Urethral polyps are one of the rare deformities of the urethra. In most cases, the urethral polyps would not be considered in the differential diagnosis process by a huge number of physicians, mainly owing to the rarity of documented cases in the medical literature and because of the wide variety of unspecified symptoms the urethral polyp might demonstrate. Urethral polyps are more common in males than in females, and they are usually diagnosed at an early age. Treatment options include transurethral resection, endoscopic suprapubic approach and open surgery. The disease prognosis is excellent as it does not usually recur after being completely removed and the risk of malignant transformation is very low. We are going to report a case of a 3-month-old boy who presented with bilateral vesicoureteral reflux and hydronephrosis, which revealed the presence of a large posterior urethral polyp. Urethral polyps are irregular growths that occur in the urethra. They are rare, and they are more common in males than in females. Posterior urethral polyps (PUPs) are more frequent than anterior urethral polyps, which are very rare. John Hunter is credited with the first documented case of urethral polyps in the literature, which he described in an ox in 1763 . In 1899PUPs are benign irregular growths in the posterior urethra. Although the lesion is uncommon, it is considered as an important cause of bladder outlet obstruction. Because of its obstructive qualities, there is a wide range of clinical symptoms that include dysuria, recurrent urinary infections, hematuria and urinary retention. Infrequently, urethral polyps may be associated with vesicoureteral reflux (VUR) and hydronephrosis and this is what we are going to report in our case.*0.5*0.5 cm in size. The polyp pedicle was attached to the verumontanum ile the polyp extended into the bladder (A 3-month-old boy presented with a history of unexplained excessive crying episodes, mostly occur during micturition. On hospital admission, physical examination was normal. Laboratory studies including blood and urine tests were normal, as well. The patient underwent abdominal and pelvic ultrasound, which showed bilateral hydroureteronephrosis involving the dilation of the entire ureters . Voiding bladder . We also bladder . HistopaAn indwelling urinary catheter was used after surgery. 24 h later the boy was discharged home in perfect condition. The boy’s parents reported later that the micturition-related crying became significantly less recurrent.1 year following the surgery, we conducted a new ultrasound and VCUG imaging which affirmed that the VUR and the hydronephrosis fully retreated on both sides . In addiUrethral polyps are uncommon benign polypoid masses of the urethra, and they typically manifest as single tumors rather than multiple separate masses. Until 2004, 181 cases of urethral polyps have been reported . In maleThe pathogenesis of this condition is still poorly understood and controversial. However, congenital, irritating, septic, traumatic and obstructive factors have been discussed and proposed as potential causes for urethral polyps. Moore and Kuppusami suggest that maternal estrogen levels during gestation could cause secondary epithelial changes which in turn might develop urethral polyps . BecauseUrethral polyps are typically asymptomatic . NeverthAlthough ultrasound imaging is important in the diagnosing process, it is not diagnostic and cannot detect the lesion successfully in most cases. VCUG assists in establishing diagnosis by showing a filling defect in the urethra and it also reveals accompanying comorbidities like VUR. The presence of urethral polyp is detected mainly by endoscopy and histologically confirmed by biopsy .The standard treatment for urethral polyps is endoscopic transurethral resection by either cold knife, scissor, electrocoagulation or laser . The resThe follow-up by doing ultrasonography and VCUG should be done after 1 year. This is what we did in our case making sure that there was no recurrence and no VUR or any other abnormalities.Urethral polyps are always considered a distinctive medical case because they are rarely discussed and described in the literature and they could be demonstrated with a wide spectrum of symptoms. As it stands, they should always be considered as an important differential diagnosis for patients with voiding dysfunction or lower urinary tract symptoms, especially in the first decade of life.


A 72-year-old man, who was treated 10 years earlier with endovascular aortic aneurysm repair, presented with a fever. Considering the concern of stent graft infection, the patient was treated with antibiotics, but his condition did not improve. He underwent stent graft resection and reconstruction with a Dacron graft. Pathological analysis of the aortic wall and computed tomography revealed recurrent intimal sarcoma, and the patient underwent resurgery. During follow-up, he underwent two additional resections for local recurrence, but he died 17 months later. Our results suggest that intimal sarcoma should be considered during the follow-up after endovascular aortic aneurysm repair. Owing to early blood metastasis and resistance to chemotherapy, patients with intimal sarcoma have a poor prognosis. In this report, we describe our experience with intimal sarcoma following endovascular aortic aneurysm repair (EVAR). This case report has been approved by the institutional committee on the ethics review board (registration number: 5504).Intimal sarcoma of the abdominal aorta is rare. Intimal sarcoma presents with intraluminal growth with obstruction of the lumen of the vessel of origin and seeding of emboli, and it is difficult to diagnose and is often diagnosed in surgical specimens or at autopsy.3). Multiple sets of blood cultures were negative for bacteremia. Echocardiography showed a normal left ventricular ejection fraction and no valvular vegetation. Compared with the computed tomography (CT) scan from the previous hospitalization, enlargement of the aneurysm sac, periaortic thickening, and periaortic inflammation related to infection were noted in the present CT scan , which was placed at another institution 10 years before the visit to our clinic. He was admitted to the hospital of origin complaining of fever and physical weariness, which had persisted for four months previously. Symptoms did not improve after antibiotic treatment, and the patient was referred to our department. Laboratory tests at admission revealed an elevated C-reactive protein (10.6 mg/dL) and no leukocytosis (white blood cell count of 7480/mmIntimal sarcoma is a rare malignant neoplasm that arises in the aorta, and its defining features are intraluminal growth with obstruction of the lumen of the vessel of origin and seeding of emboli to peripheral organs. A PubMed literature search using the search terms EVAR and sarcoma revealed only 12 cases of primary abdominal aortic sarcoma after EVAR ( The age of onset of aortic sarcoma after EVAR ranges from 56 to 85 years. Aortic sarcoma is defined as an intraluminal growth that obstructs the lumen of the vessel and emboli to the peripheral organs. However, the patients do not present with symptoms of embolism after EVAR, as in the present case. This investigation suggests that EVAR suppresses tumor growth in the aortic lumen and prevents embolism. However, most cases of aortic sarcoma after EVAR reported in the literature have described an association with foreign materials, such as Dacron or nickel and titanium alloys in SGs. In a study of 35 cases of angiosarcomas by Fenton et al., 23 cases were associated with the use of these prostheses. Therefore, the physical characteristics of the implanted materials are considered essential factors for tumorigenesis. The duration from EVAR to tumorigenesis was 4–10 years, which also suggests an association with these prostheses.Most patients with aortic intimal sarcoma are middle-aged, and the prognosis of intimal sarcomas is generally poor. The CT findings of infected aneurysms include disruption of intimal calcification; irregular arterial lumen; and periaortic gas, fluid, and/or hematoma. However, CT findings of infected aneurysms with overlapping characteristics of intimal sarcoma are more common. Half of the case reports retrieved in this report were diagnosed with graft infection. The ultrasonographic findings of intimal sarcoma were reported by Kamran et al. to have a small mass-like component of intermediate echogenicity, which shows internal vascularity in the color Doppler image. Conversely, the ultrasonographic findings of infected aneurysms are not characteristic, but the shape of the aneurysm is irregular, and the presence of air is noted. We have not confirmed any ultrasonographic findings in our case. PET scans show avid fluorodeoxyglucose uptake, but PET scans are not performed unless a tumor is suspected. It is important to be cautious of neoplastic lesions during follow-up after EVAR. However, imaging seldom permits the preoperative diagnosis of aortic sarcoma, and graft infection is often presumed, as in our case. In previous studies, preoperative diagnosis suspected graft infection in 6 of 11 cases, and in 7 cases, the diagnosis of aortic sarcoma was made by immunohistochemical examination of the surgical specimens. In our case, the final histopathological examination led to a diagnosis of intimal sarcoma. The treatment of intimal sarcomas remains difficult. Currently, in the absence of metastases, surgical resection of the tumor is the first-line treatment for intimal sarcoma. The role of adjuvant chemotherapy and radiotherapy remains unclear. However, most patients with aortic sarcoma have metastasis at the time of diagnosis, due to which the five-year survival rate remains poor.CT is a useful diagnostic tool for angiosarcomas. The imaging characteristics of aortic sarcoma include protrusive vegetation or nodular soft-tissue components, lack of atherosclerosis in the area of suspicion, heterogeneous thrombus, evidence of enhancement and neovascularity, and persistent enlargement of the excluded sac. However, there is a case report in which patients underwent en bloc resection of the aorta and common iliac vessels and survived for eight years from diagnosis to death. Early diagnosis is important because complete resection of the primary lesion suggests the possibility of long-term survival. In this case, the patient was misdiagnosed with SG infection and underwent four months of antibiotic therapy, but the tumor expanded. During follow-up after EVAR, attention should be paid to neoplastic lesions, aneurysm sac enlargement, and graft infections.In a study published by Thalheimer et al., the median survival time was only 12.8 months after diagnosis, and metastases were present in 76.2% of cases.We presented a rare case of intimal sarcoma mimicking an infected EVAR. Intimal sarcomas after EVAR are rare and difficult to diagnose. Attention should be paid to neoplastic lesions, aneurysm sac enlargement, and graft infections during follow-up.


