Glomangiopericytoma is a rare vascular neoplasm of the nasal cavity and paranasal sinuses that occurs during the sixth or seventh decade of life. It is categorized as a borderline tumor with low malignant potential and classified as a distinct entity of sinonasal tumors with perivascular myoid phenotype by the World Health Organization (WHO). We report the case of a 50-year-old woman with nasal obstruction and severe epistaxis. The nasal sinuses computed tomography (CT), and magnetic resonance imaging (MRI) demonstrated a 3.1 cm soft tissue mass occupying the upper part of the left nasal cavity invading the left paranasal sinuses and nasal septum, and the left eye medial rectus muscle. A total mass resection was performed by nasal endoscopy. The histological and immunohistochemical examination yielded the diagnosis of glomangiopericytoma. This case report aims to contribute to the knowledge of nasal neoplasms. The need for more data on this entity is the main obstacle to developing standardized treatment guidelines. We describe the clinicopathological and surgical characteristics and the radiological examination of this patient.A 50-year-old female with non-contributory medical history was admitted to the emergency department complaining of nasal obstruction and severe epistaxis of acute onset over the past few days. Under general anesthesia, nasal endoscopic examination revealed the presence of a friable reddish multilobulated mass that filled the left nasal cavity, including a large area of the nasopharynx. A tissue biopsy was performed. The control of the bleeding was achieved by tamponing the nose with surgicel.An enhanced computed tomography (CT) scan showed the presence of heterogeneous enhanced expansile soft tissue mass occupying the entire left nasal cavity, extending to a large area of the nasopharynx, and invading the left paranasal sinuses, nasal septum, and the medial aspect of the left orbital space with a significant remodeling and multifocal destruction of the surrounding bones. Mild intracranial invasion of the cribriform plate and focal destruction of the cribriform plate of the left ethmoid cells were seen. Remarkably, slight contact between the mass and the left eye medial rectus muscle was noted .The magnetic resonance imaging (MRI) revealed a 3.1 x 2.1 x 2.8 cm enhanced mass occupying the upper two-third level of the nasal cavity associated with 1.5 cm hematoma on its inferolateral aspect along with mild hemosinus in the left ethmoid cells, left sphenoid, frontal and maxillary sinuses. The mass showed heterogeneous mild hyperintensity on the T2-weighted image (T2WI), and hypointensity on the T1-weighted image (T1WI), with prominent enhancement after contrast administration . The imaDiffusion-weighted imaging (DWI) TSE at b1000 showed a hyperintense mass with no diffusion restriction. A high signal on the diffusion sequence supported the benignity of this lesion. Notably, all the radiological results were confirmed by two independent radiologists.Furthermore, cerebral digital subtraction angiography (DSA) for common carotid arteries, internal carotid arteries, and left vertebral arteries was done. Vascular blush in the left nasal cavity compatible with a nasal vascular tumor was seen. The main feeder of the blush was from the left ophthalmic artery branches  . Venous A biopsy was performed and examined by two independent pathologists. Grossly, the mass was beefy reddish to grayish pinky mass with hemorrhage. The histological examination revealed a subepithelial unencapsulated tumor proliferation separated from the surface of the respiratory epithelium by a Grenz zone. The tumor cells appeared as bland oval cells with spindled nuclei and abundant eosinophilic cytoplasm arranged in sheets and small fascicles mainly around ectatic staghorn-type vessels exhibiting perivascular hyalinization 4B. The sBecause of the vascularized nature of the tumor, preoperative ligation of the anterior and posterior ethmoidal arteries was performed. Endoscopic nasal surgery was performed under general anesthesia, where the tumor was entirely removed without bleeding. The canal roof was repaired. The orbital periosteum and the olfactive groove were cleansed to prevent tumor recurrence. The dura was intact and cleared without the complication of cerebrospinal fluid leak.10 Then, it was described as hemangiopericytoma-like intranasal tumors by Compagno and Hyams11 because of the low malignancy rate in 1976. Later, the WHO defined this tumor as glomangiopericytoma because of its similarity with glomus neoplasms.12 Remarkably, glomangiopericytoma is usually difficult to be distinguished from other benign vascular tumors such as leiomyoma, angiofibroma, and solitary fibrous tumors.13Glomangiopericytoma was first reported as sinonasal hemangiopericytoma by Stout and Murray.2 as in our case. Our patient’s medical history and clinical presentations did not provide clues for identifying an etiological factor of this tumor. In