she had been suffering from deterioration of her general condition accompanied by weakness, fatigue, lethargy, dyspnea (NYHA class ΙΙ), and a 12 kg unwanted weight loss within 2 years. No cough, sputum, orthopnea, and prior cardiac diseases were claimed. Previous medical history included multiple muscle problems and neck pain which had been treated with a diagnosis of Fibromyalgia. No radiation, chest surgery, or trauma history and no history of diagnosed cancer in her family were mentioned. The patient was a non-smoker and had no history of asbestos exposure. Medication history included Gabapentin 100 mg twice daily and oral contraceptive pills.Physical examination revealed a blood pressure of 112/80, heart rate of 100 beats/min, respiratory rate of 16 breaths/min, and a temperature of 36.5 °C.O2 saturation was 94%. The heart sounds were normal with a regular rhythm, and no murmur was found. In lung auscultation, no remarkable finding was detected. The patient did not have elevated JVP as well as abdominal ascites and edema in the lower extremities. In laboratory findings, the CBC revealed anemia (Hb: 8.0 g/dl) and thrombocytosis (PLT: 609 000 U/L). The patient's blood chemistry showed elevated inflammatory markers level.  along with an increased lactate dehydrogenase level (LDH: 1757 U/L).Chest X-ray on admission revealed a cardiothoracic index of > 50%, widened mediastinum, and pleural effusion in the left hemithorax Fig. . First EA transthoracic echocardiogram was performed and demonstrated normal left ventricular (LV) size with mild systolic dysfunction (LVEF: 45–50%), moderate LV diastolic dysfunction with annulus reversus , normal inferior vena cava (IVC) with reduced respiratory collapse, normal right ventricle (RV) size with moderate systolic dysfunction (RVSM 8 cm/s) and left atrium enlargement. Moderate mitral regurgitation, no mitral stenosis with significant MIF respiratory change, and at least moderate tricuspid regurgitation (TRG: 36 mmHg) were also reported. Additionally, Visible thickened pericardium with an obvious thickness (in size 24 mm in anterior RVOT) and mixed pericardial effusion (size 19 mm in posterior LV) and visible mass-like lesion in size approximately 42 mm in inferolateral RV were declared in the echocardiogram report , patient was isolated and underwent conservative therapy and supportive care for the COVID-19 infection during hospitalization. The patient successfully recovered from COVID-19 infection.Radiological consultation for biopsy of the lesions  was requested, and due to the thickness of the pericardium, pericardial biopsy was recommended.The patient was decided to undergo pericardiectomy surgery. Patient with severe adhesive pericarditis and multiple effusive pericardial effusion underwent midline sternotomy with oscillator saw, and all adhesions released from heart epicardium in a delicate manner from inferior side RV up to ascending aorta as well as pulmonary trunk and was sent for pathology examination due to its very bizarre appearance and consistency. According to the surgery report, during the procedure, abnormal appearance of the pericardium and macroscopic infiltrations to heart muscle were visible. Left ventricular mass resection and thymus gland biopsy were also performed. Additional files Specimens were sent to histopathology evaluation in 2 containers labeled as thymus gland and pericardial mass. Thymus gland specimen in macroscopic examination consisted of multiple fragments of fibro-fatty tissue, TM: 5 × 5 × 4 cm with foci of firm consistency. On sections, foci of firm gray, creamy areas were seen on the surface; the largest measure was 1.5 cm in greatest diameter. No mass was identified grossly.The pericardial mass consisted of multiple fragments of fibro-fatty tissue with foci of firm consistency TM: 7 × 7 × 3 cm. On sections, foci of creamy rubbery to firm area were seen measuring about 4 × 4 × 2 cm. In the microscopic examination, the section from pericardial lesion showed proliferation of mesothelial cells with a tubulopapillary architecture and few solid areas infiltrated between muscle handles and was in intimate contact with adipocyte. The tumor cells were characterized by enlarged vesicular to hyperchromatic nuclei, occasional prominent nucleoli, and moderate amount of amphophilic cytoplasm. No necrosis was identified , magnetic resonance imaging (MRI), and FDG-PET scan, which are very valuable for evaluating the tumor size, tumor location, extension to vicinal structures, and also staging of cancer , 7. HoweOur patient was presented with non-specific symptoms and electrocardiography changes accompanied by elevated LDH and inflammatory markers. After multimodality imaging, effusive constrictive pericarditis, which is considered an unconventional presentation of PPM, was diagnosed. Therefore, although PPM is known as a rare and highly lethal disease due to itlate presentation and uncertainties in diagnosis, it is of importance to be aware of this condition in various cardiac manifestations, including pericardial effusion, cardiac tamponade, patients presenting with clinical and imaging findings consistent with constrictive pericarditis, and even heart failure presentations, particularly when there is no clear explanation and response to treatment in such conditions.Additional file 1. Additional movie files show the surgery procedure, releasing adhesions from heart epicardium as well as mass resection.Additional file 2. Showing the surgery procedure.Additional file 3. Showing the surgery procedure.Additional file 4. Showing the surgery procedure.Additional file 5. Showing the surgery procedure.Additional file 6. Showing the surgery procedure.Additional file 7. Showing the surgery procedure.Additional file 8. Showing the surgery procedure.Additional file 9. Showing the surgery procedure.


Neuroendocrine tumors (NETs) are neoplasms with variable malignant potential that may arise from neuroendocrine cells. The gastrointestinal tract is a common site for primary NETs and annually 1.3 for every 100,000 persons are newly detected . AlthougHere, we report the case of a 64-year-old man with jaundice who was diagnosed with small-cell NEC in the distal common bile duct (CBD).A 64-year-old man was referred from a local clinic with complaint of painless jaundice. The patient had past medical histories of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, and gout. He had no surgical or family history of cancer.At admission, laboratory test results that present obstructive jaundice were as follows: total bilirubin 17.4 mg/dL, alkaline phosphatase 372 IU/L, carcinoembryonic antigen (CEA) 3.0 ng/mL, and carbohydrate antigen 19–9 235 U/mL. Magnetic response cholangiopancreatography revealed a focal wall thickening in the distal CBD and combined dilatation of the upstream bile duct . PositroThe patient underwent pylorus-preserving pancreaticoduodenectomy (PPPD) under a presumptive diagnosis of distal CBD cancer. In the resected specimen, 2-cm tumor tissue was located in the distal CBD . On micrNECs in the biliary system are very rare , 7, 8. Tet al. [To identify the characteristics of tumors and the clinical features, we reviewed the literature, in which 21 cases including our case were reported about the SCC from 2000 . All 21 et al.  reportedDespite the development of the imaging studies, the preoperative diagnosis of NEC is still difficult. Especially, cholangiocarcinoma presents very similar characteristics and morphology compared with NEC with various modalities including ultrasound, computed tomography, or magnetic resonance imaging. In the present study, the patient was also diagnosed with distal CBD cancer in preoperative imaging studies. Although a preoperative tissue confirmation through ERCP could be helpful, the risks of false-negative results always exist. Moreover, preoperative biopsy does not tell us whether the tumor is SCC or LCC. Measurement of serum chromogranin A is helpful to diagnose NET . ChromogAlthough WHO made the formal classification of NECs in extra-hepatic bile ducts, still little is known about the effective treatment strategy for this tumor due to its rare incidence and difficult preoperative diagnosis. Compared with the poor prognosis of conventional cholangiocarcinoma, NECs in extra-hepatic bile ducts have various clinical courses and prognoses with or without recurrences. So far, previous studies have reported quite different results about the prognosis of this tumor. Therefore, further studies with large cohorts from multiple institutions are needed to identify the clinical characteristics, to predict the true prognosis, and to establish the optimal management guidelines for this rare tumor.Gastroenterology Report online.H.I.S., J.R.K., and Y.P. conceived the study and participated in its design and coordination. J.R.S. and H.I.S. drafted the manuscript. All authors read and approved the final manuscript.None.goaa051_Supplementary_DataClick here for additional data file.


Internal hernias are rare, and a delayed diagnosis can lead to dangerous complications. A 75-year-old male with no previous surgical history presented with right upper abdominal pain and vomiting. On examination, he had guarding in the right hypochondrium with a positive Murphy’s sign. However, ultrasonography of the gall bladder was normal with dilated bowel loops. Contrast-enhanced CT (CECT) revealed a falciform hernia with evidence of obstruction. Segmental resection of the gangrenous ileum was done with a double-barrel stoma. Later on, stoma reversal was also done with no complications. An internal abdominal hernia is an abnormal protrusion of the abdominal organs through a hole in the mesentery or peritoneum, which can be congenital or iatrogenic without any hernia sac. Falciform ligament hernias are a rare type of internal hernia that occurs through a defect in the ligament. More often, falciform hernias tend to obstruct, and the preoperative diagnosis of falciform hernia is difficult. Resection of the bowel segment may be required if the herniated bowel loop is strangulated. Early intervention can prevent mortality in such cases. We report a case of strangulated falciform hernia, successfully managed with an outline of the literature.We present a case of a 75-year-old gentleman, a known case of diabetes, hypertension, and chronic kidney disease who presented with sudden onset colicky abdominal pain for two days in the right hypochondrium, associated with five episodes of bilious vomiting and abdominal distention. He had obstipation for two days. He had no prior abdominal surgeries and never had such similar episodes in the past. General examination was normal, and he was hemodynamically stable. Abdominal examination revealed a distended abdomen with tenderness and guarding in the right hypochondrium and had a positive Murphy’s sign. His bowel sounds were sluggish. The digital rectal examination had a stain of feces.Blood investigations were normal. Suspicion of acute cholecystitis was in mind. However, ultrasonography revealed a normal gallbladder with dilated and sluggishly peristaltic small bowel loops with mild ascites. X-ray abdomen showed dilated jejunal loops Figure .Contrast-enhanced CT (CECT) of the abdomen revealed herniated ileal loop through the parietal wall anterior to the liver with dilatation of proximal small bowel loops Figure .Ryle’s tube drained around 700 mL of bile. The patient was taken up for emergency laparotomy. Intraoperatively, there was pyoperitoneum with an ileal loop herniated from left to right through a defect in the falciform ligament of size 2 cm × 3 cm and was gangrenous for a length of around 10 cm for which segmental resection of the bowel with double barrel ileostomy was done in view of edematous bowel. No bands were noted. The defect in the falciform ligament was laid open. The postoperative period was uneventful, and the patient was discharged. After three months, ileostomy reversal was done and was uneventful.Based on the type of hernial orifice, internal hernias can be classified into three categories. Firstly, through the normal foramen as epiploic foramen hernia. Secondly, through the peritoneal fossa like para-cecal hernia and paraduodenal hernia. And lastly through an abnormal opening in the mesentery or peritoneal ligaments like falciform ligament hernia and broad ligament hernia . Of all,Contrast-enhanced CT diagnoses internal hernias preoperatively in patients with obstruction. It can provide a definitive diagnosis of the type and content of the hernia along with the vascularity of the bowel. Suspicion of falciform hernia is considered if a closed-loop of the intestine is seen in front or slightly caudal to the liver. A dilated intestinal loop between the liver and the abdominal wall should provoke suspicion of falciform hernia . In a reIn an era of domination by minimal access surgery, firstly, internal herniation can be prevented by slight tweaks in the technique by placing the subxiphoid trocar just to the right of the midline in laparoscopic cholecystectomy, avoiding falciform injury. Secondly, even if the aperture is created in the falciform, division of the falciform ligament, including the round ligament, can prevent herniation. Finally, removal of the subxiphoid port under vision prior to the de-sufflation of the pneumoperitoneum can prevent the postoperative chances of herniation.A falciform ligament herniation is a significantly morbid condition considering the chances of obstruction. Always morbidity is better prevented than treated. In this era of laparoscopic surgery, a few slight modifications of techniques can prevent such significant morbidity that can threaten a patient’s life. Knowledge of the falciform hernias and a high clinical suspicion is generally required so as to intervene early in the patients.