Brain tumor surgery has been using operative microscope for years. Recently, thanks to developments in surgical technology with procedures performed on head-up displays, exoscopes have been introduced as an alternative to microscopic vision.We present a case of a 46-year-old patient with a low-grade glioma recurrence of the right gyrus cinguli removed with a contralateral transfalcine approach using an exoscope  exoscope, Sony Olympus Medical Solutions Inc., Tokyo, Japan).The operating room setup for this approach is illustrated.During the procedure, the surgeon was seated with head and back in an upright position, while the camera was aligned with the surgical corridor.The exoscope provided detailed, high-quality 4K-3D images of the anatomical structures and optimal depth perception, making surgery accurate and precise.At the end of the resection, an intraoperative MRI scan showed complete removal of the lesion. The patient was discharged on postoperative day 4 with an excellent performance on neuropsychological examination.In this clinical case the contralateral approach was favorable because the glioma was located close to the midline and because it offered a straight path to the tumor, minimizing retraction on the brain. The exoscope provided the surgeon with important advantages in terms of anatomical visualization and ergonomics during the entire procedure.The online version contains supplementary material available at 10.1186/s41016-023-00320-9. In recent years, thanks to significant developments in screen-based technology with head-up displays, exoscopes have also been introduced in surgery as a viable alternative or in addition to microscopic vision. Actually, brain tumor surgeries require a magnified view of the surgical field and anatomical details, which are traditionally provided by the microscope.In particular, the contralateral approach is defined as one that uses a cross trajectory in a coronal plane to reach a lesion contralateral to the craniotomy. In microsurgery, the need to be minimally invasive often prevails on a shorter surgical route and a cross trajectory might sometimes be useful in order to preserve the brain during tumor removal .We present a case of a 46-year-old patient with a low-grade glioma recurrence of the right gyrus cinguli removed with a contralateral transfalcine approach using an exoscope  exoscope, Sony Olympus Medical Solutions Inc., Tokyo, Japan).The advantages of the contralateral approach, combined with the use of the exoscope, will be thoroughly illustrated and discussed.This is a 46-year-old male patient who was operated on in 2016 to remove a diffuse grade II astrocytoma of the right gyrus cinguli, through an ipsilateral interhemispheric approach with the head in neutral position. The follow-up with brain MRI showed no recurrence until April 2021, when a new MRI demonstrated a local recurrence. At that time, the patient complained only of a mild headache with no neurological deficits.The MRI showed a FLAIR hyperintense and T1 hypointense, no-enhanced lesion at the level of the anterior third of the right gyrus cinguli, suggestive of low-grade glioma recurrence  and maximum magnification power provided by the equipment. In this way, the camera does not interfere with the surgeon’s line of sight.In general, lesions close to the midline typically require less retraction in order to control the lateral aspect of the surgical cavity, and they could also be accessed using an ipsilateral interhemispheric approach. Conversely, eccentric lesions require more retraction, with an increased risk of retraction-related injuries and residual disease.Until now, we were always used to thinking that the position of the head was critical to ensure good exposure of the lesion, avoiding brain retraction or manipulation. The exoscope attempts to twist this well-established concept. In fact, with the microscope the line of work/light should be the same as the line of sight, unless you want to hold an uncomfortable working position with your neck bent over the lenses. With the exoscope, the line of sight can be fully different from the line of work/light and the surgeon can operate in an ergonomic position with the head upright and good alignment of the shoulders and back , 3 Fig.. ConversMoreover, the high-resolution 4K-3D images provided by the exoscope make surgery more accurate, with optimal perception of depth, colors, and magnification .Furthermore, the exoscope allows more space around the operating table and patient. This is especially useful in procedures where multiple equipment is required, for example navigation devices or ultrasound, as in our surgical case.It should not be forgotten that the exoscope offers high quality, 4K-3D images not only for surgeons, but for everyone who watches the 55-inch or 31-inch monitor using polarized glasses. This advantage can also be used for educational purposes for students and residents, because the use of external monitors and glasses gives them the same high-resolution view as the surgeon.To conclude, in case of glioma located close to the midline, the contralateral approach is favorable because it offers a straight path to the tumor, minimizing retraction on the brain. Moreover, using an exoscope, the surgeon is seated with head and back in an upright position, while the camera is aligned with the surgical corridor. This offers unquestionable advantages in terms of comfort for the surgeon and safety for the patient.Additional file 1. The advantages of a contralateral approach, combined with the use of the exoscope, in a patient with a low-grade glioma recurrence of the right gyrus cinguli can be appreciated in this 3D video.


The phosphatase and tensin homolog (PTEN) hamartoma tumor syndrome (PHTS) is a collection of diseases stemming from mutations in the PTEN tumor suppressor gene and is characterized by variable expressivity and abnormal overgrowth in multiple body systems. Its clinical manifestations include, but are not limited to, lipomas, limb overgrowth, dermatologic lesions, and malignancy. The infrequency of occurrence and broadness of clinical presentation has made the diagnosis and differentiation of different subtypes of PHTS challenging. This case report describes a five-year-old patient with a history of autism and macrocephaly who presented to the emergency department with right lower quadrant (RLQ) pain concerning for appendicitis. A physical exam was significant for right leg hemihypertrophy. Imaging ruled out appendicitis but diagnosed two large right-sided abdominal lipomas. The patient was discharged with the recommendation to pursue genetic testing given the physical exam findings and history. Following confirmation of a PTEN tumor suppressor gene mutation, the patient continued to have increased frequency of abdominal pain, developed vision changes, and was diagnosed with a benign follicular thyroid nodule. Hemihypertrophy, recurrent unilateral lipomas, and a confirmed PTEN mutation are consistent with a diagnosis of Proteus-like syndrome, a rare subtype of PHTS. Phosphatase and tensin homolog (PTEN) is a protein encoded by the PTEN tumor suppressor gene and, along with p53, is one of the most commonly lost tumor suppressor genes . PatientA five-year-old child presented to the ED with complaints of right lower quadrant (RLQ) pain, nausea, and fever for two days concerning for appendicitis. The patient's past medical history was significant for autism and macrosomia. On physical exam, the patient had right leg hemihypertrophy and macrocephaly. Abdominal ultrasound showed no acute appendicitis. However, two lipomas were found: one in the right upper quadrant (RUQ) and another in the RLQ. CT confirmed an intra-abdominal RUQ lipoma measuring 8.5 x 2.0 cm Figure  as well Over the next year, the patient developed worsening abdominal pain, blurry vision, and repeated falls. An MRI of the brain was unremarkable. Roughly eight months after the presentation to the ED, the RLQ lipoma was resected and found to be 12 x 8 x 3 cm on gross examination. Surgical pathology confirmed mature adipose tissue consistent with a lipoma. On a three-month postoperative abdominal and pelvic CT for continuing abdominal pain, the RUQ lipoma had grown in thickness to 5.5 x 5.0 cm with an increased displacement of adjacent loops of the bowel (Figure Four years after the initial presentation, the patient had a nontoxic right-sided unilateral goiter. An ultrasound found a solid right-thyroid nodule measuring 0.5 x 0.4 x 0.3 cm (Figure Proteus syndrome is an extremely rare disease characterized by partial gigantism and hemihypertrophy of the limbs as well as subcutaneous lipomas and verrucous epidermal nevi . As of 2Unlike many PTEN hamartoma syndromes, the diagnostic criteria for Proteus-like syndrome have not been defined . ProteusPTEN mutations have been implicated in many different cancers . TherefoProteus-like syndrome is a subtype of PHTS; it has been poorly described in the literature due to a lack of diagnostic criteria and variable phenotype. This case report described a presentation of PHTS with lower limb hemihypertrophy, a Proteus syndrome characteristic, accompanied by other growth abnormalities, including unilateral recurrent lipomas, a follicular thyroid nodule, and macrocephaly. PHTS patients are at an increased risk of various cancers. Earlier diagnosis will lead to earlier screening and the potential for increased longevity. More data on PHTS patients is needed to optimize benefit versus harm when it comes to screening for these patients.


It is very rare for colorectal neoplasms to metastasize to the heart in the worldwide medical literature; only a single case of well-documented colorectal cancer metastasis to the left atrium was found. The case of a 66-year-old man is explained in this paper, who was suffering from metastatic adenocarcinoma of the colon that included the left atrium. In transthoracic and transesophageal echocardiography, a large multilobulated mass was present in the left atrium. An accidental pulmonary mass was also seen in a lung spiral CT scan. The cardiac mass was taken out, and a biopsy was obtained from the pulmonary mass. Adenocarcinoma was seen in histological assessment. Immunohistochemical staining was carried out to examine the expression of cytokeratin 7, cytokeratin 20, and caudal-related homeobox transcription factor 2 (CDX2) to determine the origin of the adenocarcinoma. In addition, the expression of these proteins was linked to the attributes of the patient and tumor. Post-surgical transesophageal echocardiography showed normal left ventricle and right ventricle function with no evidence of left atrium mass. Therefore, we suggest that asymptomatic cancer patients with a history of colorectal cancer and who have developed cardiac symptoms should be immediately examined for potential cardiac metastasis. Colorectal cancer (CRC) is the third most widely identified and the second most lethal cancer in males as well as females from all over the world . The folA 66-year-old male was admitted to our hospital in late 2020 as he was experiencing transient dysarthria. The patient had undergone right hemicolectomy and adjuvant chemoradiation for adenocarcinoma 3 years back. His medical history included a cerebrovascular accident in the past and recent depression. The patient's social history was not unusual. The laboratory findings at the time of admission for complete blood count (CBC), coagulation tests, and liver function tests were within the given limits. There was an increase in erythrocyte sedimentation rate (ESR) and C-reactive protein . A positive result was obtained for the serological test for hepatitis B. Physical examination did not show any sign, and the jugular venous pulse was also normal. Neurological examination and brain CT scan were unremarkable. The patient was diagnosed with a transient ischemic attack (TIA). Transthoracic echocardiography (TTE) was requested to investigate the origin of the embolic lesion of the brain. It showed LA mass, normal LV and RV function, normal pulmonary artery pressure (PAP), and no significant valvular heart disease (VHD). Transesophageal echocardiography (TEE) was performed to examine the LA mass more closely. A large size (4×2.5cm), mobile, hypochondriac, multilobulated mass was seen in the LA roof at the right upper pulmonary vein entrance site with protrusion into it . An acciTTE after surgery and follow-up did not show any mass in the heart until nine months later. The patient had no signs of embolism during this time.CRC is the second or third most widely prevalent human malignancy and the leading cause of cancer-related deaths , 10.Autopsy series of cancer patients have shown that the prevalence of metastatic cardiac tumors is between 1.5% to 20% . It is vA few cases of well-documented metastatic CRC concerning the right atrium or ventricle were obtained from the international medical literature -16.  et al. as a consequence of tumor extension from rectal adenocarcinoma , though surgery is advised in very rare cases as a treatment for metastatic cardiac tumors, surgical treatment may particularly be effective in cases of obstructive and solitary lesions to provide relief from symptoms and an extension of life expectancy. The goal of surgical treatment in our case was to prevent mass embolism again.Surgery may improve quality of life and survival, but only in a few selected cases . AccordiA case of heart metastasis was identified by Tsujii, with over two-year survival and only chemotherapy without surgery (9). It is not always possible to carry out the surgery.In this context, a case of heart metastasis was presented by Nishida, where the patient passed away two weeks following the tumor resection .A 68.4% rate of survival was shown by Murphy and colleagues  in 19 paIn another case, a patient had to undergo right atrial colorectal metastasis resection with bovine pericardial patch reconstruction. The patient suffered from bleeding on the third postoperative day and passed away . et al. from colon cancer in a 65-year-old man. The surgery was effectively carried out on our patient, and following the surgery, the TTE showed that the patient had normal size and function of the left ventricle , which induced pressure on the right ventricle and atrium. A multilobulated mass was shown by TEE in the left atrium, measuring 4 x 2.5 cm, in addition to accidental pulmonary mass. Following the cardiac biopsy, Immunohistochemical staining for CK7, CK20, and CDX2 was performed to confirm the presence of adenocarcinoma. It was shown by TTE examination that the surgery was effective and the size and function of the left ventricle were found in normal limit.In conclusion, surgery may be appropriate treatment for given patients with metastatic cardiac tumors; however, no standardized methods have been established yet for treatment of the patients with cardiac metastases from CRC. Additional studies should be conducted to determine the most effective treatment for these patients.Not Applicable.Not Applicable. The authors declared no conflict of interest.The author(s) received no financial support for the research, authorship, and/or publication of this article.