contrast, some studies have revealed an association between glomangiopericytoma and other diseases such as hypoglycemia,14 and oncogenic osteomalacia.15It is one of the rare nasal tumors, usually present in the nasal cavity and paranasal sinuses, with notably few reported cases in the nasopharynx16 cerebral angiography was used to determine the tumor’s vascular supply and to reduce the risk of intraoperative bleeding.17 A combination of these findings may be helpful not only to suggest the presence of glomangiopericytoma but also to propose preoperative planning of the surgical approach.18CT, MRI, and DWI showed a soft vascular mass with local invasion. As CT scan and MRI are useful techniques to evaluate tumor invasion and aggression,19 Sinonasal glomangiopericytoma showed low mitotic activity and atypia, in contrast to the uncommon malignant glomangiopericytoma, which showed high mitotic activity, necrosis nuclear pleomorphism, and bone invasion.20 Immunohistochemically, glomangiopericytoma can be distinguished from other soft tissue hemangiopericytomas by smooth muscle actin and cyclin D1 positive stainings.22 However, positive reactivity to other markers, such as beta-catenin, CD34, and vimentin, was obtained in many cases.21Histological examination by hematoxylin-eosin staining revealed a subepithelial unencapsulated tumor, separated from the respiratory epithelium by the Grenz zone and interspaced with many ectatic staghorn-type vessels. The tumor cells appeared bland oval with spindled nuclei and eosinophilic cytoplasm.23 Long-term surveillance by means of nasal endoscopy at regular intervals and/or radiological examination should be included as post-operative care.23Nasal endoscopic excision of glomangiopericytoma with clean margins is considered a less invasive resection method. Chemotherapy and radiotherapy can be used as palliation approaches. However, up to 17% of local recurrence has been discovered as a result of incomplete surgical resection even after along tumor-free intervals.Glomangiopericytoma is a rare indolent tumor with low malignant potential. The diagnostic approaches include endoscopy, CT, and MRI to define of tumor extent. Angiography is highly recommended to determine the main tumor vascular feeder to reduce bleeding during the operation. Furthermore, histopathological and immunohistochemical analyses are indicated to determine the tumor’s nature, which further helps designate an appropriate treatment approach. Complete surgical resection with regular clinical management and long-term follow-up are required to diagnose possible recurrence.


Needle tract seeding is a potential, albeit rare, complication following transcutaneous biopsies, leading to the seeding of tumor cells along the path of the needle. Biopsies of adrenal masses are not routinely recommended and are only indicated, after exclusion of pheochromocytoma, when an adrenal metastasis of a primary extra-adrenal cancer is suspected or when pathological confirmation of inoperable adrenocortical cancer (ACC) may impact treatment. Despite guideline recommendations to avoid primary adrenal biopsy, very few needle tract seeding cases have been reported and none were in the context of an ACC. We report the occurrence of needle tract seeding in a patient following adrenal transcutaneous biopsy leading to ACC abdominal wall recurrence.Needle tract seeding is a rare complication of transcutaneous biopsy. It may increase morbidity and impact overall survival. It has yet to be documented in adrenocortical carcinoma (ACC).Adrenal masses can be accurately evaluated for malignancy using a combination of conventional and metabolic imaging, such as CT and fluorodeoxyglucose-PET, obviating the need for biopsies.Adrenal mass biopsy is not indicated in ACC unless advanced ACC is diagnosed, and a pathological confirmation would impact management. Tumor seeding or needle tract implantation is a rare complication of percutaneous biopsy in which malignant cells are implanted along the trajectory of the needle, thereby increasing cancer recurrence risk . The estmax 22) with area of calcification and necrosis. No other hypermetabolic lesions or adenopathies were found. The consultant hematology–oncologist at a regional hospital requested a transabdominal biopsy of the mass, which was performed in June 2017, with an 18-gauge needle from an anterior approach without image capture of the procedure. Biochemical exclusion of pheochromocytoma was not performed prior to the biopsy of the abdominal mass as it was believed to be of splenic origin. Following histological examination, a diagnosis of ACC was suspected by the local pathologist who requested consultation from the adrenal pathology expert at our institution, who confirmed the probable diagnosis of ACC.A 43-year-old woman with no significant previous medical history noted progressive abdominal fullness and left flank pain. Her family history was significant for breast cancer in her mother and maternal