Nodular fasciitis (NF) are non-neoplastic, fibroblastic lesions, typically located on the trunk and the extremities. The incidence of NF in the head and neck region is 13%-20%. However, a manifestation in the larynx of adult patients is extremely rare. Therefore, the occurrence of NF in this region can lead to diagnostic challenges and a high risk of misdiagnosis as well as potential mishandling when not aware of its possible laryngeal manifestation.Following emergency admission of a 41-year-old woman to the emergency department (ED) due to progressive dyspnea and inspiratory stridor a transnasal flexible laryngeal endoscopic examination revealed a left-lateral, subglottic mass. A subsequently performed CT demonstrated a 2.2 cm x 1.5 cm sized lesion of the subglottic larynx with profound stenosis of the lumen (Myer-Cotton grade III), no extraluminal extension, and no distant metastases. Histopathological processing of a tissue sample obtained by microlaryngoscopy and translaryngeal tracheoscopy revealed a spindle-cell lesion with immunohistochemical and molecular-pathogenic profile of NF. After tumor debulking and steroid infiltration (triamcinolone), a regrowth tendency quickly became apparent, which is why a tracheostomy had to be performed. Laryngectomy was rejected by the patient. After multiple transoral tumor reduction attempts, radiotherapy was performed according to an interdisciplinary tumor board decision to limit regrowth tendency. Subsequently, a substantial reduction of the tumor volume could be seen, although a discreet stenosis of the subglottic tracheal lumen persists in the follow-up.Laryngeal NF poses several challenges due to its rare occurrence in this location. This case report emphasizes the knowledge of this differential diagnosis and also depicts an interdisciplinary therapeutic approach aiming for function-preserving treatment of this benign but potentially relapsing pathology. Nodular fasciitis (NF) is a benign, myofibroblastic, self-limiting mesenchymal neoplasm that typically develops on the surface of the fascia and extends into the subcutis. This neoplasm can occur in any location; the upper extremity, trunk, and head and neck are the most prevalent sites. Up to 25% of all NF cases are located in the head and neck region . HoweverA 41-year-old woman with a medical history of hypertension, gastroesophageal reflux, and obesity (BMI: 50.1 kg/m2) was transferred to the emergency department (ED) due to progressive dyspnea and inspiratory stridor over the last three days. The patient showed no dysphagia or dysphonia. A transnasal flexible laryngeal endoscopic examination revealed a right-lateral, subglottic mass  of the lumen but no extraluminal extension or distant metastases Figure .Tissue samples were obtained by microlaryngoscopy and translaryngeal tracheoscopy in jet ventilation. Histology revealed a moderately cellular myofibroblastic lesion with a noticeable myxoid matrix. The tumor cells had tapering or ovoid nuclei without any atypia or pleomorphism and indistinct palely eosinophilic cytoplasm. Multifocally, prominent osteoclastic giant cells were present, and the myxoid stroma contained scattered chronic inflammatory cells. Immunohistochemistry showed uncharacteristic partial positivity for smooth muscle actin (SMA) and negative staining results for AE1/AE3, desmin, S100, CD34, STAT6, and EMA. The ki-67 proliferative index was 3%. Fluorescence in situ hybridization , a regrowth tendency quickly became apparent and due to progressive dyspnea a tracheostomy had to be performed. The patient rejected laryngectomy. After multiple transoral and transstomal tumor resection attempts, postoperative radiotherapy was conducted according to an interdisciplinary tumor and sarcoma board decision to limit regrowth tendency. A conformal photon radiation therapy (6 mV) in the subglottic region was performed with a total of 36.0 gray applicated over 18 sessions. Subsequently, a significant reduction of the tumor volume could be observed after treatment and in the follow-up period. There were sufficient translaryngeal airflow and phonation evident while temporary closure of the tracheostomy, which is why a definite operative closure of the tracheostomy was done 12 months after radiotherapy was completed.Nevertheless, a discrete stenosis of the subglottic lumen persisted due to the formation of sail-shaped scar tissue in the dorsal (sub)glottic region visible in transnasal flexible laryngeal endoscopic examination, which was not showing any signs of functional limitations in spirometry 16 months after definite therapy Figure .The pathogenesis of NF, which commonly manifests between the second and fourth decade of life, is widely unknown. In many of these lesions, a recurrent USP6 gene rearrangement could be identified, with MYH9 being the most frequent fusion partner (about 70% of cases), characterizing these lesions as benign neoplasms. Due to their self-limiting biological characteristics, the term "transient neoplasia" has been established -6.Surgical removal of NF is the established standard treatment with additional clinical benefit reported for intra- and perilesional corticosteroid injection . Even thTo the authors' knowledge, there is only one case of laryngeal NF in an adult patient described in literature after its initial description in 1984 by Jones et al. but Al Omari et al. could not provide a histopathologic workup demonstrating a USP6 rearrangement, therefore, being deficient in its diagnostic validity .The clinical and histopathological features of these lesions may result in difficulties obtaining the correct diagnosis, often being confused with other more frequent, benign laryngeal entities but also malignancies, such as sarcomas. This may result in the application of inappropriate or even overaggressive treatment strategies. This case report is the first describing a function-preserving treatment strategy for relapsing laryngeal NF.Due to the exceptional rare occurrence of NF in the larynx, this case report highlights the diagnostic challenges of a laryngeal manifestation of NF and the importance of its consideration as a differential diagnosis in rapidly growing laryngeal masses. Furthermore, it provides an intradisciplinary treatment approach if growth is not controlled by primary resection and preservation of function is aspired. Long-term patient follow-up is needed due to the potential recurrence of NF.


Intradural mature teratomas are spinal tumors containing all the germinal layers and rarely present in adulthood. This study describes an unusual case of intradural mature teratoma in a 19-year-old male who presented with persistent lower limb pain and difficulty in micturition. The magnetic resonance imaging (MRI) scan showed heterogeneously enhancing intramedullary mass in the L3-L4 vertebral region and was associated with tethering of the spinal cord. Scalloping of the posterior aspect of vertebral body and narrowing of the pedicles were present. Subtotal excision of the tumor was done because of its adherence to the conus. Attempt to completely excise such adherent intramedullary tumors can lead to permanent neurological deficits. The tissue was sent for histopathological examination which showed tissue from all the three germinal layers confirming the diagnosis. The patient showed improvement of symptoms following the surgery. This study also compared the literature of similar cases and the treatments available for this disease. Teratomas are tumors containing tissue from all the three germ layers and result from the ectopic growth of these tissues. The occurrence of these tumors in the spinal cord in adults is extremely rare , 2. ExclA 19-year-old male presented with a history of difficulty in micturition and constipation for two years and progressively increasing right thigh pain without any back pain for 6 weeks. The pain was dull aching and constant without any aggravating and relieving factors. He had been consulting urologists for the problem with micturition for 2 years. The physical examinations revealed intact sensory and motor function of bilateral lower limbs but reduced perianal sensation was present along with normal anal tone. There was no obvious deformity in the spine and no cutaneous abnormalities. The lower limb deep tendon reflexes were diminished. The routine laboratory examinations were normal.The magnetic resonance imaging (MRI) revealed a well-defined lobulated, intramedullary heterogeneously enhancing mass 5 cm × 3 cm × 3.3 cm at the L3-L4 vertebral levels, suggestive of being predominantly cystic. The lesion showed components consistent with fat predominantly in the peripheral aspect. The intramedullary fat component was also seen in the conus in the superior aspect of the lesion. A mild peripheral postcontrast enhancement was seen. The spinal cord was found to be low lying terminating at the L2-L3 level due to tethering. The cauda equina nerve roots were displaced laterally by the mass lesion. Posterior element defects were present in the L5 level and proximal part of the sacrum Figures . The CT The patient underwent laminectomy from L2 to L5 level and exploration of the spinal cord tumor. Intraoperatively, a distended dura was found after laminectomy. The dura was dissected, and the ill-defined cystic mass was found with a membrane 2-3 mm thick Figures . The tumHistopathological examination of the mass revealed keratinized stratified squamous epithelium along with adnexal structures as well as mature fatty tissue, bony tissue without evidence of obvious malignant components Figures .The final histopathological diagnosis was that of a mature cystic teratoma. The postoperative period was uneventful, and the patient remained stable.The thigh pain was relieved following the surgery while the bowel and bladder function improved after six months of surgery. A repeat MRI scan done one year after surgery showed no evidence of recurrence.Teratomas of the central nervous system are very rare and account for about 2% of all teratomas while their occurrence in the spinal cord is less common compared to intracranial teratomas. Approximately 0.1–0.5% of all spinal cord tumors are found to be teratomas and their occurrence in adults is even rarer , 5. It iThe clinical presentation of adults with spinal teratomas are highly variable depending upon the level of location of the tumor in the spinal column  and whether the tumor is intramedullary, intradural extramedullary, or extradural . The preIt is difficult to differentiate teratomas from other tumors of the spinal cord based only on imaging studies. Computed tomographic studies may show calcifications or differences in the densities within the tumor . MRI is The treatment for symptomatic patients with teratoma is surgical resection. Laminectomy for exposure and removal of the tumor and spinal decompression is done. The goal of surgery is to decompress the neural elements without causing additional damage to the normal neural parenchyma. Histopathological examination after removal of the tumor is necessary for the definitive diagnosis of the teratomas . The ideThe misplaced germ cell theory and the dysembryogenic theory are the popular theories regarding the origin of teratomas. The dysembryonic theory is that the teratomas arise from a pleuripotent cell line which differentiates chaotically in a disturbed environment during their development . Accordiα-fetoprotein and are associated with yolk sac or endodermal sinus tissue [Teratomas are classified as three major types of mature, immature, and malignant teratomas. While mature teratomas contain well-differentiated tissue, immature teratomas contain poorly differentiated nonmalignant tissue. Malignant teratomas are highly aggressive and have a poor prognosis. They present with high-level serum s tissue , 14.Long-term follow-up of the cases is required to rule out possible recurrence with repeated MRI imaging , 13, 22.Intradural extramedullary teratomas are rare tumors. The definitive diagnosis is based on the intraoperative and histopathological examination. Total surgical excision is the primary treatment modality. Long-term follow-up is required to rule out the recurrence of the tumor.