Dermatitis artefacta (DA) is a condition whereby self-induced skin damage is the means used to satisfy a desire to assume the sick role.To describe clinical evaluation, diagnosis, treatment and evolution of an 15 years-old woman with DA.Retrospective review of clinical records, including dermatology, psychiatry and Pathology.A 15-year-old woman, who come to the Child Psychiatry consultations derived by the Dermatology Service, which is attended by the appearance of multiple bullous lesions throughout the body. Since August, the patient has reported a worsening of her mood, with feelings of loneliness and vital emptiness, with somatic and psychic anxiety referred. In the Dermatology office, she does not recognize self-infliction and the patient is derived to psychiatry consultation and solicited a skin biopsia. In the psychiatric interview, she recognizes that burns occur with a deodorant spray. She admitted doubts about her sexuality for months, claiming to be homosexual for the first time. When she burns, feels pleasure and relief. At the exploration: She wears a gay pride flag bracelet. Expressionless attitude. Cold contact. Approachable. Slightly collaborative. Without major affective disorders. No somatic anxiety, nor psychic. Short speech, impoverished language. Personality traits Cluster B and C. •Salamanca Questionnaire: Dependent personality, and in the background anxiety and histrionic. •Plutchik Impulsivity Scale: 14. •Toronto Alexithymia Scale: 64The prognosis of the condition is variable, but it has been shown that resolution of the underlying psychosocial stressor leads to improvement. Multinucleated keratinocytes, a pathognomonic lesion of cryodermatitis artefacta, are discovered in the Pathology.


Perineuriomas are benign, rare neoplasms of the nerve sheath, basically in two forms: intraneural and extraneural. Extraneural forms are mainly found in the trunk and limbs, while visceral organs are rarely affected. To date, there have been no previous reports in the literature of bladder perineurioma. In this case, we report a young adult with hematuria and bladder tumor which after surgical resection and immunohistochemical study was confirmed to be a perineurioma. Therefore, this should be included in the differential diagnosis during the analysis of resections of bladder tumors. Perineurioma was first described by Lazarus and Trombetta in 1978, as a rare group of benign neoplasms of the nerve sheath, being composed exclusively of cells with perineural differentiation. They represent approximately 1% of all soft tissue neoplasms . There aPerineuriomas basically appear in two main forms: intraneural, restricted to the limits of peripheral nerves, and extraneural, mainly found in the skin and soft tissues of the trunk and limbs . Head, nThis is the case of a 29-year-old patient, without previous comorbidities and no use of medications. He presented with painless macroscopic hematuria for about three weeks, related to physical effort and sexual intercourse. No previous episodes or traumatic or inflammatory history was reported, and systemic examinations were normal.Ultrasound of the urinary tract was performed, showing bladder with a prominent vegetating lesion, with the presence of visible vascularity detected by color Doppler signal, measuring 3.3 x 3.4 x 4.1 cm, immobile to the change of position, in its posterior wall with signs of malignant neoplasm  is formed by elongated spindle cells with tapered nuclei, light eosinophilic cytoplasm, indistinct cell boundaries with elongated and extremely thin bipolar cytoplasmic processes found at least focally, presenting great variability in architectural patterns, among them, storiform, fascicular, reticular, plexiform, infiltrative and myxoid. The sclerosing perineurioma (SP) presents the sclerotic stroma with a large amount of collagen, it is composed of cells that are arranged between the collagen bundles in small nested rows, trabecular or spiral. These cells have two distinct shapes, a fusiform and wavy and another rounded and epithelioid with evident cytoplasm, both of which may be present in the same lesion. The nuclei are small and hyperchromatic and the nucleus is indistinct. Mitosis figures are rare or absent and there is no nuclear pleomorphism. Some lesions have thin-walled dilated blood vessels and nerve fascicles are present in the midst of the neoplasm ,4.In clinical practice, an accurate diagnosis will require an experienced pathologist with or without the aid of immunohistochemical profiling -5. In inUsing immunohistochemistry, perineuriomas are positive for epithelial membrane antigen (EMA) and negative for S100, a family of calcium-binding proteins and neurofilaments, which differentiates them from schwannomas. Other non-specific antigens frequently expressed by these cells are Glut-1, claudin-1, collagen IV, and laminin -6.The treatment of perineuriomas consists of surgical excision and the recurrence is rare -6.This case describes an extraneural perineurioma occurring in the bladder, a location that to our knowledge has not yet been described in the literature. Therefore, it should be included in the differential diagnosis during the analysis of resections of bladder tumors, mainly in young adults, in whom the presentation of a bladder tumor is uncommon.


The deposition of colored endogenous or exogenous substances in the tissues of the tongue may result in pigmented lesions of the lingual mucosa. The accurate identification of the underlying condition can be difficult to achieve and relies mainly on patient history and clinical and histological evaluation. We present the case of a 30-year-old male referred to our hospital with a chief complaint of extensive pigmentation of the lingual dorsum. A diagnosis of physiologic pigmentation based on clinical and histological findings was made. Since some life-threatening diseases may present solely as pigmented lesions of the tongue, an early diagnosis is of utmost importance. The accumulation of colored substances in the tissues of the tongue can result in pigmented lesions of the lingual mucosa ,2. PigmeWe report the case of a previously healthy 30-year-old male, Fitzpatrick skin type V, who presented with a chief complaint of extensive pigmentation of the lingual dorsum. The lesion had spontaneously appeared one year ago, with no history of oral trauma or inflammation. Color and size remained unchanged for the last six months. No other symptoms were described. The patient denied consumption of medication, alcohol, or tobacco. There were no records of melanoma or other pigmented oral lesions, intestinal polyposis, or Addison’s disease in the family. Physical examination revealed a diffuse asymmetrical brownish-black pigmentation covering most of the dorsal surface of the tongue but absent on its ventral surface Figure . There wPhysiologic pigmentation is a common feature that occurs mainly in non-Caucasian individuals, without gender predilection, and with a prevalence directly proportional to age ,7. MelanPigmented lesions of the tongue can range from harmless normal variants to life-threatening conditions. A thorough investigation including patient history, clinical examination, and, if necessary, histopathological evaluation is mandatory for diagnosis.In this case report, we described an atypical physiologic pigmentation of the tongue. Although benign in nature, its unusual presentation demanded a histological characterization. Since about one-third of oral melanoma arise from previous benign pigmented lesions, periodic evaluation of these lesions must be considered.