grandmother at ages 60 and 45, respectively. An abdominal ultrasound was remarkable for a left flank mass presumed to be secondary to splenomegaly. A lymphoproliferative syndrome was thus suspected, and a fluorodeoxyglucose-PET (FDG-PET) scan was ordered and identified a single left 15-cm retroperitoneal abdominal mass, displacing the stomach, pancreas and anterior cortex of the left kidney. The mass was highly avid on FDG-PET , and the patient was discharged on 30 mg of hydrocortisone per day, in three divided doses.Pathology was that of a high-grade ACC with oncocytic features, measuring 16 × 13 × 10 cm, a Weiss/Aubert score of 6/7, a proliferation index (Ki67) of 12%, overexpression of p53 protein, a complete surgical resection (R0) and no positive adenopathy  and B.FAPC, ATM, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CHEK2, EPCAM (deletion and duplication testing only), MEN1, MLH1, MSH2/6, MUTYH, RAD51D, NBN, PALB2, PMS2, PTEN, STR11, SMAD4 and TP53).The patient consented to medical genetic evaluation, which revealed the absence of germline mutation in current panel of oncogenic predisposition genes  at 19.7 μg/mL and one episode of toxicity up to 31.6 μg/mL, requiring reduction of mitotane to a sequential regimen consisting of 500 mg on day 1, 1 g on day 2 and 1.5 g on day 3 for a few months, followed by alternating between 1.5 and 2 g/day. Mitotane levels were consistently between 14 and 20 μg/mL on the latter regimen.Regular abdominal and thoracic imaging were performed at 3 months interval following surgery, alternating conventional CT and FDG-PET, and were initially negative for recurrences or metastases.Two years later, the patient presented with a 3-cm mass located in the left anterior abdominal wall, which was not seen on FDG-PET scan done 3 months earlier . Biopsy max 8.5 and 4.5, respectively. Following CHUM adrenal tumor multidisciplinary team’s discussion noting the rapid extended recurrence, we decided to first administer 2500 cGy in five fractions to each of the abdominal wall and the left adrenal bed recurrences (2 IV over 2 h on day 1 and etoposide 100 mg/m2 IV over 2 h on days 1–3 every 21 days, for a total of four cycles, the last in June 2021. Concomitantly, we maintained treatment with 1 g of mitotane daily, 27.5 mg of hydrocortisone in three divided doses and a therapeutic mitotane blood level of 15.9 μg/mL. Close follow-up imaging is planned at 3-month interval.One year later, she developed two new recurrences  and C2: urrences , followeurrences . An FDG-This report provides a unique demonstration of ACC recurrence in the anterior abdominal wall, following transcutaneous biopsy of adrenal mass, despite therapeutic doses of adrenolytic adjuvant therapy with mitotane. Despite the clinical guidelines recommendation to avoid adrenal mass biopsy to prevent tumor spilling during this process, previously confirmed cases of such occurrence have not been documented prior to this report. The overall risk of needle tract seeding as a complication of transcutaneous biopsies of abdominal masses is very low, and most cases occurred in pancreatic, liver and renal carcinomas . Other tet al. recently reported that using a higher cut-off value for pre-contrast density on CT would allow for better specificity for ACC diagnosis without compromising on sensitivity and thus suggested using 20 HU as the threshold to exclude malignancy (en bloc resection of localized ACC is recommended for achieving the best possible outcome, and adjuvant mitotane therapy should be introduced for all resected ACC with a high risk of recurrence: stage III, incomplete resection and ki67 > 10% (Other authors suggested different cut-offs to be used. Overall, tumor size less than 3 cm (In recurrent and advanced ACC, treatment options include complete resection of recurrences or metastases whenever possible; however, second-line treatments such as radiation therapy, radiofrequency ablation, cryotherapy and chemoembolization can all be considered depending on site of recurrences and patient preference, and should be tailored to each patient . A recenAs for adjuvant chemotherapy, cisplatin ± etoposide with mitotane has been used as first line in high-risk settings, in particular, in aggressive ACC: Ki67 > 30%, vena cava thrombus, stage IV or incomplete tumor resection  and gemcIn conclusion, our case highlights the importance of following expert consensus in the management of adrenal masses, in particular, ACC. As the prognosis of advanced ACC is significantly worse than that of completely resected stage I–II tumors (The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this case report.This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.Written informed consent for publication of their clinical details and clinical images was obtained from the patient.N Y wrote the first draft of the manuscript. I B, H O, P P, O P, M L, D R and A L, each wrote parts of the final manuscript. All authors read and approved the final manuscript.