Malignant tumors, such as acute leukemia and solid cancers, frequently cause disseminated intravascular coagulation. However, cases of disseminated intravascular coagulation as a complication of bursitis were not reported previously.A 72-year-old Japanese woman was scheduled to undergo resection of a rapidly growing subcutaneous tumor-like lesion on her left back. Preoperative blood tests suggested disseminated intravascular coagulation. The resected lesion was cystic tumor containing a hematoma. After the operation, the patient completely recovered from disseminated intravascular coagulation, indicating that disseminated intravascular coagulation in this case was caused by the tumor. Pathological examination of the resected tumor revealed considerable fibrin deposition and angiogenesis on the cyst wall, which was presumably a response to inflammation and indicated presence of repetitive intratumoral bleeding, subsequently leading to a diagnosis of chronic hemorrhagic bursitis.Clinicians should note that, despite being benign, soft-tissue tumors accompanied by inflammation with angiogenesis and repetitive intratumoral bleeding can cause disseminated intravascular coagulation, albeit rarely.The online version contains supplementary material available at 10.1186/s13256-021-02773-x. Disseminated intravascular coagulation (DIC) is a pathological condition wherein the coagulation system is activated systemically and persistently in the presence of underlying diseases, such as bacterial infection, leukemia, and malignant neoplasms. Intravascular clots formed throughout the body occlude small blood vessels, which cause multiple organ failure that may be critical in some cases –3. AlthoA 72-year-old Japanese woman perceived protrusion on her back. She had a history of appendectomy, diabetes, cholecystectomy, hypertension, and transverse colectomy. At approximately 40 days before the surgery, a subcutaneous tumor-like lesion 65.0 mm in diameter in the patient’s left back was identified through magnetic resonance imaging  . Body temperature was 36.7 °C. Any symptoms indicating infection were not observed. MRI revealed an increase in size to 95.6 mm in diameter Fig. b. HemorrAfter general anesthesia was induced, the patient was placed in the prone position. The skin over the lesion area had been raised by the tumor Fig. d. The tuBlood examination was performed to evaluate the status of DIC at POD 0 (after the operation), 1, and 2  a lobular structure, which is usually observed in cases of hemangioma, had not been found in the area of vascular proliferation on histopathological examination, (2) the genesis of hemangioma from the synovial bursa had not been reported, and (3) this diagnosis was consistent with that by MRI. According to the results of the histopathological examination, a substantial amount of hematoma and extensive neovascularization with fibrin deposition had been observed inside the tumor and on the cyst wall, respectively. It was presumed that vascular proliferation was reactive angiogenesis to inflammation. These findings indicate that hemorrhage and inflammation had been present and that platelets and coagulating factors were consumed inside the tumor, resulting in DIC. Nevertheless, it should be notable that the bleeding area was just inside the lesion and was 10 cm in diameter.Angiogenesis, a normal physiologic reaction of a living body, occurs in an inflamed site. However, such neovascularization is sometimes vulnerable. In such cases, it may bleed easily in the synovial bursa, considering that it moves and is scraped for cushioning. In cases wherein bleeding inside the solid tumor is observed, compression from the surrounding tissues may provide astriction. However, when the bleeding unfortunately occurs inside the synovial bursa, that is, inside the cavity as in the present case, astriction may not work. The present case indicated that chronic inflammation accompanied by angiogenesis and repetitive bleeding could perhaps be a potential factor for DIC despite being a local lesion. In such cases, surgical resection should be selected for the prevention or treatment of DIC.This is the first report to describe the case of DIC as a complication of chronic hemorrhagic bursitis. The tumor-like lesion was a cyst containing a hematoma, while extensive angiogenesis and fibrin deposition were observed on the cyst wall. Despite being benign, the lesion accompanied by inflammation with angiogenesis and repetitive intratumoral bleeding can cause DIC.Additional file 1: Table S1. Blood examination results. Blood examination at postoperation day (POD)-2 indicated DIC with a fibrinolytic phenotype, which ameliorated after the operation


Pyloric gland adenoma (PGA) is often associated with pyloric gland metaplasia. It has high malignant potential but a low clinical diagnosis rate. Therefore, we reported a case of PGA and reviewed the literature to summarize the clinicopathological features of pyloric adenoma.A 62-year-old female underwent gastroscopy due to intermittent acid regurgitation and heartburn, which revealed a 4×6 mm flat, elevated lesion in the greater curvature of the upper gastric body, with depression in the central region and blood scab attachment.Biopsy revealed gastric adenoma with low-grade intraepithelial neoplasia. The patient was treated with ESD, and pathology showed gastric pyloric gland adenoma with low-grade dysplasia. The cells were positive for MUC6 and MUC5AC immunohistochemically.The patient received proton pump inhibitors and gastric mucosal protective agents for one month after ESD. She occasionally presented acid regurgitation and heartburn, with no abdominal pain, abdominal distension, melena, or hematochezia. Follow-up gastroscopy will be reexamined 1 year later.PGA has nonspecific performance under endoscopy, and its diagnosis mainly depends on pathology. Clinicians need to increase their ability to recognize such lesions and treat them in time to improve the prognosis. Pyloric gland adenoma is a precancerous lesion that can evolve into adenocarcinoma through low-grade intraepithelial neoplasia to high-grade intraepithelial neoplasia, with a reported carcinogenesis rate of 12–47%.–4 However, PGA has no specific symptoms, and anemia related to autoimmune gastritis (AIG) is more common.Pyloric gland adenoma is a type of gastric adenoma.Therefore, it is necessary for clinicians to be aware of this entity. We report a case of pyloric gland adenoma found by routine gastroscopy and summarize the endoscopic and pathological features of PGA through a literature review.2Helicobacter pylori infection, which was eradicated successfully 2 years ago. Her father died of pancreatic cancer and had no family history of gastric or colon cancer. There were no abnormalities during physical examination.A 62-year-old woman suffered intermittent acid regurgitation and heartburn for 3 years. She occasionally had dull pain in the upper abdomen but no nausea, vomiting, melena or weight loss. She took omeprazole irregularly to reduce the symptoms. She had a history of chronic superficial gastritis and Gastroscopy revealed a type IIa lesion in the greater curvature of the upper gastric body, 4×6 mm in size, colorless change, that exhibited depression in its center and blood scab attachment. Close observation and FICE mode image enhancement showed that the demarcation line was positive and the surface pattern was slightly disordered Fig. . The patThe patient was treated with endoscopic submucosal dissection (ESD). The pathological results showed that resected mucosal tissue was 4×3.3 cm in size, and there was a superficial protuberant lesion (Type 0–IIa) on the surface of approximately 0.6×0.4 cm. The histological diagnosis was gastric adenoma of the pyloric type (with low-grade dysplasia), the lesion was limited to the mucosal layer, and the horizontal and vertical margins were negative. Immunohistochemistry staining showed MUC6 , MUC5AC , MUC2 (–), CD10 (–), Syn (–), p53 (wild type), Ki-67 (less than 5%), Pepsinogen-I (–), Pepsinogen-II , and ATPase (–).The patient recovered well and was followed up for 6 months. At present, she has no abdominal discomfort. Gastroscopy was scheduled to be reexamined 12 months after the operation.3Helicobacter pylori infection-atrophy and intestinal metaplasia-dysplasia-gastric cancer).,7 However, several studies have demonstrated well-differentiated adenocarcinomas arising in nonintestinalized gastric mucosa, such as gastric-type well-differentiated adenocarcinomas in hyperplastic polyps of the stomach in 1985. There has been a question of whether well-differentiated adenocarcinomas of the stomach are exclusively intestinal type. Along with the development of research, gastric-type well-differentiated adenocarcinoma has been proposed. According to the WHO classification standard published in 2019, gastric adenomas are divided into intestinal type and gastric type according to the direction of differentiation, while gastric type adenomas are further divided into pyloric gland type and foveolar type. In Japan, gastric adenoma refers to pyloric gland adenoma, while foveolar-type intraepithelial neoplasia/adenoma is classified as highly differentiated adenocarcinoma.Gastric cancer is a common tumor of the digestive system, and it has always been a hot topic for researchers. The occurrence of traditional gastric adenocarcinoma is the result of the stepwise progression of gastric mucosal inflammation  and often exists in the form of polyps in the stomach (69%).,12,13 It can also occur in the duodenum, esophagus (Barrett's esophagus), bile duct, gallbladder, pancreas, small intestine, rectum and even cervix, mostly related to pyloric glandular metaplasia. Histologically, PGA consists of dense tubular glands . The lesions were covered with monolayer cuboidal to low columnar epithelial cells with round nuclei at the base of the cells, no obvious nucleoli, and lightly stained eosinophilic cytoplasm, showing a ground glass shape and no apical mucinous cap. Immunohistochemically, the tumor cells were positive for MUC6 and MUC5AC and negative for intestinal-type markers such as MUC2, CD10 and CDX2. It has been reported that MUC6 and MUC5AC have unique immunohistochemical expression patterns useful for the diagnosis of PGA. MUC6 is diffusely and strongly positive in the whole PGA lesion, while MUC5AC has low or no (lost) expression in the surface epithelium. Ekrem Çakar et al reported a case of PGA with high-grade dysplasia, which suggests that PGA has the potential to become cancerous, which requires the attention of clinicians and pathologists.PGA was first reported by Elster in 1976.PGA has different performance under endoscopy and is difficult to diagnose accurately. Therefore, we reviewed the relevant literature and summarized the endoscopic manifestations, pathological features, and gene and chromosome mutations associated with PGA Table  to impro There have also been a few cases in the remnant stomach. Under white-light model gastroscopy, most PGA lesions appear as polypoid and nodular protuberances or as uneven mucosa, flat eminences, ulcer-like lesions or submucosal tumor (SMT)-like lesions.,12,18 The average lesion size is 1.0 –2.5 cm. Some cases suggest that there are openings on the surface of the protuberant lesions, which should be distinguished from ectopic pancreas, neuroendocrine tumors (NETs), SMT-like adenocarcinoma and proliferative polyps. Immunohistochemistry is helpful for differential diagnosis and for judging the source of lesions of nonmucosal origin. The relationship between PGA and background mucosa is still controversial. Vieth M et al investigated 90 lesions of PGA and showed that autoimmune gastritis (AIG) was found in 34% of cases, of which the infection rate of HP was 30%. Only 3.8% of cases had a normal gastric mucosa. However, the results of another study were quite the opposite: 22.4% of PGA patients had AIG, and 35.8% had normal gastric mucosa. Studies by Zong-Ming