Fetal brain tumors are a rare entity with an overall guarded prognosis. About 10% of congenital brain tumors are diagnosed during fetal life. They differ from the postnatally encountered pediatric brain tumors with respect to location and tumor type. Fetal brain tumors can be benign or malignant and infiltrate or displace adjacent brain structures. Due to their high mitotic rate, they can show rapid growth. Outcome depends on age of diagnosis, size, and histological tumor type. Findings like polyhydramnios and macrocephaly encountered on routine ultrasound are frequently associated. Detailed prenatal anomaly scan and subsequent fetal magnetic resonance imaging (MRI) may identify the brain tumor and its severity. Both maternal and fetal prognosis should be included in prenatal counselling and decision making. Fetal brain tumors (FBT) are very rare. They occur in 0.34/1,000,000 live births and account for 10% of all antenatal tumors ,3,4,5. ADepending on the tumor type, diagnosis is usually made in the late second or third trimester ,3,10. InWe present four fetuses with matching prenatal US and MRI diagnosis of FBTs presenting at our high complexity tertiary referral center between 2011–2019. Goal of this case series is to familiarize physicians with the various primary brain tumors that can be encountered on prenatal imaging and the respective value of US and MRI to narrow down differential diagnosis.Case 1: A 35-year-old G1P1 was diagnosed at 18 weeks and 6 days gestational age with a fetal brain mass of unclear etiology at her referring institution. Outside fetal MRI showed a 2.5 × 4.2 × 3.9 cm suprasellar, predominantly solid, partially cystic midline mass lesion elevating the floor of the third ventricle, high grade compression and displacement of the mesencephalon and brainstem with resultant supratentorial ventriculomegaly and macrocephaly A,B.Follow-up ultrasound at 20 weeks and one day showed a rapid enlargement in the predominantly solid component of the intracranial mass, measuring 5 cm × 6.3 cm × 7 cm, macrocephaly with a head circumference (HC) of 285 mm (>5SD above the mean) and polyhydramnios  A,B.Prominent arterial feeders originating from the middle cerebral artery (MCA) were noted. The MCA peak systolic velocity was >2 MoM (multiple of the median) suggesting a high cardiac output status or fetal anemia. Cardiothoracic ratio was normal. There were no signs of fetal hydrops. Based on the imaging characteristics a germ cell tumor, e.g., teratoma was considered the most likely diagnosis. The parents received extensive multidisciplinary counselling on fetal prognosis and potential maternal complications, mostly due to the large head size. They opted for palliative/comfort care at delivery. Pregnancy was complicated by a preterm premature rupture of membranes (PPROM) with subsequent delivery at 25 weeks outside of our institution. The newborn died at 1 h of life. Histopathological results and mode of delivery are unfortunately unavailable.Case 2: A 17-year-old G1P0 was referred at 35 weeks and 5 days of gestation to our institution. Ultrasound showed a highly perfused mass lesion located in the posterior fossa associated with hydrocephalus, macrocephaly  and mildly increased amniotic fluid volume (AFI 23 cm). On fetal MRI, a well perfused posterior fossa infratentorial mixed solid and cystic mass lesion was seen associated with moderate to marked supratentorial hydrocephalus. Cystic elements of the lesion were seen herniating through the tentorial incisura into the supratentorial compartment. Diffusion weighted imaging (DWI) showed restricted diffusion within the solid tumor component, which could be indicative of a medulloblastoma versus an atypical terato-rhabdoid tumor (ATRT) A–D.Patient delivered two weeks later (38 weeks) by cesarean section after PROM. A male newborn, with a weight of 3090 g and Apgar scores of 5 and 6 at respectively 1 and 5 min of life was admitted to our neonatal intensive care unit (NICU). MRI performed on the first day of life showed a 50% increase in tumor size, measuring 7 cm in maximal diameter, compressing, and infiltrating nearly the complete cerebellum and vermis as well as much of the midbrain structures. High grade obstructive supratentorial ventriculomegaly with a cystic intraventricular tumor component was again observed. The cystic component appeared T1-hyperintense indicating the high proteinaceous content. The solid tumor component showed multiple serpiginous flow-related signal voids A–C.After multiple multidisciplinary discussions, it was determined that the tumor was inoperable, and parents opted for comfort care. Baby died on the second day of life from respiratory insufficiency. Parents declined autopsy.Case 3: A 35-year-old G3P2 pregnant patient was referred to our institution because of a suspected fetal brain tumor at 38 weeks of gestation after initial suspicion for this diagnosis at 34 weeks. Ultrasound and fetal MRI at referral revealed a well circumscribed T2-hypointense solid cortical/subcortical lesion in the left occipital lobe measuring 4.3 × 2.9 × 3.1 cm A,B, whicThe lesion exerted mild local mass effect on the left occipital horn without midline shift or hydrocephalus. On US, the lesion was mildly heterogeneously hyperechogenic and presented with an asymmetrically increased arterial flow in the left common carotid, middle cerebral and posterior cerebral arteries. There was no evidence for associated hemorrhage. Polyhydramnios was not observed. A neuroglial tumor with the differential diagnosis of cortical dysplasia was suspected. A female newborn was delivered via elective C-section. MRI and computer tomography (CT) scan performed on day one of life showed a 4.7 cm × 3 mm × 3.5 cm mass lesion in the left occipital lobe with T2-hypointense susceptibility related signal loss due to areas of microcalcification A–C.Resection was performed on day 5 of life, followed by chemotherapy. Histopathology demonstrated a glioneural tumor with varying histomorphologies and anaplastic features. The patient successfully completed 12 months of chemotherapy with Cytoxan, Carboplatin, Etoposide and Vincristine following an individualized protocol. She is now 10 years old without tumor recurrence. Neuro-oncology follow-up was discontinued after 7 years without recurrence of disease. She is meeting normal neurodevelopment milestones.Case 4: A 26 years old G2P1 patient presented at 28 weeks for further diagnostic work-up for ventriculomegaly in twin B in a dichorionic diamniotic twin pregnancy. Ultrasound at 31 weeks and 1 day showed a complex cystic-solid mass lesion in the left frontal lobe measuring 33 × 34 × 38 mm surrounded by echogenic brain parenchyma. Additionally, irregular echogenic borders of the third ventricle and lateral ventricles were observed suggesting intraventricular hemorrhage A. HC wasBiopsy of the nodules, supratentorial ventriculostomy (ETV) with placement of an externally draining ventricular drain was performed. Pathology did not show viable tumor tissue. Subsequent need for the placement of a permanent ventriculoperitoneal (VP) shunt was indicated. This is a very unusual course, published and discussed by Peterson et al. . The girOur case series exemplifies various entities of FBT, the course of pregnancy and their postnatal outcome. Mortality is high and overall survival rate can be as low as 16%, depending on the histopathology, location and growth pattern of the tumor . In our The gold standard for diagnosis of FBTs is histopathological examination. Molecular analysis can aid for further accurate classification . Both caAssociated congenital anomalies can be present in 14–20% of cases, including anomalies of the corpus callosum in case of a pericallosal/midline lipoma and cleft lip and palate in case of teratoma ,18,19,20In our case series, we observed one case with suspected teratoma, one case with confirmed and one with suspected ATRT and one case with a glioneural tumor. Unfortunately, in 2/4 cases we do not have histopathological confirmation of the tumor histology. The differential diagnosis was based on pre- and postnatal MRI (case 1 + 2). Even though, post mortem autopsy is the gold standard, in case of parental decline, high quality prenatal imaging, and also postnatal or postmortem MRI add important information and can help to narrow down differential diagnosis ,26. A unIn our experience, diagnosis of teratomas occurred early in pregnancy at 18 weeks GA (case 1). This is in accordance with the current literature, reporting that tumors found before 22 weeks GA are most often teratomas with an average age at diagnosis of 27 weeks, while gliomas and other entities are usually diagnosed after 32 weeks of pregnancy . The priMacrocephaly and obstructive, tumor related ventriculomegaly was present in 2/4 cases and are frequent concomitant findings ,19. TheyMaternal mirror syndrome is described in extremely severe cases of high-cardiac output failure leading to fetal hydrops ,30.Polyhydramnios is a well described finding in FBT. It occurs in up to one third of all cases and was seen in 2/4 cases of our series ,18. One Prognosis is generally poor and worsens with increasing tumor size and decreasing gestational age at diagnosis . Demise FBTs are a very rare entity. Prenatal counselling using high quality prenatal ultrasound, fetal MRI and clinical features should be multidisciplinary. In the light of the generally guarded fetal prognosis, associated increased risk of maternal morbidity and mortality during ongoing pregnancy and delivery, early termination of pregnancy may be discussed. However, as exemplified by case four, fetal prognosis, tumor development and life expectancy may be different than previously thought and readjustment of treatment plan may be necessary after birth. Histopathological confirmation of the prenatally suspected diagnosis is the gold standard and molecular analysis is increasingly used to further classify the tumor. Because of the rarity of FBTs, most conclusions and recommendations are based on case series. Larger multicenter studies are needed to provide better information on prenatal treatment options, pregnancy monitoring, and postnatal outcome in terms of survival and neurodevelopment.