Thymic atypical carcinoids are extremely rare tumors and have a poor prognosis owing to their aggressive clinical course. The efficacy of treatments other than complete surgical resection is unclear. We herein report a postoperative recurrent case of thymic atypical carcinoid treated with everolimus and octreotide long‐acting repeatable (LAR). A 75‐year‐old woman was admitted to our department because a nodule was detected in the right lobe of thymus by annual computed tomography. The patient underwent thymothymectomy, and a diagnosis of thymic atypical carcinoid was made. One year and seven months after surgery, she developed multiple metastases in the lung, hilar and mediastinal lymph nodes, liver, and bone. Everolimus 10 mg/day was administered; however, the dose had to be reduced to 5 mg/day due to grade 3 hyperglycemia and grade 3 interstitial lung disease. Metastatic lesions other than liver metastasis markedly responded to everolimus, although the liver metastases gradually progressed. Three years and six months after surgery, she was administered octreotide LAR 30 mg per month in combination with everolimus. She has maintained stable disease for 8 months after the application of this combination therapy. Currently, only a few reports have described systemic antitumor therapy for thymic carcinoid. We herein report a postoperative recurrent case of thymic atypical carcinoid treated with everolimus and octreotide long‐acting repeatable (LAR). Thymic neuroendocrine tumors (NETs), first reported by Rosai and Higa in 1972, are rare malignant tumors accounting for less than 5% of all anterior mediastinal neoplasms.We herein report a recurrent case of thymic atypical carcinoid treated with everolimus and octreotide long‐acting repeatable (LAR).A 75‐year‐old woman was admitted to our department due to a mediastinal mass detected by computed tomography (CT) at annual follow‐up. She had undergone mastectomy of the left breast plus axillary lymph node dissection for left breast cancer 13 years earlier. Three years after surgery, she developed multiple bone and subcutaneous metastases. She was started on anastrozole 1 mg per day, and the metastatic lesions shrank significantly.Chest CT on admission revealed a 2.0‐cm well circumscribed tumor in the right lobe of the thymus Figure . No posiThe postoperative course was uneventful. Macroscopically, the lesion was a well circumscribed tumor 1.7 × 1.4 cm in size with a soft, fleshy, and pale tan‐white cut surface. A histopathological examination showed that the tumor consisted of small‐size round cells with nuclear pleomorphism and small nucleoli, arranged in nests, lobules, and trabeculae with 10 mitoses per 10 high‐power fields and no necrosis Figure . ImmunohAs complete resection with microscopically negative margins was achieved, she received no adjuvant therapy. However, 1 year and 7 months after resection of thymic atypical carcinoid, multiple metastases in the lung, liver, and bone were found on CT. Positron emission tomography revealed a high uptake in those lesions. Somatostatin receptor scintigraphy (SRS) revealed an increased uptake in the above‐mentioned lesions and hilar and mediastinal lymph nodes Figure . SubsequHowever, the patient developed grade 3 hyperglycemia and grade 3 interstitial lung disease 1 month after the application of everolimus. The dose of everolimus had to be reduced to 5 mg/day due to these drug‐induced adverse events. Metastatic lesions other than liver metastasis markedly responded to everolimus, leading them to be unidentifiable on SRS, although the liver metastases gradually progressed (Figure There are no trial‐proven therapeutic strategies in thymic NETs due to the rarity of this disease. Therapeutic protocols are thus adopted from NETs of other origin. According to the current ESMO guidelines on lung and thymic carcinoids, based on the very limited data available, surgery is recommended for thymic carcinoids deemed radically resectable.Everolimus is an oral inhibitor of the mammalian target of rapamycin pathway, approved as the first agent for therapy of pulmonary NETs based on the results of the phase III RADIANT‐4 study.In thymic carcinoids, only a few cases have been reported that were treated with everolimus, octreotide, pasireotide, sunitinib, or chemotherapy.In summary, we describe for the first time a particularly rare case of thymic atypical carcinoid, in which postoperative recurrence has been managed with everolimus plus octreotide LAR. We believe that the accumulation of more cases will lead to the development of effective therapy for this disease.TS, HH, and KO made substantial contributions to the conception of the study. TS and KO drafted the original manuscript. TN, EH, HH, and KO reviewed the manuscript draft and revised it critically for intellectual content. All authors approved the final version of the manuscript to be published.The authors have no conflicts of interest to declare.