Chen et al showed that 60% of PGA showed an intestinal metaplasia background, and 40% of lesions were associated with AIG. Thus, further study is needed to clarify the relationship between PGA and background mucosa. At present, there is a lack of data about the manifestations of PGA under magnifying endoscopy and endoscopic ultrasound. According to the literature reports, the surface pattern of the lesion is star-shaped or elongated in magnified NBI mode. Demarcation lines, surface microvasculature (loop-like vessels) and surface microstructure pattern changes, and even structural loss, will be observed when accompanied by intraepithelial neoplasia or even carcinogenesis. The lesions were located in the superficial layer of the mucosa; even in the submucosa, there were isoechoic patterns, and some areas showed nonechoic patterns under endoscopic ultrasonography.,16Stomach PGA was mostly found in the fundus and body (64%), followed by the cardia (8%) and antrum (7%) of the stomach; the intermediate zone is the least common (5%).According to the immunohistochemical characteristics, PGA can be divided into three types:1.mixed type: both MUC6 and MUC5AC are expressed, but MUC6 expression is much greater, and the expression of MUC6 in deep glands is generally between 20% and 90%;2.pure pyloric type: MUC6 is diffusely expressed, and MUC5AC is expressed only in the superficial fovea epithelium; and3.foveolar-dominant type: diffuse MUC5AC expression, MUC6 expression in deep glands < 10%. Mixed PGA is more common. A Japanese study showed that the loss rate of mismatch gene repair proteins in PGA was similar to that in intestinal adenomas but much lower than that in foveolar-type adenomas, suggesting that PGA microsatellites are relatively stable. Namrata Setia et al confirmed this through second-generation sequencing. However, the results of another US study were contradictory, and further study according to ethnicity is needed.In the early stage of PGA, there may be no change in dysplasia; rather, this stage is mainly characterized by the dense distribution of glands. After the appearance of dysplasia, the nuclear/cytoplasmic ratio is increased. It has been reported that the expression of p53 in PGA is lower than that in intestinal adenoma but increases progressively from high-grade intraepithelial neoplasia to adenocarcinoma in PGA. The high expression of p53 may indicate that PGA has a relatively high carcinogenic potential. GNAS and KRAS mutations were also found to occur frequently in gastric PGA. Namrata Setia et al showed that the mutation rates of GNAS and KRAS in PGA were 67% and 41%, respectively, and that 2 mutations existed simultaneously in most cases. Histological techniques and CGH analysis showed amplifications of chromosomes 17pq and 20q in PGA and amplification of chromosome 20q in invasive gastric adenomas. Thus, the above studies on the genetic and chromosomal features of PGA confirm its high carcinogenic potential.Kushima et al successfully confirmed the instability and precancerous nature of PGA for the first time and confirmed the “pyloric adenoma-adenocarcinoma sequence” of PGA by comparative genomic hybridization (CGH) analysis, which showed that PGA shared genetic and phenotypic characteristics with gastric adenocarcinoma.It has been reported in the literature that larger lesions, villous tubular structure, AIG and mixed PGA are more likely to become cancerous. Although the local recurrence rate of PGA is less than 10%, it is necessary to follow up according to the postoperative pathological results.The patient's lesions were Type 0-IIa, located on the greater curvature of the upper part of the stomach. Pathology showed that the glands and cells were similar to the pyloric glands and were accompanied by low-grade intraepithelial neoplasia. Immunohistochemistry showed that MUC5AC was diffusely expressed, and deep glands expressed MUC6, which meets foveolar-dominant type PGA.In the process of endoscopy, endoscopists should pay attention to whether there is the possibility of PGA when finding protuberant lesions of the stomach body, which need to be differentiated from fundus glandular gastric cancer, hyperplastic polyps, and submucosal tumors. Detailed observation, biopsy and pathological examination, especially immunohistochemistry, play an important role in its diagnosis. To improve the diagnostic ability of such diseases. First, endoscopists were needed to learn more about PGA, including predilection sites, endoscopic morphological characteristics and high-risk groups. Second, endoscopists should strictly follow the endoscopic examination standard specifications and carefully examine during the operation. Finally, endoscopists and pathologists were needed to maintain good communication. For the disease to be diagnosed, endoscopists should give the pathologist a reminder, and the final diagnosis should be given after mutual consultation.4Pyloric gland adenoma is common in elderly women. Under endoscopy, most of the lesions were polypoid-like lesions, which usually occurred in the fundus and body of the stomach. The pyloric gland-like structure was observed pathologically under light microscopy. Immunohistochemistry, MUC6 and MUC5AC were helpful for diagnosis. Because of its malignant potential, clinicians should attend to the possibility of pyloric gland adenoma and pursue timely treatment.Conceptualization: Hai-Long Li, Yan Wang, Xue-Song Yang, Li Wang, Lei Zhang, xiangchun Lin.Resources: Yu-Bo Ren.Writing – original draft: Hai-Long Li, Yan Wang.Writing – review & editing: xiangchun Lin.


Imaging limitations, invasive tissue biopsies and poor information over the course of treatment to evaluate ‘real-time’ tumor dynamics justify the emerging use of liquid biopsies in the field of brain tumors. Circulating tumor cells (CTCs) from high-grade astrocytomas might reach the circulation by crossing the blood–brain barrier. Here, for the first time, CTCs cytology in a case of pylocitic astrocytoma is described. An obstructive hydrocephalous due to a lateral mesencephalic tectum mass occluding the Silvio Aqueduct was diagnosed in a young, 18 years old, male. Considering the location of the tumor and the rapid deterioration of the neurological status, it has been decided to urgency treat the patient with ventriculoperitoneal shunting. Magnetic resonance imaging showed a nodular shaped lesion localized within the left lateral mesencephalic tectum. Stereotactic biopsy was not approachable due significant risk of neurological consequences. The diagnosis was performed by blood sampling, a non-invasive procedure for the patient, in order to provide tumor information. Cytopathological features on detected circulating atypical GFAP positive cells led to pilocytic diagnosis confirmed by the patient’s 68 months outcome. A dramatic improvement in every aspect of intracranial tumors management has occurred in the last two decades. Nevertheless, the combined analysis of clinical signs, symptoms, and magnetic resonance imaging (MRI) and computed tomography (CT)-scan findings is not always diriment to perform a diagnosis, and brain biopsy is required. Many authors have reported significant post-operative complications rate associated to the biopsy procedure , 2. A peTo increase our knowledge about these tumor entities, characterized by a topographical anatomical dislocation that cannot be reached by conventional biopsy and/or surgical procedures, liquid biopsy represents an alternative and non-invasive strategy. In this field, liquid biopsy is intended as the procedure of isolation and analysis of circulating tumor cells, directly from a single blood sample. We have recently optimized and described an original protocol , 6 by whA case of a 18-year-old male student having suffered from headache and visual impairments for about two months is reported. Neurological examination was negative. CT-scan performed in urgency revealed the presence of triventricular hydrocephalus caused by stenosis of the cerebral aqueduct. The most urgent therapeutic goal was mainly the management of the hydrocephalus, therefore a ventricular-peritoneal shunt placement  was used to provide an alternative flow pathway for the cerebrospinal fluid. The critical location of the lesion discouraged the STB procedure to obtain histopathological specimens available for the diagnosis. In addition, biochemical analysis of cerebrospinal liquor resulted normal with regard to cell count and protein content. Flow chart adopted in the diagnostic phase is reported in Post-shunting (20 days) MRI showed a significant decrease of the ventricular size. Moreover, the MRI revealed a nodular lesion within the mesencephalic tectum with hypo-intense areas on the T1-weighted images  to highlight rare cells numerically sufficient and viable for further characterization. After 14 days, the adherent cells were fixed and stained for cytological examination  documented that the lesion was stable. Moreover, the area of altered signal at the quadrigeminal plate, hyperintense on T2/Fluid Attenuation Inversion Recovery (FLAIR), hypointense on T1-weighted images, placed at the entrance of the aqueduct of Sylvius, decreased in width. MRI was repeated evert 6 months in the first 2 years; afterwards, an annual MRI was performed, without changes in the radiological picture. Clinical outcome (68 months) supported by follow up corroborates the pathological diagnosis of pilocytic astrocytoma/low grade glioma.The patient provided written consent in accordance with ethical principles, relevant guidelines and regulations of the Declaration of Helsinki in accordance with experimental protocols included in the study approved by the local ethical committee, with study number 2013.34. The consent includes also authorization to publish the collected data for medical/scientific purposes in accordance with local laws.In the present case, the management of hydrocephalus was the most urgent goal, while the management of tectal gliomas, due to the slow growth of this type of tumor, was conservative and included long-term monitoring , 17. TheA major question about our results was: why circulating cells deriving from a benign cerebral lesion can be detectable in the bloodstream? Despite the MRI showed a post-contrast low enhancement of the mesencephalic lesion, this signal supports the hypothesis of the corresponding breached blood-brain barrier (BBB) according to i) the low CBV resulted by PWI findings  can provPyloytic astrocytoma is a slow-growing, circumscribed tumor frequently occurring in children and young adults in cerebellum optic nerves or brain stem. In the brain stem, it may occur as exophytic or deep lesions that may be difficult to biopsy. Through our procedure it was possible to formulate a diagnosis that allowed to decide the patient’s long-term management, avoiding further dangerous or useless diagnostic approaches. The possibility of having in short-term culture a population of cells with characteristics superimposable to single CTCs that may or may not be detected by other methods, may be an opportunity to verify the value of molecular biology techniques such as cancer genome studies and single-cell transcriptome for tumor heterogeneity. Such techniques could definitively prove their usefulness for a personalized approach to patient diagnosis and therapy , 22. We The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The study was approved by the local ethical committee, with study number 2013.34. The patients/participants provided their written informed consent to participate in this study.Conceptualization, NM and GV. Writing—original draft preparation, NM and GD. Writing—review and editing, NM, GD, and CM. Cytological evaluation: GD and CM. Visualization, NM and RR. Supervision, GD, GV, DT, US, and NM. All authors contributed to the article and approved the submitted version.This work was supported by the “Matteo’s friends Association”.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.