Intracystic hemorrhage is a rare complication of multiple hepatic cysts and can lead to hemorrhagic shock. Hence, measures should be taken to prevent the rupture of cysts. The incidence of intestinal perforation is high in patients undergoing hemodialysis. The diagnosis can be difficult in a patient without typical symptoms. We report the case of a woman in her late 60s with multiple renal and hepatic cysts, which caused chronic renal failure managed with dialysis. She presented with abdominal pain and was diagnosed with intrahepatic cystic bleeding. Continuous intravenous fentanyl was administered for pain management, which temporarily alleviated pain, but abdominal pain recurred with increased intensity when she resumed feeding. Subsequently, a contrast-enhanced computed tomography revealed perforation of the lower gastrointestinal tract. Therefore, in cases of intrahepatic cystic hemorrhage that require administration of analgesics, the complications of other diseases that may also cause acute abdominal pain should also be considered. Intrahepatic cyst hemorrhage is a relatively rare complication with multiple liver cysts, with a reported incidence of 2-5% . There hIn the present study, we report a case wherein the diagnosis of lower gastrointestinal perforation in a patient on maintenance hemodialysis was complicated by the use of continuous intravenous fentanyl as an analgesic for pain caused by intrahepatic cystic hemorrhage.The patient was a woman in her late 60s with a history of polycystic liver diseases (PLD) associated with autosomal dominant polycystic kidney disease (ADPKD), resulting in chronic renal failure. The patient was on maintenance hemodialysis for seven years before being admitted to our hospital. She had also undergone stent-graft insertion for a left common iliac artery aneurysm. Her paroxysmal atrial fibrillation was managed with warfarin for prevention of thrombosis, and she was not on any other anticoagulants or steroid therapy. Other comorbidities included valvular heart disease, hypertension, dyslipidemia, and hyperuricemia.2, blood pressure, and pulse rate were 15 breaths/min, 94%, 162/92 mmHg, and 97 beats/min, respectively, and she remained conscious. Pallor on the eyelid conjunctiva and yellowing of the ocular conjunctiva were absent. Abdominal tenderness was present and mainly localized to the left side of the upper abdomen. Additionally, localized muscular defense and diminished intestinal peristalsis were observed.On the day of admission, the patient presented with upper abdominal pain that worsened on inhalation since she woke up. The feces were brown and soft. Maintenance dialysis was started by her family doctor. However, she was referred to our hospital owing to increasing upper abdominal pain and nausea. Her height and weight were 155 cm and 46 kg, respectively. Respiratory rate, SpOOn presentation, blood tests showed a WBC count of 2,900/µL, a hemoglobin level of 11.9 g/dL, prolonged prothrombin time test-international normalized ratio of 1.56, elevated D-dimer of 6.18 µg/mL, and c-reactive protein (CRP) level of 1.74 mg/dL. Venous blood gas findings (room air) were pH of 7.282 and lactate of 3.3 mmol/L.Abdominal contrast-enhanced computed tomography (CT) scan showed multiple cysts throughout the liver. The mass in the lateral segment of the left lobe showed heterogeneous enhancement in the early contrast phase and diffused enhancement in the late phase, indicating intrahepatic cystic hemorrhage. Edematous changes were also observed from the rectal to the sigmoid colon wall, suggesting coexisting enterocolitis. Although the left common iliac artery aneurysm did not change in size, an endoleak was noted Figure .The patient was diagnosed with intrahepatic cystic hemorrhage and admitted to the ICU with a conservative treatment plan due to the absence of anemia progression and stable hemodynamic status.On admission, there were no significant changes in vital signs. Since the patient’s abdominal pain was severe with a numerical rating score (NRS) of 7, fentanyl (0.05 mg/h) was administered continuously as an analgesic. Since the CT scan indicated enteritis, the patient was put on fasting till the abdominal pain was reduced.After fentanyl administration was started, abdominal pain had reduced, and 24 hours after admission to the ICU, the abdominal pain had almost disappeared with an NRS of 1. Hence, continuous intravenous fentanyl administration could be discontinued. Abdominal echocardiography showed no increase in fluid retention of the hepatic cysts over time. Blood tests showed no decrease in hemoglobin level and stable circulation dynamics. CRP was elevated (16.9 mg/dL), but fever and elevated WBC count were not observed. After confirming that there was no increase in abdominal pain and no anemia progression, the patient was started on oral liquid nutrition 36 hours after admission to the ICU, and abdominal pain increased again. However, the site of abdominal pain was not consistent, and there were no symptoms of peritoneal irritation. The patient subsequently developed fever, became restless, and complained of pain in the entire abdomen (NRS 3). There was no evidence of board stiffness or recurrent pain. Seventy hours after admission to the ICU, a large amount of dark red blood was observed in the feces. Blood test findings showed an elevated CRP of 33 mg/dL (Figure Contrast-enhanced CT scan revealed the cause of the increased abdominal pain and bloody stools. There was a discontinuity in the sigmoid colon and a fecal mass and free air in the mesentery Figure ; right. However, there was no change in the size or increase in hematoma of the hemorrhagic liver cyst. Thus, the patient was diagnosed with a perforation of the sigmoid colon, and emergency surgery was deemed necessary. Since our operating room was full, the patient was transferred to an available facility. The emergency surgery was performed on the same day. Intraoperative findings showed perforation of the sigmoid colon diverticulum and the formation of a retroperitoneal abscess. Abdominal cavity drainage and Hartmann surgery were performed.Postoperatively, the patient had a stent-graft infection of the left common iliac artery, which required long-term antimicrobial treatment, but her condition improved after the surgery, and she was transferred to a rehabilitation facility on the 53rd day.In the present case, a small amount of free air was missed on the initial CT, and after admission to the ICU, the symptoms of lower gastrointestinal perforation were masked by continuous analgesia. This delayed the diagnosis of lower gastrointestinal perforation. In gastrointestinal perforation, detection of free air on abdominal CT has been reported to be most conducive to diagnosis. On the other hand, the diagnostic sensitivity of free air for lower gastrointestinal perforation has been reported to be 70-80% [PLD is relatively rare and may be present alone or in association with ADPKD and autosomal recessive polycystic kidney disease ,9. ApproIntrahepatic hemorrhage is a rare complication of hepatic cysts , with a Intrahepatic cystic hemorrhage often presents with sudden right upper quadrant abdominal pain, and sudden abdominal pain has been reported in 85% of the cases ,13,14. IThe patient’s abdominal pain was confined to the upper abdomen on the first day but flared up on the third day and involved the entire abdomen. This indicated that the cause of the abdominal pain had shifted from a hepatic cyst hemorrhage to generalized peritonitis due to perforation of the lower gastrointestinal tract. However, the abdominal pain due to lower gastrointestinal perforation and peritonitis may have been masked by the continuous intravenous fentanyl administration. The dose of fentanyl used at the start was 0.05 mg/h, but it may have been necessary to start with a smaller dose or to use a protocol of finely calibrated increases or decreases according to abdominal pain.Perforation of the gastrointestinal tract is a severe and surgical emergency ,16. The Diverticular perforation is reported to be the most common cause of lower gastrointestinal perforation in long-term maintenance hemodialysis patients . It is aIn the present case, abdominal pain was confined to the upper abdomen on the first day, and there was no elevated inflammatory response, including elevation of leukocyte counts. The patient’s initial diagnosis of intrahepatic cystic hemorrhage causing upper abdominal pain complicated the diagnosis of lower gastrointestinal perforation.Acute abdominal disorders in patients undergoing dialysis are characterized by elevated CRP rather than elevated leukocytes, and in this case, CRP was also elevated over time during hospitalization . We beliWe reported a case wherein the diagnosis of lower gastrointestinal perforation was complicated by intrahepatic cystic bleeding. The intrahepatic cystic bleeding presented as abdominal pain and resulted in the use of fentanyl for analgesia. Intrahepatic cyst bleeding is a relatively rare complication of multiple hepatic cysts and rarely causes abdominal pain severe enough to warrant intervention with narcotic analgesics. In cases of intrahepatic cystic hemorrhage that require administration of analgesics, including this case, it is necessary to note the complications of other diseases that may also cause acute abdominal pain.


Seminal vesicle neoplasms are extremely rare. Schwannoma is a benign tumor of the peripherical nerve sheath composed of Schwann cells. Most of these tumors are silent and become symptomatic with compression of adjacent organs and nerves.We present a case of a 72-year-old man who presented with a several months history of predominant storage lower urinary tract symptoms and painful ejaculation. Prostate-specific antigen (PSA) was within normal ranges, and imaging documented a retrovesical nodular lesion adjacent to the right seminal vesicle with 5 cm in width. We successfully performed a robotic-assisted laparoscopic surgery to excise the lesion. Anatomopathological analysis revealed a schwannoma. Neoplasms of the seminal vesicles are a relatively rare entity. Within these, benign neoplasms are the most frequent and include fibromas, cystadenomas, leiomyomas, schwannomas, and papillary adenomas. Otherwise, primary malignant neoplasms include adenocarcinoma of the seminal vesicle, sarcomas , seminoma, squamous cell carcinoma, and extra-gastrointestinal stromal tumors . These aThis is a case report of a 72-year-old man with well-controlled arterial hypertension and no past surgical or family history. He was referred to a urology appointment because of predominant storage lower urinary tract symptoms, namely pollakiuria, urgency and straining, and painful ejaculation with several months of evolution. The International Prostate Symptom Score (IPSS) was 13, and the patient was mostly dissatisfied with his urinary condition. A digital rectal examination revealed a prostate with a fibro-elastic consistency, well-defined edges, and an apparent mass in the region of the right seminal vesicle detached from the prostate. The PSA was within the normal range (2.5 ng/mL), with normal renal function and urinalysis. Uroflowmetry demonstrated an arc-shaped curve with a Qmax of 13.5 mL/seg. Transrectal ultrasound showed a 5 cm wide nodular image adjacent to the right seminal vesicle. The prostate was 54 cc. He subsequently underwent a pelvic MRI, which showed a well-delineated nodular and polylobulated mass measuring 54 x 49 x 53 mm, posterior and lateral to the bladder, in close contact with the right seminal vesicle Figure . There wThe patient was counseled regarding the risks, benefits, and alternatives to surgical resection. A successful transperitoneal robotic-assisted excision of the mass was performed. Under general anesthesia, the patient was placed in a dorsal lithotomy position. Ports were placed in the standard W configuration with an assistant port in the right lower quadrant, like other pelvic surgeries. We started by identifying the right ureter at its intersection with the iliac vessels. This was dissected free and suspended with a vessel loop to facilitate touchless manipulation. It was mobilized distally towards the ureterovesical junction, where the tumor of the seminal vesicle was found. The retrovesical mass was not adherent to any surrounding structure and was carefully dissected. The seminal vesicle and the right vas deferens were identified. The mass was removed with a segment of the right seminal vesicle attached through the supraumbilical incision. The total operative time was 90 minutes without any adverse events. The postoperative period was well tolerated, and the patient was discharged two days later.The histopathological and immunohistochemical analysis showed a fusocellular neoplasia composed of cells with elongated nuclei expressing S100 protein. In contrast, CD34 and NF markers were negative and compatible with schwannoma Figure . The segAfter surgery, the patient experienced an improvement in his storage urinary symptoms with an IPSS of 5, no complaints of erectile or ejaculatory dysfunction, and no signs of recurrence after one year of follow-up.Schwannomas are the most common benign tumors of peripheral nerves . They arThe etiological study usually includes an imaging exam (CT scan and/or MRI) to characterize the location, size, and extent of the tumor. Most cases reported to date included a transrectal biopsy for histological characterization. He R et al.  describeSeminal vesicle tumors are rare, and their clinical diagnosis and surgical approach can be challenging. Imaging studies play an essential role in the diagnosis. The presence of a symptomatic seminal mass should prompt surgery. In our opinion, a robot-assisted approach is an excellent option for this pathology.