Teratomas often occur in the gonads, while Extragonadal mature cystic teratomas are reported occasionally, with the most common site being the omentum. Teratoma in the Douglas sac is extremely rare. we report a rare case of mature cystic Teratoma in the Douglas sac in a 71-year-old woman who underwent laparoscopic surgery. A cyst with a diameter of approximately 6 cm from Douglas was found during surgery, and the mass was separated from both ovaries. Microscopically, the cyst was a mature cystic teratoma that did not originate from the ovary. Teratomas are germ cell-derived tumors with the potential to differentiate into somatic cells. Most teratomas contain at least two types of embryonic tissue components. According to differentiation degrees of the tissues contained, teratomas can be divided into mature ones and immature ones. Mature cystic ovarian teratoma, also known as dermoid cyst, is a benign tumor, accounting for 85–97% of germ cell tumors and more than 95% of teratomas. It is primarily composed of ectodermal, mesodermal, and endodermal mature tissues, and usually dominated by ectoderm, mostly cystic, which can be monocystic or polycystic. The content is oil-like, often mixed with hair, and the cyst wall is often lined with multi-layered squamous epithelium and appendage hair follicles, sebaceous glands, sweat glands, etc. Immature teratoma is a malignant germ cell tumor that reproduces the differentiation characteristics of embryos and fetal tissues. Its tissues contain different amounts of immature tissues, largely primitive and embryonic neuroectodermal tissues. Teratomas often occur in the gonads, while extragonadal mature cystic teratomas are occasionally reported, with the most common site being the omentum majus . HoweverA 71-year-old women was admitted to the hospital because of “a prolapse of vaginal mass for more than 3 years and a pelvic mass found 1 month ago.” When the patient stood upright, a broad-bean-sized mass prolapsed out of the vagina, and the symptom disappeared by itself when the patient rested. She has been post-menopausal for 25 years, with 4 pregnancies and 3 children, and received cataract surgery 6 years ago. Physical examination showed no obvious mass palpated in the abdomen and no tenderness. Gynecological examination showed no abnormality in the vulva and vagina, atrophic and smooth cervix, uterus in the middle position and metratrophia, no tenderness, and a cystic mass of a diameter of 6 cm felt behind the uterus with clear boundary, smooth surface, and acceptable mobility without tenderness. No obvious mass was palpated in bilateral adnexal areas. Tumor markers are largely normal. Pelvic ultrasound showed a mixed echogenic mass on the left side of the pelvis. The mass size was about 7.4*5.4 cm.A laparoscopic exploratory operation was performed under general anesthesia on 10 August 2017. During the operation, it could be observed that the uterine surface was smooth, and a mass with a diameter of about 6 cm was seen in Douglas’ pouch. The surface of the mass was smooth, without obvious connection with the uterus and bilateral appendages, but its back was tightly adhered to the posterior wall of the uterus, the right appendages, and the mesentery . The bilThe patient had an uneventful postoperative course. Pathological examination after surgery showed that the tumor was mature cystic teratoma .Mature cystic teratoma is a congenital tumor that originates from pluripotent stem cells and contains tissues from at least two of the three germ cell layers. They usually have a parthenogenetic origin with a 46, XX karyotype and characteristic stagnation after Meiosis I. Meckel  first deThere are three proposed theories about the causes of these extragonadal sites: (1) Primary teratoma may originate from displaced germ cells. (2) Teratoma may occur in the supernumerary ovary. 3) Teratoma may be caused by automatic amputation of ovarian dermoid cyst. The first mechanism is during early fetal development when germ cells migrate from the yolk sac along the hindgut to the reproductive crest. Germ cells become arrested between the yolk sac entoderm and the dorsal mesentery  Teratoma. SupernuThe cases in many reports are parasitic dermoid cysts in the omentum majus, while the cases of teratomas located in the Douglas’ pouch are rare. We focused on the parasitic cysts located in the Douglas’ pouch to investigate the disease characteristics as reference for clinical diagnosis and treatment. We performed a PubMed search using keywords “extragonadal” or “parasitic,” “teratoma,” “Douglas,” or “cul-de-sac,” and found 24 articles. The clinical data of the 24 cases of parasitic dermoid cysts in Douglas’ pouch is given in When extragonadal teratomas develop in the uterus, cervix, and oviduct, symptoms such as abnormal uterine bleeding and vaginal masses may occur. Patients with Douglas’ pouch teratomas may suffer from hypo gastralgia . Some paThe original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.YY and MZ: acquisition of data and writing—original draft. MC, HT, and ZQ: analysis and interpretation of data and visualization. JL, HW, and MB: perform the analysis with constructive discussions. JC: conceptualization, funding acquisition, resources, supervision, and writing. BX: conceptualization, supervision, and writing. All authors contributed to the article and approved the submitted version.