Rectourethral fistula is a rare disease with a wide variety of etiologies and clinical presentations. A definitive surgical procedure for rectourethral fistula repair has not been established.A 13-year-old boy sustained a penetrating injury to the perineum, and developed a symptomatic rectourethral fistula thereafter. Conservative management through urinary diversion and transanal repair was unsuccessful. Fecal diversion with loop colostomy was performed, and three months later, a fistula repair was performed via a transperineal approach with interposition of a local gluteal tissue flap. There were no postoperative complications, and magnetic resonance imaging studies confirmed the successful closure of the fistula. The urinary and fecal diversions were reverted 1 and 6 months after the fistula repair, respectively, and postoperative excretory system complications did not occur.The transperineal approach with interposition of a local gluteal tissue flap provides a viable surgical option for adolescent patients with rectourethral fistulas who are unresponsive to conservative management. Rectourethral fistulas (RUFs) are abnormal communications between the rectum and urethra. They induce significant disability and have been associated with marked distress. Patients present with passage of urine from the rectum, or fecaluria, and pneumaturia. Acquired RUFs are caused by surgical complications, pelvic irradiation, malignancy, chronic infection, and trauma . ConservA 13-year-old boy sustained a penetrating injury involving the perineum. While skating, he fell and bruised his perineum with another person’s ice skate blade. He developed a RUF with pneumaturia and urine leakage through the rectum. Minimally invasive management with UD using an indwelling urinary catheter and transanal simple suture closure of the fistula failed. Six months after the injury, he was referred to the Hiroshima University Hospital. Laboratory data showed no inflammation. Pelvic magnetic resonance imaging (MRI) revealed a fistula connecting the posterior membranous urethra and the low anterior rectum  was inserted using a cystoscope from the urethral meatus, passed through the fistula, and derived from the anus. A 6-cm transverse incision was made at the perineum 2-cm above the anal verge. Using electrocautery, the depth of the incision was increased in the posterior urogenital diaphragm region. Upon fistula incision, a guidewire, passing through the fistula, was encountered (Fig. Following complete fistula division, debridement was performed on the unhealthy and scarred tissues around the rectal and urethral openings. A simple interrupted suturing technique was performed in each layer to close the rectal and urethral openings using absorbable sutures [4-0 Vicryl; Ethicon, Johnson & Johnson, Somerville, NJ, USA Fig. a–c, 4-0 One month after the procedure, urethrography showed no signs of anastomotic leakage and stricture. The suprapubic catheter was then removed. The patient had mild urinary incontinence, which improved in a few months. Additionally, urinary stream improved with no residual urine. Three months after the surgery, follow-up pelvic MRI showed a triangle-shaped local flap located between the urethra and rectum without any gaps. Two months later, a repeat MRI revealed no flap atrophy Fig. a. There After confirming no RUF relapse by urethrography, the fecal diversions were reverted 6 months after the RUF repair. Postoperatively, his fecal appearance and frequency were normal with no incontinence. At present, there has been no recurrence of the RUF for more than 5 years since the surgery.Acquired RUFs are commonly caused by multimodal prostate cancer treatment involving radiation , 7. The Various surgical procedures for RUF repair have been reported. The basic surgical principles are excision and debridement of the fistula tract and separation of the rectum and urethra with tissue interposition . These RVarious tissue flaps can be interposed between the repaired urethra and rectum –13, but More than 80% of acquired RUF cases in children were trauma-related. Unlike adult cases, which were often related to prostate cancer therapy, the perineum and buttocks of pediatric patients were not irradiated . Based oFive months postoperatively, the pelvic MRI showed no atrophy or interposed flap deviation. There were no complaints of motor or sexual dysfunction. Based on these outcomes, the gluteal local tissue flap is a viable option for young and healthy patients without a history of radiation to the perineum region.The transperineal approach with interposition of a local tissue flap from the buttocks was a viable surgical option for repairing non-irradiated RUFs in an adolescent patient that was unresponsive to conservative management.


Oral common blue nevus is an asymptomatic, benign, rare, pigmented lesion and sometimes clinically indistinguishable from other pigmented lesions such as the cellular blue nevus or early-stage malignant melanoma. Since it shows clinical similarities with a malignant lesion and with cellular blue nevus that can itself suffer malignant transformation, the decisive diagnosis is crucial for adequate treatment, follow-up, and prognosis. Diagnosis confirmation is given by histological analysis, the reason why most oral pigmented lesions are excised. The following case presents an asymptomatic oral pigmented lesion of the hard palate discovered during observation in an emergency setting due to an abscess of dental origin. The lesion was fully excised, and histological examination reported a “common blue nevus.” In this case, we intend to present a rare lesion of the oral cavity and the importance of performing a routine oral examination when given a chance as a preventive approach. Oral melanocytic nevi (OMN) are rare, benign tumors of melanocytes –7. The pOral blue nevus has a prevalence of 0.1% in the general population, appears mainly from the third to the fifth decades, and women tend to be more affected than men , 7, 14. The following case presents a 40-year-old male with an asymptomatic pigmented lesion located in the left hard palate, discovered during an emergency visit due to a dental abscess. The lesion was fully excised with the histological diagnosis of “common blue nevus of the oral mucosa.” This case report presents a rare lesion of the oral cavity that has a risk of malignant transformation, thus highlighting the importance of the routine oral examination as a preventive approach.A 40-year-old male presented in the Stomatology Emergency Room with chief complaint of toothache in the fourth quadrant. He had a history of treated pulmonary tuberculosis, high blood pressure, abdominal surgery after trauma, and obstructive sleep apnea-hypopnea syndrome, treated with continuous positive airway pressure (CPAP). He was medicated with nebivolol, valproic acid, bromazepam, and risperidone and slept with continuous positive airway pressure. He denied any history of alcohol intake or smoking habits. Regarding family history, he alleged to have had an aunt with oral cancer.While being diagnosed with an acute apical periodontitis of the inferior right first molar, during oral examination, it was found a black melanocytic-type lesion on the posterior half of the left hard palate . The lesThe acute dental infection was primarily addressed. Regarding palatal lesion, given the fact that he was unaware of the palatal lesion, and therefore there was no way of knowing if it had a recent growth and due to his alleged family history, an excisional biopsy was scheduled and blood analysis was requested.The blood tests revealed normal, besides slightly elevated hemoglobin (17.9 × 10 g/L).The biopsy was performed under local anesthesia with lidocaine + adrenaline (1 : 80000) and a number 15 scalpel blade. The lesion was excised with a 2 mm margin, and local hemostasis was obtained with a periodontal dressing.Histological examination of the lesion revealed a “common blue nevus of oral mucosa” Figures  and 3.Upon follow-up, the patient remains asymptomatic, and the surgical wound is fully closed , with noBlue nevus is very rarely seen in the oral cavity , 7, 14. Although the ABCDE system may be a helpful tool in considering malignancy in the oral cavity, clinical impression is insufficient for definite diagnosis and most pigmented lesions end up excised , 17. ThiDue to the fact that most oral pigmented lesions are benign, excision usually is required only when the patient reports discomfort ; howeverde novo [Around 30% of all OMM develop from previous existing pigmented lesion, while most are de novo . Still, de novo , 14, 17 de novo , 19, 20.de novo , 21; mosde novo , 15.Some oncogenic protein mutations have been described in common nevi and in both cutaneous and oral melanoma; the most consensual finding is a mutation in Bioinformatics Resources and Applications Facility (BRAF). The suggested mechanism for this association is that BRAF mutations trigger the proliferation of melanocytic cells, thus forming a nevus. When a growth-arrest response occurs, the proliferation ceases. This mutation, however, is only found in less than 10% of OMM compared to 80% found in cutaneous melanoma; furthermore, some studies suggest that blue nevus rarely has such mutation, which may imply that they represent a distinct type of melanocytic neoplasms , 11, 22.The final diagnosis is therefore of utmost relevance since treatment and prognosis of benign pigmented lesions are far different from OMM , 8.This case presents the uncertainty of malignancy of an oral pigmented lesion which is, by itself, very rare, and data are scarce regarding its proper approach. An oral examination in an emergency setting regarding dental problems revealed the lesion. An excision was performed, with the positive reassurance that only an excisional biopsy can provide, that no malignancy was found associated with the palatal lesion.