Adrenal myelolipomas are rare, hormonally silent, adipose and myeloid-containing lesions that are mostly asymptomatic. If they do present it is usually with mass-related flank pain or spontaneous haemorrhage. A 55-year-old female presented with right flank pain after a fall from a static pushbike. Computer tomography identified a large adrenal lesion with surrounding acute retroperitoneal haemorrhage. A conservative approach to treatment was decided on as the patient remained haemodynamically stable. The patient developed a pulmonary embolism during the time of conservative management and therefore had to be anticoagulated with close monitoring. Outpatient surveillance imaging was reassuring, hormonal screening was negative and biopsy confirmed myelolipoma. We report a rare presentation of adrenal myelolipoma with the sequelae of haemorrhage from low-impact trauma and the challenges of conservative management. Adrenal myelolipomas (AMLs) are benign and hormonally silent lesions of the adrenal interstitium. AMLs are rare with an autopsy prevalence of 0.08–0.2% . They arA 55-year-old Caucasian female presented to the emergency department (ED) after falling from sitting on a static pushbike onto her right flank. She immediately incurred right flank pain with nil other symptoms at time of the event. Her medical history was insignificant and she did not take any regular medications. Blood tests on admission indicated there may be an intra-abdominal injury due to raised lactate of 3 and a blood pH of 7.304. An urgent CT abdomen and pelvis (CTAP) with contrast was performed which showed a large (15.2×13.8 cm), predominantly fat containing mass in the right suprarenal region causing displacement of the right kidney and pancreas, with surrounding hyperdense fluid suggestive of acute retroperitoneal haemorrhage .The patient was subsequently transferred over to the local specialty Urology Centre. Here the patient became tachycardic and required supplemental oxygen. A suspicion of increasing blood loss or a pulmonary embolism (PE) was raised. A repeat CTAP in arterial and venous phases along with a CT pulmonary angiography (CTPA) was conducted. The CTAP again showed a large right-sided retroperitoneal mass, now described as mixed fat and soft tissue densities characteristic of AML. The surrounding retroperitoneal bleeding was thought to have increased in size, indicating likely active haemorrhage . CTPA shThe patients’ ongoing oxygen requirement along with the CT findings of increasing size of haematoma resulted in admission to the high-dependency unit (HDU) for high-flow oxygen administration and close monitor for signs of haemodynamic instability. Throughout the patient remained hameodynamically stable and did not require transfusion .The patient was stepped-down from HDU after 4 days. Thereafter, management options were explored including interventional radiological embolization of feeding artery, surgical exploration +/− adrenalectomy and conservative bed rest with empirical broad-spectrum antibiotics and tranexamic acid. As the patient remained stable and no appropriate target vessels were identified on imaging for embolization, a conservative management approach was deemed most suitable in this case.After 7 days, the patient was discharged with advice to rest with minimal exertion for the following 6 weeks. Low-molecular weight heparin was not prescribed due to risk of worsening haematoma. An outpatient CTAP was planned for 2 weeks post-discharge.On interval CT scanning, the adrenal lesion was shown to have decreased in size (14.3×13.2 cm), likely due to reduction of intralesional haematoma, and no active haemorrhage identified . There wAfter identifying a lesion on imaging, the ESE advises that assessment of hormone excess should be analysed, including dexamethasone suppression test, plasma-free metanephrines or urinary fractionated metanephrines . These wTo further confirm a benign lesion, an ultrasound-guided biopsy of the adrenal lesion was performed which gave a histological confirmation of myelolipoma.AMLs are rare, benign, slow growing, non-secretory and biochemically inert lesion of the adrenal gland. They are composed of adipose and haematopoietic cells of myeloid tissue. They are most commonly asymptomatic and diagnosed primarily incidentally on cross sectional imaging in up to 90% of cases i.e. adrenal incidentaloma . The adr


Acute atypical mastoiditis, with temporal and/or facial edema, is called squamozygomatic mastoiditis. There are only a few reports of this occurrence in the literature, which occurs because of an inflammatory process spread to the zygommatic apophysis, when mastoid pneumatization reaches the zygoma or the squamous portion of the temporal bone. Diagnosis is made based on clinical history, physical exam and mastoid CT scan. Treatment is carried out with antibiotic therapy and surgery.to present a case of squamozygomatic mastoiditis and review the literature. Patients and methods: report of a case treated in our hospital during the year of 2003 and literature review through the Internet, we also reviewed otolaryngology books from known authors.squamozygomatic mastoiditis is an atypical mastoiditis in which the inflammatory process spreads to the zygomatic apophysis. The infection reaches the temporal bone squamous portion and makes a fistula between this portion and the temporal muscle, shifting the pinna of the ear downwards and it may reach the face, eyes and eyelids. Diagnosis is carried out by clinical history, physical examination and mastoid CT Scan. Treatment is surgical, associated with antibiotic therapy. Acute mastoiditis is an acute otitis media complication and currently has a lower incidence when compared to the pre-antibiotic era; consequently the atypical mastoiditis presentations have become proportionally rarer.An acute mastoiditis may occasionally present itself as a temporal and/or facial edema. In these cases, the mastoid air cells inflammation may spread through the cells from the zygoma arch root cells toward adjacent soft tissue, such as, for example, the temporal muscle, being called squamous-zygomatic mastoiditis.The goal of the present paper is to describe a case of squamous-zygomatic mastoiditis and to review the literature.In this paper, the authors aim at presenting a case of squamous-zygomatic mastoiditis and to review the literature.Report on a case evaluated in our hospital in 2003 and literature review through the Internet using the key words: mastoiditis, temporal osteomyelitis, and we also used otorhinolaryngology books from renowned authors.L.R.C., female, 50 years, Caucasian, with chronic renal insufficiency, under hemodialysis, evaluated by our Otorhinolaryngology Department in December of 2003 with progressive right temporal hypoacusis, otalgia and otorrhea on the right side, low fever (38°C), edema and pain, with symptoms that had started two weeks before. She did not complain of visual changes. During her examination, we found a bulging in her right temporal region with supra-auricular fluctuations and pinna shifting downwards. Her otoscopic exam was normal on the left side and she had an important edema in her external auditory meatus, preventing the introduction of an ear speculum, and thick otorrhea in small amounts. Her neurological exams were also normal.Her mastoid and cranium contrasted CT scan showed an increase in cystic soft tissue in her right side temporal region with peripheral contrast uptake, and right-side mastoid cells obliteration. Small right temporal lytic lesion, near the mastoid, with contrast uptake at the adjacent dura mater.Lab exams showed 18% hematocrit, 6g/dl hemoglobin, 4600 leucocytes/mmThe temporal mass was punched and we had a green purulent secretion oozing out - about 30 ml - which was sent for microbiological exam.We started her on broad spectrum antibiotic therapy with 500mg Imipenem bid .In two days, the patient evolved with pain worsening and edema increase in the temporal region, extending to the periorbital region; then emergency surgery was indicated.The patient was operated upon, through the retroauricular approach, and we found a thick and greenish secretion, a large area of tissue necrosis, bone erosion and dura-mater exposure, which, by the way was intact. We cleaned and drained the area. We sent the material to microbiology and histopathology.Hemoculture result: Streptococcus pneumoniae, sensitive to Ampicillin. After six days of Imipenem, and following the result of the hemoculture, the antibiotic was exchanged for 1g Ampicillin bid .Scintigraphy with technetium showed an increase in abnormal uptake in the right temporal lobe, and the diagnosis was of temporal osteomyelitis.Pathology exam of the surgical specimen did not show neoplasia.Patient had pain release, facial and temporal edema reduction and was discharged after three weeks of hospital stay, and was followed in an outpatient basis with oral antibiotics - 500mg amoxicillin PO, once a day , for twelve weeks.She kept on weekly outpatient follow up during the first month after hospital discharge, with a clear progressive improvement. During the next three months, she was followed up monthly, without complaints. A control scintigraphy with technetium and gallium was done in May of 2004, when there was a mild contrast build up in the right temporal region. A low probability test for osteomyelitis.The patient is currently under outpatient follow up.The classic manifestation of acute mastoiditis is based on pain, hyperemia and retroauricular edema, with pinna protrusion, usually after an episode of upper airway infection. Symptoms of otalgia, headache, rhinorrhea and hearing loss are common. Low fever is usually present. In otoscopy there usually is evidence of acute otitis media (1/2).Squamous-zygomatic mastoiditis is an atypical form of mastoiditis and is more frequent in children. It is the propagation of the inflammatory process down to the zygomatic apophysis root when the mastoid pneumatization reaches the zygoma and/or the squamous portion of the temporal bone. The infection hits the temporal bone squamous process and ends up creating a fistula between the latter and the temporal muscle (1/4). The purulent collection is deep in the temporal area and may follow the internal face of the temporal muscle and exteriorize in the masseter or genian zygomatic regions. After organized, the abscess pushes the pinna downwards and the collection reaches the face, eyes and eyelids. The patient complains of a painful pressure in the temporal region and there may be trismus (1/3).Diagnosis is made following a detailed history and physical exam, radiological images with contrasted and not contrasted CT scan of the mastoid bones (1).Culture material must be obtained as fast as possible in order to better guide the use of antibiotics (1). Material for culture can be obtained through tympanocentesis or an aspirate of the supra-auricular region in case of fluctuation. Hemoculture can be ordered, however it is rare to be able to isolate the major agent involved, Streptococcus pneumoniae.The flora responsible for acute mastoiditis in both the classic and atypical manifestations of the disease is similar, however not identical as far as the bacteria that cause acute otitis media is concerned. The most frequently found pathogen is the Streptococcus pneumoniae, followed by Streptococcus pyogenes, Staphylococcus aureus and Haemophilus influenzae. Anaerobes such as bacteroid and Peptostreptococcus, gram-negative bacilli such as Pseudomonas, Klebsiella, Escherichia coli and Proteus are also less frequent agents (5).The surgical treatment is indicated in the atypical manifestations of mastoiditis and must be associated with empirical antibiotic-therapy with a proper antibiotic agent against the bacteria found in the acute mastoiditis, until the results from the microbiology exams point to the most efficient antibiotic to be used against the right bacteria (1).Squamous-zygomatic mastoiditis and other atypical manifestations, because they are rare, may be diagnosed later, causing harm to the patient such as a possible temporal osteomyelitis (4).Temporal osteomyelitis is a rare entity in clinical practice. It is, in general, a complication of infectious processes that involve the temporal bones, such as acute and chronic otomastoiditis, cholesteatomatous chronic otitis media, and malignant otitis media. Although it may evolve fatally, causing fast death by intracranial complications, temporal osteomyelitis, seen during cases of otitis media and acute mastoiditis, almost always evolve more silently, giving some time to deter the infectious process by means of surgeryToday, acute otitis media bears a lower incidence of intra and extra cranial complications when compared to the pre-antibiotic era. Acute mastoiditis in its classical and atypical manifestations became proportionally rarer, especially the atypical manifestations, such as squamous-zygomatic mastoiditis, which was frequently discussed in the literature of the 40's; however, today there are very few reports of this clinical manifestation.Otorhinolaryngologists must know and remember the possibility of having atypical mastoiditis, such as the squamous-zygomatic that may happen with temporal and facial edema, temporal region pain and trismus.