Juvenile ossifying fibroma (JOF) is a rare type of tumor originating from the bones of the face or cranium. It usually arises in the maxilla and rarely in the mandible. The complications related to the tumor are because of local expansion and resultant effect on the nearby organs. We present the case of an eight-year-old girl with a history of headache and chronic epistaxis for the past six months who presented acutely to the hospital due to swelling, redness, and pain in both eyes, with continuous epistaxis. After investigations, she was found to have a nasal tumor that was confirmed to be JOF of the nasal bone on histopathology. Surgical management was done and the tumor was resected. Juvenile ossifying fibroma (JOF) is a benign, fibro-osseous tumor that can occur in the extremities, head, and neck involving the craniofacial bones of children less than 15 years of age . Rarely,An eight-year-old, previously healthy, unvaccinated girl presented with a one-week history of fever, right-sided periorbital swelling, bilateral eye redness, and pain. She reported a history of intermittent chronic epistaxis for the preceding six months, which had increased in amount and frequency. It was associated with intermittent headache and nasal discharge for four to six months. On examination, she was afebrile, vital signs were normal, there was right eye periorbital swelling with erythema, painful right eye movement with visible blood in the nasal canal bilaterally, and a visible mass in the left nasal cavity extending to the right. She also had mild proptosis of the right eye, with no restriction of eye movements in all directions and bilateral equal-reacting pupils Figure . Other sLaboratory investigations showed leukocytosis with neutrophilia and mildly elevated C-reactive protein and erythrocyte sedimentation rate. Renal function and liver function were within normal limits. Blood culture and eye secretion cultures were negative.A computed tomography (CT) scan of the brain and orbit showed a tissue density (highly suggestive of vascular soft tissue) in the nasal cavity with extension into the nasopharynx and surrounding sinuses Figure . A CT scMagnetic resonance imaging (MRI) of the orbit revealed the mass in the nasal cavity with a picture of chronic invasion into the surrounding structure Figure .MRI and magnetic resonance venography of the brain were unremarkable. Other imaging including chest X-ray and ultrasound of the abdomen were normal. Other specialties including Ophthalmology and Ear, Nose, and Throat were involved in the further management of the patient.She underwent an endoscopic examination of the nasal cavity bilaterally that revealed a vascular lesion, which was obstructing the left nasal cavity. A biopsy of the lesion was taken and the histopathology sections are demonstrated in Figure The patient was operated on under general anesthesia, which showed that the nasal mass Figure  involvedShe received intravenous antibiotics in the hospital for four weeks. Once epistaxis had improved and periorbital cellulitis resolved, she was discharged with close follow-up. After three months, she had a recurrence of the mass as she presented with epistaxis, bilateral eye pain, and headache. She was managed by a multidisciplinary team including otolaryngology, oncology, and general pediatrics. The mass was fully resected and she was discharged in good condition. She is doing well and remains symptom-free on follow-up two months after the second surgery.JOF is a rare tumor that appears in the craniofacial bones and has been reported in children less than 15 years old. It is a benign, fibro-osseous, locally aggressive tumor that usually increases in size, expands to surrounding structures, and may lead to facial asymmetry . PrognosJOF usually does not cause any symptoms on its own, rather the symptoms arise due to local expansion which is usually painless but can cause pressure and sometimes deformities to the surrounding organs. Cases of this tumor have been reported in the maxilla and rarely in the mandible. Maxillary growths usually involve the nasal cavity or the orbit. When extension occurs in the nasal cavity, symptoms can arise due to obstruction of the nearby sinuses presenting with sinusitis. In addition, epistaxis can occur due to local expansion, as was the case with our patient. If the tumor involves the orbit, the patient can present with dystopia, proptosis, and painful eyes . In our Management of this tumor is by surgical excision. Conservative approaches such as curettage are not optimal as this tumor has a very high chance of recurrence . HoweverJOF is a rare clinical entity that is locally aggressive in nature and has an unpredictable recurrence, which poses a challenge and warrants awareness among clinicians. The majority of the cases are asymptomatic and present once the complications occur. As in our case, the patient had a common symptom of epistaxis but given its chronicity should warrant suspicion of an underlying pathology. Furthermore, this tumor is mainly found in the maxilla but in rare cases like ours can grow in other craniofacial bones such as the nasal bone. Biopsy aids in confirming the diagnosis, and surgical excision remains the mainstay of treatment.