Dysgerminoma is a rare malignant tumor of the ovary, more frequently occurring in young women. The main signs of pseudo-Meigs syndrome (PMS) are ascites and hydrothorax accompanying benign or malignant ovarian tumors (no fibroma or fibroma-like tumor).A 19-year-old woman with fever and chest tightness for 2 days.Pectoral-abdominal computed tomography (CT) scan and contrast-enhanced magnetic resonance imaging revealed a large amount of right pleural effusion, a small amount of ascites, and a huge abdominopelvic mass measuring about 29.2cm × 11.8cm × 8.4 cm in the left ovary. The result of hydrothorax examination was consistent with the diagnosis of exudative pleural effusion. In addition, Rivalta-test showed a positive result and lactate dehydrogenase was elevated. The histopathological diagnosis was a giant germ cell tumor, which was consistent with dysgerminoma in terms of both morphology and immunophenotype. Based on these findings, a diagnosis of malignant ovarian neoplasm with PMS was made.Surgical resection of the tumor was performed.The patient recovered well after operation, and the pleural effusion and abdominal ascites vanished. No recurrence was observed during the 1-year follow-up period.Ovarian dysgerminoma with PMS is a rare malignant tumor of the ovary, which often occurs in young women. It should be considered in differential diagnosis of patients with a pelvic mass, ascites and pleural effusion. Early diagnosis and surgical treatment are beneficial to prolonged survival. About 75% dysgerminomas occur in adolescents and young adults. Dysgenic gonads and sexual maldevelopment as represented by Turner syndrome, testicular feminization and triple X syndrome are supposed to be related to the occurrence of dysgerminoma.Ovarian germ cell tumors originate from primordial germ cells, accounting for 20% to 25% of all ovarian neoplasms, but only 3% to 5% of them are malignant. After that, another syndrome of the same type may appear, which is termed as pseudo-Meigs syndrome (PMS). But whether the tumor type in PMS is benign or malignant was not initially described by Meigs despite the similar clinical presentation; it may be a mature teratoma, struma ovarii, ovarian carcinoma, or metastatic gastrointestinal malignancy.Meigs syndrome is a rare condition that manifests as an ovarian fibroma or fibroma-like tumor with ascites and pleural effusion. The hydrops usually resolves after removal of the tumor.Here we report a case of ovarian dysgerminoma complicated by PMS, which is extremely rare in the literature. It is our hope that this case report could enrich the information about the clinical manifestations of this disease.2A 19-year-old women who complained of fever and chest tightness for 2 days presented to the emergency room of our hospital on March 11, 2020. An urgent chest computed tomography (CT) scan as part of the workup for possible pulmonary disease revealed a large amount of right pleural effusion and a small amount of left pleural effusion, for which a drainage tube was indwelled to expel the pleural effusion. Hydrothorax examination showed a positive Rivalta test result and elevation of lactate dehydrogenase (LDH), which was consistent with exudative pleural effusion, and the diagnosis of a malignant tumor was suspected. However, cytological examination did not find malignant cells in the pleural fluid.Abdominal and pelvic CT scans revealed a huge abdominopelvic mass measuring about 29.2 cm × 11.8 cm × 8.4 cm, with a small amount of ascites. The tumor also compressed the right ureter, causing mild hydronephrosis. Subsequent contrast-enhanced magnetic resonance imaging (MRI) revealed the mass with solid and cystic components on the left side of the abdominopelvic cavity, which was suspected as an ovarian neoplasms , vimentin (−), leukocyte common antigen , placental alkaline phosphatase (+), cluster differentiation 30 (CD30) (−), CD117 (+), α-fetoprotein (−), podoplanin (+), human chorionic gonadotropin (HCG) , and inhibin-α (−) Fig. . The finThe patient recovered well postoperatively and received no further treatment. The pleural and peritoneal effusions resolved completely a week after surgery. One month after operation, LDH, CA-125, NSE, and ROMA levels returned to the normal ranges. The patient has been followed up for a year, and no sign of recurrence has been observed so far.3 Dysgerminomas typically demonstrates a reasonable response rate to chemotherapy and radiation therapy. Some patients can receive bleomycin, etoposide, and cisplatin according to the surgical method and tumor stage. The classical clinical manifestations of dysgerminoma are an abdominal mass and pressure symptoms with elevation of serum LDH.,9 The presence of tumor nest multiplicity, central blood vessels and ovarian vascular pedicle on radiological images may aid in diagnosing dysgerminoma. This tumor is the ovarian counterpart of testicular seminoma and is therefore histologically similar. About 80% to 90% dysgerminomas are unilateral and consist of undifferentiated germ cells and large vesicle cells scattered in the bed sheet or umbilical cord. Immunohistochemistry often showed positive CD117 in about 80% cases, which may be correlated with the presence of a KIT gene mutation. The positive expression of organic cation/carnitine transporter 4, spalt like transcription factor 4 and D2–40 may also be detected in dysgerminoma.,13 Although dysgerminoma does not always affect hormone secretion, positive HCG expression of syncytiotrophoblast giant cells was observed in 3% cases. As in other benign or malignant ovarian neoplasms, dysgerminoma may contain functional ovarian stroma with luteinized stromal cells. In the present case, the histopathological examination results were consistent with the diagnosis of dysgerminoma; and the absence of malignant cells in the pleural fluid meant no pleural metastasis of malignant tumors.According to previous reports, the incidence of dysgerminoma is relatively low, and most cases occurred in women younger than 20 years. Fortunately, ovarian dysgerminoma can usually be detected in the early stage and has a good prognosis after systemic therapy, with an overall survival rate of more than 80%. Surgery is often a curative therapy for early-stage ovarian dysgerminoma. The cure rate of a unilateral tumor without capsular invasion or spread is high as 96%. Until 1937, this syndrome was named Meigs syndrome when Meigs and Cass presented a case series of patients who had ascites and hydrothorax in association with an ovarian fibroma. Subsequently, some scholars have reported several cases of benign and malignant ovarian tumors (no fibroma or fibroma-like tumor) with pleural effusion and ascites. They termed this clinical manifestation as PMS.,17 Until now, the pathophysiology of these syndromes remains unclear. Researchers find that the pleural effusions in most patients with this entity tumor are inflammatory exudates, which may be related to the translocation of ascites via diaphragmatic pores, the release of inflammatory cytokines and growth factor, and the obstruction of venous and/or lymphatic drainage by a pelvic tumor. A definitive diagnosis of Meigs syndrome or PMS can only be made in retrospect following the resolution of fluid accumulations after removing the ovarian tumor. It is of clinical significance to use these syndromes as the differential diagnosis of pleural effusion, especially in young women who desire fertility or pregnant.An ovarian mass, ascites, pleural effusion, and elevated CA-125 almost indicate the presence of malignant disease and/or metastasis. In 1887, Demons et al reported the first case of pleural effusion associated with a benign ovarian cyst.In summary, we have presented a rare case of ovarian dysgerminoma with PMS. Ovarian dysgerminoma should be considered in young women with a pelvic mass, ascites, and pleural effusion.Conceptualization: Xin Jin.Investigation: Guangtao Xu.Supervision: Xin Jin.Writing – original draft: Xin Jin, Xuebo Li, Deqing Chen, Xiuhui Jin, Guangtao Xu, Bo Hu, Xiansi Zeng.Writing – review & editing: Xin Jin, Xuebo Li, Guangtao Xu.


Epithelioid hemangioendothelioma (EHE) is an uncommon malignant vascular tumor characterized by epithelioid or histiocytoid endothelial appearance. Here we present the case of a 65-year-old female with recurrent EHE of the left calcaneum. The patient had developed soft-tissue swelling over the lateral aspect of the left hindfoot three years ago, which was previously managed by excisional biopsy as per medical records and the histopathological examination (HPE) had revealed an EHE. A year later, she again developed a painful swelling with superficial ulceration over the same region and presented to us. A plain radiograph of the foot showed a soft-tissue swelling with cortical breach over the lateral aspect of calcaneum. MRI revealed a mass encasing peroneus tendons, with extension into the lateral surface of calcaneum. CT angiography revealed a mass eroding the lateral cortex of calcaneum and receiving blood supply from calcaneal branches of peroneal artery. PET-CT scan did not reveal any other primary or metastatic site. Core needle biopsy of calcaneum was suggestive of EHE. Limb salvage was difficult as the tumor was recurrent and involved the skin and the weight-bearing part of the calcaneum. The patient was managed with trans-tibial amputation. Immunohistochemical (IHC) staining of the excised tissue was positive for CD34, Vimentin, SMA, and Fli-1. The margins were negative for any tumor cells and she did not require any adjuvant therapy. At two years follow-up, she was free of any further recurrence or metastasis. Recurrent tumors of this variety are fast-growing with metastatic potential and may cause mortality. Hence, they need to be managed aggressively. Epithelioid hemangioendothelioma (EHE) is a rare tumor of vascular origin, with an epithelioid and histiocytoid appearance. They originate from vascular endothelial or pre-endothelial cells and comprise less than 1% of all vascular tumors . In our A 65-year-old female presented to our outpatient department (OPD) with complaints of recurrent swelling over the lateral aspect of the left foot associated with pain and difficulty in walking for three months. The patient had developed soft-tissue swelling over the lateral aspect of the left foot three years back, which had been treated at an outside facility with an excisional biopsy of the swelling, according to the medical records. The histopathological examination (HPE) had revealed an EHE of the left calcaneum with positivity for Fli-1, CD31, and Vimentin. The patient had not received any adjuvant chemotherapy or radiotherapy after this procedure. A year later, she again developed swelling over the same area with ulceration of the overlying skin, for which she presented to our OPD. The swelling was insidious in onset, gradually progressive in size and associated with pain.The patient was a known case of type two diabetes mellitus and hypothyroidism for which she was already on medication. She was a non-smoker and non-drinker. She had a normal sleep pattern; there was no history of significant weight loss, and no alteration in appetite and normal bowel and bladder habits. There were no respiratory symptoms or difficulties. There was no positive family history for any cancer.The swelling was 5x4 cm in size, round to oval in shape, located over the lateral aspect of the left hindfoot with superficial ulceration of the overlying skin; no venous prominence, sinus or fistula were present. It was tender to touch, with no superficial rise of temperature. It was pulsatile in nature, immobile in both axes, fixed to the underlying bone and overlying skin. It had well-defined margins and a smooth surface and was compressible but not reducible Figure . There wThe radiographs of the ankle and foot showed a soft-tissue swelling over the lateral aspect of the left foot with lucency in the calcaneum and cortical breach over the lateral aspect of the calcaneum Figure . MagnetiWe performed a trans-tibial amputation considering the age of the patient, the recurrent nature of the swelling and the chances of metastasis.Grossly, the cut section of the hindfoot showed the tumor involving the calcaneum and subcutaneous tissue Figure . HPE of As the margins of the resected tumor were negative for tumor cells, any adjuvant chemo/radiotherapy was not required. The patient was mobilized with a below-knee prosthesis. At two years after surgery, there was no evidence of any recurrence or metastasis.The term epithelioid hemangioendothelioma (EHE) was first described for a vascular neoplasm of soft tissue by Weiss and Enzinger in 1982 . Deyrup Most of the cases of EHE are associated with low mortality but some show metastasis and can result in mortality of a patient . EHE is Dechambre et al. reported a case of a 28-year-old woman with pain in the left heel and a lytic polylobulated lesion in the left calcaneus with numerous small nodules in both lungs . The patPlumby et al. reported the case of a 60-year-old male who had presented with right foot pain worsened by activities. Initial radiographs were reportedly normal and corticosteroid injection administration into the sinus tarsi did not provide any relief . MRI hadEHE is associated with a recurrence rate of nearly 10%, in contrast to conventional hemangioma . Broida Angelini et al. reviewed 62 patients with EHE of bone who were treated from 1985 to 2010 and found that the survival of patients at ten years follow up was 97% for unifocal tumors compared to 74% for multifocal tumors. They also reported a recurrence rate of 25% .Lai et al. reported a case of a two-year-old boy with recurrent and locally metastasizing vascular tumor involving the skin, subcutaneous tissue and muscle of the right forearm, right distal radius and ulna, and multiple lymph nodes of the right axilla . He was The role of adjuvant chemotherapy and/or radiotherapy is still not clear in cases of EHE. In cases of localized EHE, radiotherapy is usually given after surgical resection to control any residual disease or recurrence. The use of chemotherapy, however, is reserved for cases with widespread disease .The EHE is a very rare tumor of the bone. It may be associated with recurrence and metastasis too, which can alter the prognosis in patients. There is a requirement of prompt diagnosis in these patients and adequate tumor resection too. In our case, we had the option of performing a limb salvage surgery initially with arterial embolization of the vessels feeding the tumor followed by marginal excision of the tumor and reconstruction of the calcaneum with flap coverage of the raw area. Our patient had a rapidly growing recurrent swelling with involvement of the weight-bearing area of the heel and ankle, along with ulceration of the overlying skin, which posed a hindrance to obtaining a wide tumor-free margin. There were risks of flap necrosis and metastasis. Hence, considering the advanced age and co-morbidities like diabetes mellitus and hypothyroidism, duration of the surgery, and need for adjuvant chemo/radiotherapy, we performed a trans-tibial amputation after thorough discussion with the patient and attendants.EHE is a rare tumor and recurrence, though rare, is reported in the literature. It is the most aggressive type of hemangioendothelioma with a risk of metastasis, which can result in mortality of the patient. Visceral involvement can worsen the prognosis in such tumors.Solitary EHE of the calcaneum is extremely rare. Therefore, to effectively manage tumors of this variety, it is imperative to identify them early. Hence, recurrent EHE warrants a quick and thorough workup with prompt and aggressive management.