Background: Mesenchymal chondrosarcoma is a rare but aggressive subtype of sarcoma. The majority of involvement locates in the axial skeleton. Treatment modalities include radical surgery, local radiotherapy, and systemic chemotherapy. However, the long-term survival outcome remains poor. Case presentation: We present the case of a 33-year-old male with a palpable chest wall mass for one year, diagnosed with mesenchymal chondrosarcoma with surgical removal. Later, he had an unusual pancreatic tail tumor as the first presentation of disease metastasis which was proven by surgical resection one year later. Conclusion: Although mesenchymal chondrosarcoma locates mainly in the axial skeletal system, extra-skeletal soft tissue or organ involvement might be seen occasionally. Active surveillance with multidisciplinary team management could significantly prolong survival outcomes. Mesenchymal chondrosarcoma (MC) was first described by Lightenstein and Bernstein in 1959 . VisceraA 33-year-old male presented with a painless, palpable chest wall mass for about one year with a gradually increased size. The breast sonography showed a 7.5 cm oval mass with heterogeneous echogenicity and calcifications. He received an image-guided biopsy with morphology showing sheets of primitive round and oval cells with foci of cartilaginous differentiation and abrupt transitions with surrounding round cells. The immunohistochemistry stain showed AE1/AE3 (−), LCA (−), actin (−), desmin (−), S100 (+ on the chondroid island), CD34 (−), CD99 (+), TLE-1 (+), and FLI-1 (−). There was no available gene fusion result. Based on the morphology and immunohistochemistry stain results, mesenchymal chondrosarcoma was diagnosed. Without evidence of distal metastasis, he received chest wall excision with partial resection of the left third, fourth, and fifth ribs and reconstruction with a left latissimus dorsi muscular flap. The pathologic stage revealed T2N0M0, FNCLCC grade 3. The pathology also showed a deep surgical margin involved. He refused adjuvant local radiotherapy or chemotherapy. Then, he received active surveillance after surgery without evidence of tumor recurrence for about one year. During the regular follow-up abdominal computerized tomography scan one year after the diagnosis, a new poorly enhanced mass lesion about 3.4 cm in size with calcified nodules was detected over the pancreatic tail . He rece2/day, Adriamycin 20 mg/m2/day, ifosfamide 2000 mg/m2/day, and dacarbazine 250 mg/m2/day as a continuous infusion over 72 h) for six cycles. The follow-up computerized tomography scan showed stable disease, and he still received systemic chemotherapy for further disease control.Six months later, he further developed tumor recurrence over the scalp and left axilla, and superior sagittal sinus involvement. He successfully underwent occipital craniectomy with tumor removal and cranioplasty successfully without significant neurological deficits. However, the disease progressed four months later with several metastatic lesions, including on the ribs, cervical spine, femoral neck, pelvis, and lymphadenopathies. Then, he received palliative chemotherapy with a MAID regimen (mesna 2000 mg/mMesenchymal chondrosarcomas are highly malignant tumors. They are characterized by differentiated cartilage admixed with solid, highly cellular areas composed of undifferentiated small round cells . The exaThe average age is 25 to 30 years , youngerMost importantly, the presence of tumor metastasis and a 1 cm size increase were both independently associated with an increased risk of death . AnotherClinically, patients with pancreatic metastases usually present with abdominal pain and icterus, while some remain asymptomatic and are diagnosed on routine follow-up . RadioloHistologically, the tumor is characterized by poorly differentiated small round cells with an abrupt transition to hyaline cartilage . The immDue to the limited cases and lack of large-sized randomized clinical trials, mesenchymal chondrosarcoma has no standard treatment. However, based on several case experiences, the consensus is that patients should receive radical surgery and possible chemotherapy . The besIn the presented case, an unusual presentation with a pancreatic tail mass as the first distal metastasis was detected one year after the initial diagnosis. We arranged a laparoscopic pancreas distal partial pancreatectomy for surgical resection. The histologic examination confirmed a metastatic mesenchymal chondrosarcoma. Further, the patient received palliative chemotherapy with the MAID regimen with the best stable disease response and still received treatment. We summarized the cases with an unusual metastatic site of the pancreas from the literature. A total of 16 cases have been reported . There wMesenchymal chondrosarcoma is a rare but poor-prognosis tumor. Metastasis and tumor size contribute to decreased survival outcomes. Thus, long-term follow up is necessary, and earlier diagnosis and treatment are indispensable. In addition, although mesenchymal chondrosarcoma is usually located in the skeletal system, an extra-skeletal site is also possible. A metastatic tumor should be considered when presented with a pancreatic mass in mesenchymal chondrosarcoma patients. Diagnostic tools include image studies such as computerized tomography scans and magnetic resonance images. An immunohistochemistry stain reviewed by an experienced pathologist is warranted. Treating metastatic mesenchymal chondrosarcoma with radical surgery with chemotherapy might improve the long-term outcome.


Intussusception in adults is a rare pathology due to the telescoping of a bowel segment into a section adjacent to it. Almost all cases are linked to a pathological lead point, which is often a colorectal carcinoma where the intussusception involves the large intestine. Likely to occur in the same clinical setting, the differential diagnosis between intussusception and colon carcinoma by ultrasound in the emergency department can be quite challenging. We present a rare case of transient colonic intussusception with a well-differentiated colon adenocarcinoma as the lead point in a 43-year-old patient. The point of care ultrasound (POCUS) revealed the target sign characteristic of intussusception at the level of maximum pain, associated with a pseudokidney sign. However, the pseudokidney sign was indeed an adenocarcinoma of the ascending colon visualized by colonoscopy and per op. Intussusception is a condition in which part of the intestine folds into the section adjacent to it. It is an extremely rare entity, and hence its diagnosis in adults requires strong clinical suspicion. Challenges often arise because the signs and symptoms are nonspecific and frequently mimic many alternative diagnoses . Unlike Imaging is usually required to make the diagnosis, and fluoroscopy with contrast enema remains the gold standard. However, CT, being the modality of choice for the evaluation of acute abdomen in adults, has been reported to make more diagnoses of intussusception as well as transient intussusception, which is often an incidental finding. Abdominal ultrasound can also identify the characteristic target sign of intussusception in some cases, particularly in patients with a palpable abdominal mass that is more than 90% sensitive ,4.If intussusception is not diagnosed promptly, it puts the patient at risk for severe complications that can jeopardize the vital prognosis. Therefore an early and prompt diagnosis is crucial for the optimal management of the condition ,5. We prThis case report concerns a 43-year-old woman who was seen at the emergency department for an acute exacerbation of intermittent abdominal cramping pain localized at the right lumbar region, which she had been experiencing for three years. A review of systems also revealed progressive weight loss. She reported having experienced an episode of melena for about a year. Physical examination revealed a soft, depressible abdomen with no evidence of a palpable mass. The results of the complete blood count revealed moderate normochromic normocytic anemia with a hemoglobin level of 10.6 g/dl.She was transferred to the radiology emergency department. There, an abdominal ultrasound revealed a target sign, located in the right lumbar region, in the area of maximum pain, with an anteroposterior diameter of 5.41 cm, associated with a pseudokidney sign at the ipsilateral side, measuring 6.50 cm on its long axis. This led to the diagnosis of right colonic intussusception Figures . A colonWithin a week, her clinical picture worsened with an intermittent increased abdominal pain that was accentuated in the right lumbar region, radiating towards the epigastric, associated with episodes of nausea and non-bilious vomiting. She was emergently hospitalized. The physical examination revealed a right lumbar rebound tenderness, with no evidence of a palpable mass. A bedside ultrasound was performed, which showed a target sign on the right lumbar region at the point of maximum pain, measuring 3.32 x 2.10 cm, and a pseudokidney sign measuring 6.81 x 3.13 cm located on the right flank Figures . She wasDue to a gradual improvement of her symptoms until a period of full pain resolution and being hemodynamically stable, the intervention was postponed until the results of the colonoscopy were obtained. The colonoscopy showed a vegetating lesion involving the entire circumference of the colon and 80% of its lumen at the level of the middle segment of the ascending colon, measuring 5-10 cm in length (Figure Preoperatively, a control ultrasound was performed during the asymptomatic phase, which highlighted a pseudokidney sign, but without evidence of a target sign. She then underwent a right hemicolectomy with the postoperative diagnosis of transient colonic intussusception on the adenocarcinoma of the ascending colon. The surgical specimen revealed a cauliflower-shaped mass 1/3 in the middle and 1/3 in the upper side of the ascending colon, associated with mesenteric lymphadenopathy and without any evidence of colonic intussusception, necrosis, or intestinal perforation Figures -8. She wIntussusception is extremely rare in adults and usually presents with intermittent abdominal pain, along with bloating, nausea, non-bilious vomiting, or bilious in case of obstructions. The classic triad of abdominal pain, vomiting, and passage of blood per rectum found in children is often absent in adults. In case of ischemia of the telescoped intestinal segment, it can present as episodes of the passage of blood through the anus. On physical examination, the pain may be diffused or localized with a reduction in intestinal transit. Without specific signs, imaging is generally necessary for the diagnosis, as the condition is associated with a plethora of alternative diagnoses ,6,7.The diagnosis of colonic intussusception in our case was discovered incidentally. It was characterized by visualization on the right lumbar area of a target sign with an anteroposterior diameter of 5.41 cm at the point of maximum pain and a pseudokidney sign on the ipsilateral side measuring 6.50 cm on the long-axis view. It has been reported that in an appropriate clinical setting, ultrasound can achieve 98.5-100% sensitivity in the diagnosis of intussusception. In general, the ultrasound signs used for making the diagnosis of intussusception are the target sign, the pseudokidney sign, and the crescent-in-doughnut sign ,4. On ulAmong other things, we have the target sign with a sensitivity of more than 90% in the presence of a palpable mass , and theOne of the widely used radiological modalities for the diagnosis of intussusception in adults is the abdominal CT scan with a sensitivity of 58-100% and a specificity of 57-71% . The preFluoroscopy with contrast enema remains the gold standard for the diagnosis of intussusception, which demonstrates the intussusception as an occluding mass prolapsing into the lumen, giving the “coiled spring” appearance . HoweverIn a 2020 systematic review on the diagnostic accuracy of intussusception in children in the emergency department, POCUS had a sensitivity rate of 94.9% and a specificity rate of 99.1%. The main limitation of this study was the fact that the ultrasound was operator-dependent. The two main ultrasound signs used to make the diagnosis were the target sign and the pseudokidney sign . Even ifThe most common acute surgical complications of colon cancer are perforation, obstruction, and bleeding . These dGiven that nearly 90% of cases of intussusception in adults are related to a pathological lead point, and that 65% of them are associated with a gastrointestinal carcinoma, mostly colorectal carcinoma , any patPercutaneous ultrasound-guided biopsy is a widely accepted procedure for the diagnosis of abdominal and retroperitoneal lesions, with high accuracy, low complication rates, and very low mortality rates -19. In aThe ultrasound-based differential diagnosis between colonic intussusception and colonic adenocarcinoma can be quite difficult as both of them can present the same sonographic features. However, as our case report highlighted, this patient's condition raised strong suspicion related to colon cancer. She presented to the emergency room with nausea, vomiting, acute abdominal pain, and rebound tenderness at the right lumbar region associated with a target sign in every painful episode, which was in fact a case of transient colonic intussusception on a right colon adenocarcinoma. The pseudokidney sign, which was present even during the asymptomatic phase, was in fact the colon adenocarcinoma serving as the lead point for the intussusception. In an acute setting, any patient whose condition raises strong suspicion of colon cancer, presenting with a target sign and a pseudokidney sign during POCUS, should be considered as a case of intussusception until proven otherwise. The target sign was the key sonographic finding that allowed for the differential diagnosis between intussusception and colon carcinoma. Once the potential lead point is identified, an emergency percutaneous echo-guided biopsy can be performed to accelerate the delay of treatment, and thereby reduce the risk of severe complications. However, besides those concerning stable patients, more studies need to be conducted on the risks associated with the use of percutaneous ultrasound-guided biopsy in acute care units.