The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies, with one severely malformed twin (the “acardiac”) lacking autonomous placental blood supply and being perfused by the co-twin (the “pump”), through arterio-arterial  vascular anastomoses located on the placental surface. The prognosis is poor: mortality is 100% in the acardiac twin because of its severe malformations and about 50–55% in the pump twin, mainly due to heart failure and prematurity. So, the goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. Intuitively, the earlier the diagnosis, the better the outcome. Herein, we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence, which are of interest since the objective of early diagnosis was achieved by means of transvaginal and 3D ultrasound, two techniques which revealed themselves as being useful to this purpose but are underused in the literature. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence. Chorioangiopagus parasiticus, is an extremely rare complication of monochorionic twin pregnancies and the most severe form of Twin-to-Twin Transfusion Syndrome (TTTS) [The Twin Reversed Arterial Perfusion (TRAP) Sequence, also known as e (TTTS) .While van Gemert et al.  estimateAlthough several theories have been postulated ,5, the preversed arterial perfusion as the reflux blood from the circulation of the pump twin, so poor in oxygen, reaches the acardiac twin by pressure gradient through the umbilical artery (or arteries) and moves away through the umbilical vein, which is in the opposite direction to what usually happens. This circulation has negative consequences for both twins. The thin oxygen-poor blood flow stolen by the acardiac twin usually prevents its upper body formation, with the development of only lower extremity sketches. Specifically, the acardiac twin can assume four different anatomical forms [Acardius acephalus, in which the pelvis and lower limbs are well developed, the head and thoracic organs are missing, and poorly developed upper extremities may be present or absent.The most common subtype is the Acardius anceps is the most developed subtype, since both the upper and lower extremities are present and typically well-formed, and head and face are present too, although poorly formed.The Acardius amorphus is the least developed subtype, a shapeless mass without differentiable organs, extremities, or anatomic structures.The Acardius acormus is an extremely rare subtype; here, the head is the only recognizable organ.The In this severe condition, one fetus, lacking autonomous placental blood supply, is perfused by the twin through arterio-arterial  vascular anastomoses located on the placental surface ,7. The dal forms :The mostOn the other hand, the pump twin may develop polyhydramnios, cardiac failure and hydrops, up to death , due to Herein we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence which, in compliance with the patients’ preference, we managed with a conservative-only approach, even when early diagnosis was achieved by means of transvaginal and 3D ultrasound. Both our cases ended up as Stevenson’s literary bestseller: with the death of both protagonists. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence.At 22 weeks of gestation, a 30-year-old female of Caucasian ethnicity with gravida 1 parade 0 abortion 0 (G1P0Ab0) was referred to our Obstetrics Department for the detection of a suspicious intramniotic amorphous mass during a routine second-trimester fetal anatomy scan. The patient, without a family history of twins, had conceived spontaneously. Anamnesis was silent for drug use, alcohol drinking, smoking, or pregnancy infection and she was healthy and with a normal BMI. During first-trimester ultrasound screening performed elsewhere, the acardiac fetus was not noted and the other one appeared to be normal. Then, the examiner who performed the second-trimester ultrasound anatomy screening detected the presence of a suspicious amorphous mass beside the apparently normal fetus, thus referring the patient to our secondary hospital.Acardius acephalus twin (even if the pelvis and lower limbs were not completely developed). Lastly, ultrasound also revealed the presence of polyhydramnios with a 13 cm maximum vertical pocket of amniotic fluid.Our abdominal echography, performed by means of a GE Healthcare Voluson E10 ultrasound machine, revealed a monochorionic twin pregnancy with one acardiac fetus and one pump fetus. During the scan, we could not find a definite membrane separating the two twins; hence sonographically, we thought this twin pregnancy fell under the monochorionic monoamniotic twin pregnancy. The pump twin had a borderline hydrocephalus and a right aortic arch, but there were no signs of high-output cardiac failure . As per the Williams package, the weight of the pump twin was 481 g , consistent with menstrual age. The acardiac twin at the 2D abdominal ultrasound appeared to be an amorphous mass measuring 67 mm (maximum length), without the heart and with a lower limb consisting of femur and sketches of tibia and fibula A. It wasParents were extensively counselled about this rare condition, the possible prognosis, and all the different management alternatives (which we will discuss later in this article). The couple eventually refused invasive investigations and opted for elective termination of the pregnancy (TOP), which was performed uneventfully by prostaglandin induction. Fetal autopsy showed that the pump twin