Superior ophthalmic vein thrombosis (SOVT) is a rare ophthalmologic emergency. The most common etiologies include infection, trauma, inflammation, and malignancy, as well as thyroid-related orbitopathy. Early identification and timely intervention can lead to a significant decrease in complications that include cavernous sinus thrombosis (CST), vision loss, and death. This rare disease entity almost always makes its initial presentation to internal medicine or emergency medicine (EM) physicians. In this report, we present a case of SOVT that presented overnight to the emergency department for worsening right facial swelling and orbital pain. We discuss our experience with the evaluation and management of SOVT and provide a review of the currently available literature to emphasize the importance of obtaining a full history and physical examination, seeking early imaging studies, and ophthalmology consultation for patients with suspected SOVT. Primary care and emergency medicine (EM) physicians serve as the initial medical contact for patients with a broad spectrum of diseases. Superior ophthalmic vein thrombosis (SOVT) is a rare ophthalmologic emergency almost always first presented in the primary care or emergency setting. The presentation of SOVT varies depending on the underlying pathology, with the most common etiologies being infection, trauma, neoplasm, and vasculitis . The mosWe describe a case of OC-induced SOVT initially treated as conjunctivitis and, after further investigation, successfully managed with intravenous (IV) antibiotics and anticoagulation. The purpose of this case report is to emphasize the importance of obtaining a full history with a focused physical examination, seeking early imaging studies, and ophthalmology consultation for patients with suspected SOVT.A 44-year-old male with uncontrolled diabetes mellitus (DM) type II secondary to medication noncompliance presented overnight to the emergency department for worsening right hemifacial swelling and sharp orbital pain with flu-like symptoms that started 10 days prior. He reported right-sided ocular pain but denied changes in visual acuity or color perception. Physical examination revealed periorbital swelling, tenderness, and erythema that extended down to the right maxilla. Phlebitis was appreciable along the bilateral frontal sinuses and extended inferiorly to the nasal ridge. The ocular examination revealed chemosis, ptosis, and conjunctival injection in the right eye. The patient was admitted to medical service and started on acyclovir and clindamycin for suspected herpes zoster-induced conjunctivitis with possible sinusitis.Despite aggressive management, reoccurring febrile episodes were noted overnight, and cellulitis appeared to worsen the following morning. Further history revealed that the patient works in construction and frequently wipes his face with gloved hands. He also reported medication noncompliance due to a lack of insurance. A thorough examination revealed ocular pain and pain with extraocular movement, with no diplopia. Visual acuity, color perception, and pupillary light reflex were bilaterally intact. Laboratory studies were remarkable for leukocytosis of 14,600/mL with neutrophil predominance and glycohemoglobin of 11.1%. The remaining laboratory studies, including renal function and hepatic function, were unremarkable.Maxillofacial computed tomography (CT) with IV contrast was obtained due to the concern of orbital involvement Figures  and 2. CSOVT is a rare but serious clinical condition that requires immediate intervention. Delay in care can result in permanent blindness and fatality. Infection-induced SOVT usually presents with orbital cellulitis, frequently as a result of direct inoculation from sinusitis . Due to The distinguishing feature of SOVT is optic nerve or orbital involvement. The impairment of visual acuity, color perception, and pupillary light reflex can suggest optic neuropathy. In addition, pain or paralysis with eye movements, proptosis, or diplopia suggests inflammation of extraocular muscles and thus orbital involvement ,18. In tStaphylococcus aureus (seven out of 10 cases) [Staphylococcus aureus (MRSA) [Staphylococcus and Streptococcus anginosus were also reported [Staphylococcus aureus. Coverage for MRSA should be individualized; previously reported cases of MRSA infection were both associated with the intravenous use of illicit drugs [In patients with infectious SOVT, the most common bacteria was 0 cases) ,12-14,20s (MRSA) ,14. Coagreported ,21. Therit drugs ,14.Initial anticoagulation and steroid use have been reported, although the benefit of either therapy is unclear at this time . AnticoaSOVT is a rare medical emergency often initially presented in the primary care or emergency care setting. A focused history and physical examination to rule out orbital involvement and optic neuropathy are critical. Early detection and treatment of SOVT prevent progression to CST and its detrimental sequelae. Fortunately, the majority of the cases reported complete recovery. Suspected cases of SOVT should trigger early imaging studies and urgent ophthalmology consultation to minimize detrimental complications.