Pancreatic neuroendocrine tumors (pNETs) are a heterogenous group of rare epithelial neoplasms. For most patients, surgery remains the only treatment modality to cure pNETs, and is recommended for patients with surgically resectable disease. Many of these tumors are non-functional tumors and do not produce clinical symptoms, so patients may present with locally advanced tumors, which invade surrounding organs or neighboring blood vessels. The presence of vascular involvement had previously been considered a contraindication to surgery, but, in recent years, at centers with considerable experience, aggressive surgery to remove pNETs with vascular reconstruction has been performed safely and with good long-term survival. In this review, we will discuss the considerations for resectability, review novel surgical approaches, and present the available evidence on the immediate and long-term postoperative outcomes.Complete surgical resection of pancreatic neuroendocrine tumors (pNETs) has been suggested as the only potentially curative treatment. A proportion of these tumors will present late during disease progression, and invade or encase surrounding vasculature; therefore, surgical treatment of locally advanced disease remains controversial. The role of surgery with vascular reconstruction in pNETs is not well defined, and there is considerable variability in the use of aggressive surgery for these tumors. Accurate preoperative assessment is critical to evaluate individual considerations, such as anatomical variants, areas and lengths of vessel involvement, proximal and distal targets, and collateralization secondary to the degree of occlusion. Surgical approaches to address pNETs with venous involvement may include thrombectomy, traditional vein reconstruction, a reconstruction-first approach, or mesocaval shunting. Although the amount of literature on pNETs with vascular reconstruction is limited to case reports and small institutional series, the last two decades of studies have demonstrated that aggressive resection of these tumors can be performed safely and with acceptable long-term survival. Pancreatic neuroendocrine tumors (pNETs) are a rare type of pancreatic neoplasms, only comprising about 7% of all pancreatic tumors, with an incidence of 2–3 per million ,2. The tThe concept of vascular reconstruction has already been widely discussed in the treatment of locally advanced pancreatic adenocarcinoma. The 2009 expert consensus statement advocated for pancreatic resections with vein resection/reconstruction as a recommended standard of practice for pancreatic adenocarcinomas locally invading the portal vein (PV), superior mesenteric vein (SMV), or porto-mesenteric confluence in institutions experienced and capable of doing these technically challenging operations . In thisPatients undergoing a preoperative assessment of their tumor are standardly evaluated by either computed tomography (CT) or magnetic resonance imaging (MRI), given their excellent sensitivity for detecting vascular involvement in patients with pancreatic adenocarcinomas or NETs . The tecAn important observation that has come up in previous reports of resection of pNETs is that, despite the reports of excellent sensitivities of CT imaging for identifying involvement of major vessels, there can also be false-positive results, where the radiologic abutment or invasion is not synonymous with the actual vascular involvement at the time of surgery. In one early report of surgical resection for larger pNETs >4 cm, only 50% of all patients who showed evidence of tumor involvement of the PV or SMV (due to a lack of fat interposition of the tumor and vein) at the preoperative evaluation were confirmed to have true invasion at the time of surgery . In anotAlthough infiltration of adjacent vessels is more common overall, another rare finding with pNETs is the presence of tumor thrombus within the portal, splenic, or mesenteric veins. This may be clinically relevant, contributing to portal hypertension with gastric varices or gastrointestinal bleeding. Tumor thrombi may directly extend from the tumor as an appendage into the lumen of adjacent veins, causing enlargement of the affected vessel. In these cases, MRI may offer imaging advantages through the use of multi-phasic flow-sensitive sequences for the detection of tumor thrombi or for characterizing the composition of the thrombus . ContrasThere is no established standard for the surgical management of venous involvement in the resection of pNETs, and many strategies have been reported through various case studies. Patients all require high-resolution cross-sectional imaging to evaluate individual considerations, such as anatomical variants, areas and lengths of vessel involvement, proximal and distal targets, and collateralization secondary to the degree of occlusion.Tumor thrombosis is an uncommon finding and may be associated with about 5% of pNETs . It can In a case when a portion of the circumference of the vein is involved, but the lumen remains patent, traditional vein reconstruction can be performed in a variety of ways. For pNETs in the head of the pancreas, complete mobilization of the specimen is accomplished, including uncinate dissection of the superior mesenteric artery (SMA). This would leave the specimen attached at the site of vein involvement only. Proximal and distal control of the PV or SMV is attained with vascular clamps, and the vein is resected en bloc with the tumor. Adequate outflow can typically be preserved throughout the dissection, until the point of clamping and removal of the tumor. Venous reconstruction can be completed via several established techniques. For sidewall adherence, a longitudinal ellipse of the vein can be resected and reconstructed with a transverse venorrhaphy or patch venoplasty, so as not to narrow the vein. For segmental resection of the vein (with or without splenic vein preservation), primary end-to-end closure can be performed for shorter segments (<2.5 cm) with adequate mobilization, to allow tension-free reconstruction . For lonLarge left-sided tumors with complete PV/SMV occlusion create a surgical challenge, given the presence of extensive venous collaterals . If a trThe surgical strategy of mesocaval shunting involves the creation of a shunt between the SMV and inferior vena cava (IVC) to allow diversion of the portomesenteric blood flow and variceal decompression during pancreatic dissection . SelectiThe growing literature focused on venous resection for locally advanced pNETs is currently limited to observational case series and case reports from the past two decades. The outcome variables examined are varied across publications, but generally include the length of stay, postoperative morbidity, readmissions, patency, and, in some reports, survival. Case reports, primarily from Japan, as well as Turkey and Australia, have reported success in surgically addressing locally advanced pNET with vascular involvement. The majority of these involved portal vein reconstruction ,23,24,25The earliest case series reporting vascular reconstruction for pNET was published in Sweden by Hellman et al. . Of the There were several additional case series with 2–7 patients each ,31,32. TThen, in 2020, Titan et al.  presentePreliminary data from our own single-center experience performing vascular reconstruction for pancreatic tumors with complete portomesenteric occlusion include 15 patients diagnosed with pNET. Of these patients, five patients underwent traditional vascular reconstruction (in the standard order of dissection → resection → venous reconstruction), one with early in-line venous reconstruction , two witOver time, the literature has shown how vascular resection and reconstruction have been increasingly considered for pNETs. Data, however, remain limited to case reports and case series. As authors have previously noted, case reports and case series represent observational data and level IV evidence, but often spark the development and discussion of new techniques and treatment options . While t68Ga-DOTATATE), has been shown to be very accurate for detecting many types of NETs [68Ga-DOTATATE is beneficial in the overall clinical management of patients, its identification of unknown primary tumors, metastases to the liver, and assessment of global tumor burden in extrahepatic disease [These cases can be highly complex, and patients should be evaluated in a multidisciplinary tumor board setting with expertise from various specialties  for appropriate preoperative planning and postoperative care. The procedures require technical expertise in vascular control and experience with multiple forms of revascularization in the case of unexpected findings or greater vein involvement at the time of surgery. Aggressive surgery has been suggested to be beneficial in patients with pNETs and vascular involvement for several reasons, including (1) improved overall survival compared to those who did not have surgery, (2) improved surgical techniques that have led to safe surgery and acceptable complication rates, (3) amelioration of secondary variceal bleeding consequences of the tumor, and (4) medical therapies alone ) have been reported to show short-term disease stabilization or reduce tumor burden, but, in general, have not been able to downsize extensive local disease with some vascular involvement to make it surgically resectable without vascular reconstruction, as is sometimes observed in other tumors ,30. Our  of NETs . Specifi disease . However disease . Many ot disease . HoweverSurgery for pNETs is performed to cure disease, provide relief from hormonally active tumors, or prevent serious life-threatening complications related to the tumor, such as obstruction from the mass effect or bleeding from vascular shunts or varices, as a result of splenic vein occlusion. All of these goals may be met with successful resection of these primary pancreatic tumors, even in the setting of local vascular involvement. Advanced surgical techniques, such as early in-line venous reconstruction or mesocaval shunting, allow for the decompression of mesenteric hypertension for safe pancreatic dissection in the setting of complete venous occlusion. Several studies have shown the safety and feasibility of these radical procedures with acceptable disease-free survival and long-term outcomes. Major vascular involvement in pNETs should not be considered a contraindication to surgery, and favorable results support an aggressive approach in these patients at tertiary high-volume centers.