Acute mesenteric ischemia is a challenging acute condition which is often caused by occlusion of an intestinal vessel. Therapeutic algorithms include revascularization of the occluded vessel and a surgical procedure to remove necrotic intestine. Sometimes necrotic intestine is hard to identify visually. Therefore, tools such as hyperspectral imaging (HSI) and indocyanine green fluorescence angiography (ICGFA) might be helpful for objective intraoperative evaluation of intestinal perfusion.We present a case of an 80-year-old woman with an acute superior mesenteric artery occlusion and subsequent intestinal gangrene. After endovascular arterial revascularization, we performed an explorative laparotomy in which we assessed intestinal perfusion by HSI and ICGFA. Both HSI and ICGFA showed a sharp perfusion borderline in the proximal jejunum. The distal intestine showed low tissue oxygenation (HSI) and inhomogeneous perfusion (ICGFA).Both methods showed reproducible results for tissue perfusion and, thus, could provide additional information on the extent of necrotic bowel with need for resection. Therefore, both modalities might be used in future image-guided surgery in cases of acute mesenteric ischemia where visual discrimination of intestinal perfusion is challenging in order to resect as much bowel as necessary to improve patient outcome. Both methods exert different strengths: i.e. ICGFA is real-time angiography, whereas HSI may expose intestinal necrosis in spectroscopy.We show, for the first time, simultaneous imaging of HSI and ICGFA in a case of acute mesenteric ischemia. Both imaging modalities reveal similar results reliably concerning intestinal perfusion. Mostly, it is caused by superior mesenteric artery (SMA) occlusion . Open suThere are two possible tools available to asses intestinal perfusion during surgery for AMI nowadays: Hyperspectral imaging (HSI)  and IndoWe report a case from our tertiary referral hospital of an 80-year-old woman with acute mesenteric ischemia due to SMA occlusion in who we were able to record both imaging techniques during the primary explorative laparotomy.The case is reported in accordance with the SCARE 2020 guidelines of reporting surgical cases .2An 80-year-old woman with a known cardiovascular medical history who was living on her own, presented to our emergency room via ambulance with upper abdominal pain and vomiting for the last 12 h. As the troponin T was massively elevated, primary clinical suspicion was an untypical presentation of myocardial infarction. The subsequently performed coronary angiography could not identify any coronary pathologies. Because of the persistent abdominal pain, the blood lactate of 15 mmol/l and 23 exp9/l leucocytes, the surgeon on call was involved. Clinical examination showed diffuse abdominal pain with no localized tenderness. The abdominal CT angiography demonstrated a distal occlusion of the SMA with no radiographic signs of advanced bowel necrosis a. In accAs data about HSI and ICG in mesenteric ischemia were lacking at that time and with a certain hope that the questionably necrotic intestine would recover after revascularization, we decided to refrain from resection of the macroscopically less perfused segment and to judge it in a second look surgery 48 h later. During the early post-operative course, the patient’s condition deteriorated, so that we decided to perform an early second-look almost 20 h after the initial procedure. We found bowel necrosis of the previously less perfused segment and went on with resection. After stabilization of the initial multi-organ failure, a third look could be performed in which the remaining intestine was vital and an anastomotic stoma was performed . During 3In this case, we demonstrate our first experience of simultaneous application of HSI and ICGFA to evaluate the intestinal perfusion and viability in a case of AMI due to SMA occlusion.Indocyanine green (ICG) is a fluorescence dye which is activated by the specific wavelength of 805 nm and its emission spectra are detected with the respective device . To perform real-time angiography, the dye is injected intravenously and within a minute fluorescence signals occur, depending on tissue vascularization and circulation time. We have described the technique in detail before . Several2, 2 and NIR PI differed remarkably between visually well and poorly perfused intestinal segments. Additionally, the segments with impaired perfusion also showed spectral peaks at 630 nm, representing tissue necrosis. These peaks could be found directly distal of the perfusion limit . The exact technical details of this imaging method have been described previously . Brieflyon limit d, actual2 and NIR PI values in HSI. Similarly, both methods were able to show the missing microperfusion. Both measurements reflect the low ischemia tolerance of the intestinal tissues compared to the adipose tissues of the mesentery. Furthermore, ICGFA demonstrated a loss of fluorescence signal of the smaller intestinal vessels, possibly due to local thrombosis after SMA occlusion and subsequent cessation of the local blood supply. This might be the reason for the increased hemoglobin content in ischemic tissues, as reported previously by our group [During the explorative laparotomy of our case, HSI and ICGFA were able to clearly delineate the perfusion border of the jejunum at the time of primary operation. In accordance with the preoperative angiography, the proximal jejunum was vital, followed by 50 cm of potentially necrotic bowel. This was represented by visibly perfused vessels in ICGFA and by high StOur group .There are two main points to consider when applying HSI and ICGFA: On one hand, ICGFA heavily relies on the correct administration of the drug . Otherwise it might result in false-negative imaging. On the other hand, the most recent version of the TIVITA® Tissue suite does not provide real-time analysis of tissue perfusion at video-rate.The retrospective analysis of this case brings up several points: The initial clinical suspicion of myocardial infarction, brought up by high troponin levels, was delaying the correct diagnostic measures. But this reflects the every-day challenge of diagnosing acute mesenteric ischemia, as symptoms may vary. The elevated cardiac markers were probably due to a septic cardiomyopathy. Furthermore, the cardiologists could have performed an angiography of the SMA while performing the coronary angiography to exclude mesenteric ischemia. Unfortunately, it took some more hours until the revascularization of the SMA took place. Today, controversy exists on whether open or endovascular revascularization is preferable . As we hAlthough data on intraoperative imaging in AMI are scarce, the results are encouraging with regard to improving patients’ outcome. Further large-scale and prospective studies are needed to gain more knowledge and to establish intraoperative imaging during surgery for AMI.4In our case, we show that HSI and ICGFA both display intestinal perfusion in AMI in a similar quality with HSI having the advantage of visualizing necrotic tissues through spectroscopy and ICG in performing real-time angiography. We provide evidence that a useful tool for the management of AMI might be available in the near future. Hence, further studies are needed to evaluate the usefulness of HSI and ICGFA in AMI to improve patients’ outcomes.Hannes Köhler was employee of Diaspective Vision. The other authors have nothing to declare.The project did not receive any funding.N/A.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.MM and JW performed the surgery, acquired data, analyzed data and drafted the manuscript.SE performed the angiography, provided radiologic imaging and critically revised the manuscript.HK performed HSI analysis and critically revised the manuscript.IG analyzed data and critically revised the manuscript.All authors have read and approved the final manuscript.Not applicable.Matthias Mehdorn, M.D.Not commissioned, externally peer-reviewed.


Synovial sarcomas (SS) represent a unique subset of soft tissue sarcomas (STS) and account for 5–10% of all STS. Synovial sarcoma differs from other STS by the relatively young age at diagnosis and clinical presentation. Synovial sarcomas have unique genomic characteristics and are driven by a pathognomonic t chromosomal translocation and subsequent formation of the SS18:SSX fusion oncogenes. Similar to other STS, diagnosis can be obtained from a combination of history, physical examination, magnetic resonance imaging, biopsy and subsequent pathology, immunohistochemistry and molecular analysis. Increasing size, age and tumor grade have been demonstrated to be negative predictive factors for both local disease recurrence and metastasis. Wide surgical excision remains the standard of care for definitive treatment with adjuvant radiation utilized for larger and deeper lesions. There remains controversy surrounding the role of chemotherapy in the treatment of SS and there appears to be survival benefit in certain populations. As the understanding of the molecular and immunologic characteristics of SS evolve, several potential systematic therapies have been proposed. Synovial sarcoma is a relatively rare malignancy representing a soft tissue sarcoma (STS) of uncertain differentiation. It accounts for 5–10% of all STS ,3. The aAlthough many synovial sarcomas originate near articular structures, the name synovial sarcoma is a misnomer in that these lesions do not originate from intra-articular synovium, but from primitive mesenchymal cells . SynoviaSynovial sarcomas often do not present with the typical STS presentation of a large and quickly growing painless mass . InsteadPlain radiographs are not required for diagnosis but are typically performed as part of the initial workup and can identify adjacent bony remodeling, bone invasion or calcification of the soft tissue mass  14,15,1,115,16. Similar to other STS, magnetic resonance imaging (MRI) with and without contrast is the gold standard for diagnostic imaging for synovial sarcoma  17]. MR. MR17]. Although synovial sarcomas generally present as a non-specific heterogenous mass, there are some unique features, which can aid in differentiation from other STS. Synovial sarcomas predominately present as well-defined, heterogeneously enhancing solid tumors that are multilobulated in nature . A triplComputed tomography (CT) with contrast can be utilized when an MRI is contraindicated or unavailable. Synovial sarcoma appears hypointense compared to muscle with heterogeneity in larger lesions . CT alloA biopsy and pathologic assessment are required to differentiate synovial sarcoma from other STS subtypes and define the tumor grade. As with all STS, a biopsy should be performed prior to definitive surgery to avoid inadequate resection and misdiagnosis . OptionsHistorically, open incisional biopsies have been considered the gold standard for soft tissue lesions as they provide larger volumes of tissue. When compared to CNB and FNA, IB tend to have higher diagnostic accuracy but this comes with a higher rates of complications when compared to percutaneous techniques . Core neStaging investigations are imperative and allow for a better understanding of disease prognosis and risk of recurrence or metastases. The tumor stage also helps to formulate a treatment plan by a multidisciplinary sarcoma team. Staging of synovial sarcoma involves cross-sectional imaging of the affected extremity, systematic staging with a chest CT, and pathologic assessment. The two most commonly utilized staging systems are the American Joint Committee on Cancer (AJCC) system and the Enneking staging system ,27. The Synovial sarcomas are malignant and metastasize, most commonly to the lungs with up to 13% of patients having distant metastases at the time of diagnosis . Histori2 >10 mitoses per 1.7 mm2) [The gross pathology appearance of synovial sarcoma is usually tan or grey and may be multinodular or multicystic . Most sy1.7 mm2) . Occasio1.7 mm2) . Immunoh1.7 mm2) . NY-ESO-1.7 mm2) .Synovial sarcoma is characterized by a pathognomonic translocation t(X:18) which is present in >95% of cases  32]. Th. Th32]. As with all sarcomas, the treatment plan for synovial sarcoma is individualized to each patient. Both patient and tumor variables are taken into account in a multidisciplinary setting to determine the ideal treatment strategy for each patient.The mainstay of treatment for synovial sarcoma remains surgical excision with negative margins with the addition of radiotherapy and/or chemotherapy based on patient and tumour characteristics . HistoriThe goal of limb-salvage surgery in synovial sarcoma is to achieve oncologic control of the tumour while providing the patient with a functional limb postoperatively. Negative surgical margins are of upmost importance as they predict both local recurrence and overall survival ,37,38. WDue to its atypical presentation , synovial sarcomas have a high rate of presentation following an unplanned excision, with up to 50% of patients presenting after unplanned excision ,44. UnplIn select cases, limb-salvage techniques are not recommended and primary amputation may be required . AmputatNeoadjuvant or adjuvant radiation therapy is recommended for larger tumors (>5 cm), or in any case where a close margin may be required to preserve a major neurovascular structure or bone . In largUnlike the majority of STS, synovial sarcoma appears to be more chemosensitive, although there is still controversy surrounding which subgroups of patients benefit from systemic therapy . In geneIn children and adolescents with intermediate or high-risk tumours , adjuvant or neoadjuvant chemotherapy is generally undertaken with the most common agents being ifosfamide and doxorubicin. In the absence of available RCTs, prospective multicentred cohort studies have demonstrated adequate response to chemotherapy . Recent The role of chemotherapy in adult patients with synovial sarcoma is less clear. Eilber et al. (2007) demonstrated that chemotherapy improved distant relapse-free survival in patients with high-risk synovial sarcoma . Their gChemotherapy is also considered in metastatic or unresectable disease ,59. In gThere has been interest in the development of targeted medical therapies in the treatment of synovial sarcoma . New ageThe current literature suggests the five-year survival rates ranges from 59–75% ,64. Ther2 and no necrosis [There are several well documented key prognostic factors including tumor size, grade and anatomical location, patient age at diagnosis, negative surgical margins and adjuvant radiotherapy ,67,68,69necrosis ,74.Similar to other STS, tumor size and grade has repeatedly been shown to have prognostic value in patients with synovial sarcoma ,54,67. IAlthough synovial sarcoma has a similar clinical presentation in children and adults, there is a growing evidence that they have different outcomes, with children having significantly better survival rates ,9,39. UtSynovial sarcomas (SS) represent a unique subset of STS and account for 5–10% of all STS. Synovial sarcoma differs from other STS by the relatively young age at diagnosis, anatomic location (peri-articular) and clinical presentation . Given this unique presentation, it is important for orthopaedic surgeons to recognize synovial sarcoma and avoid inappropriate interventions. Synovial sarcomas have unique genomic characteristics and are driven by a pathognomonic t chromosomal translocation and subsequent formation of the SS18:SSX fusion oncogenes. Surgical excision remains the mainstay of treatment with radiation therapy utilized in high-risk tumors. Chemotherapy appears to have benefit in high-risk tumors in younger patients but there remains conflicting data in the adult population. Synovial sarcoma requires longer follow-up due to its risk of late recurrence.