had no abnormal anatomy except a right aortic arch. Instead, the acardiac monster lacked cephalic extreme, main organs, and upper limbs A. It onlThe second case we report concerns the prenatal diagnosis of a TRAP Sequence by means of transvaginal color Doppler imaging in early gestational age.A 35-year-old female of South Asian ethnicity with gravida 1 parade 0 abortion 0 (G1P0Ab0) came to our hospital to undergo first-trimester ultrasound screening at 12 weeks of gestation. Pregnancy was spontaneous. The patient’s medical history was silent, and she had a family history of twin pregnancy.Acardius acephalus twin. The application of 3D ultrasound clearly showed the lower limb, the central anechoic cyst, and other anatomic details, thus confirming and better scanning the 2D ultrasound findings  of 52 mm , fetal heart rate (FHR) of 145 bpm, and nuchal translucency of 1.1 mm. The placenta was posterior, the funiculus was formed by three vessels and the amniotic fluid volume appeared to be normal. Next to the fetus, the sonographer noticed the presence of a suspicious amorphous mass measuring about 33 × 25 mm which did not appear to be in continuity with the fetus but moved in a consensual manner to it. Therefore, the examiner performed a transvaginal ultrasound, and it became clear that the mass was a severely malformed fetus. Head, heart, main organs, and upper limbs were absent. The only recognizable anatomical structures were a rudimental vertebral column behind an anechoic cyst A and thefindings D. The abThe couple was scrupulously informed about this rare condition, the possible risks for both twins, and all the different management alternatives. They refused any invasive investigation and decided to do only observation first. We repeated ultrasound after two weeks, noting that the pump fetus had grown regularly (CRL = 7.7 cm) and, with color Doppler, that the perfusion into the umbilical cord of the acardiac fetus had not declined C, thus jUnfortunately, the patient spontaneously miscarried two weeks later, before the subsequent check. The histological examination confirmed the MCMA pregnancy complicated by TRAP Sequence, based on the placental specimen. Due to technical reasons, the macroscopic pathologic images of the TRAP Sequence twins were unobtainable.The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies. Besides reporting two interesting additional cases, this study aims to contribute to the TRAP literature with a much needed summary of the existing evidence regarding three fundamental aspects of this rare condition, that is, diagnosis, prognosis establishment, and management. To the best of our knowledge, this is the first study of this kind, thus making it a potential key resource for all obstetricians, in particular those who will come across this pregnancy pathology for the first time.To be able to make a TRAP diagnosis firstly means to be able to differentiate an acardiac twin from a vanishing or severely malformed co-twin . It requTo date, Color Doppler and pulse wave Doppler velocimetry studies represent the best methods with which to confirm the pathognomonic reversed blood flow into the acardiac twin through its umbilical artery ,14,15,16To the best of our knowledge, the diagnosis of acardia is almost always made in the second ,21,22,23Guimaraes and colleagues  used magThe cases we reported are of interest since the diagnoses were achieved by means of 3D ultrasound too, which is a faster and a less expensive method than MRI, and does not require the help of a radiographer ,36,37. TThe prognosis of monochorionic pregnancies complicated by the TRAP Sequence is poor: mortality is 100% in the acardiac twin ,40 becauSome studies have shown that the acardiac twin size is correlated with the pump twin outcomes.Jelin et al.  examinedFrom the investigation of 13 cases of TRAP conducted in the Children’s Hospital of Philadelphia , it emerAlso, Sepulveda and colleagues  believedMoore and coworkers  suggeste and 10% ,20,22,24Regarding early pregnancy, some studies reported that ultrasound indicators such as pump twin’s CRL and acardiac twin’s upper pole-rump length (URL) carefully indicated the pump twin outcomes. Themp twins ,48. Tangmp twins  recentlyA spontaneous interruption of the vascular connection between the twins has been shown to occur ,28,33,50Chen et al.  reportedTang et al.  identifiAs far as we are concerned, we did not document the twins’ vascular connection weakening in our Case Report Two, and at the second sonographic check, the reversed arterial perfusion to the acardiac was still present and well evident B. This wFew studies ,52 have that TRAP pregnancy, which still remains the subject of scientific debates. The goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. We present an overview of the possible management approaches.To provide potential prognosis predictors is essential because it improves the physician’s likelihood of choosing the best management for The first option the couple has is the observational-only approach, with possible study of the fetal karyotype , Sullivan and colleagues  believedOne study  conducteAlso, Jelin et al.  and MannAn alternative to expectant management is the prophylactic interventional approach, with the aim of interrupting blood flow from the pump twin to the acardiac one. Several minimally invasive procedures have been progressively introduced  and, to https://clinicaltrials.gov/ct2/show/NCT02621645, accessed on 15 September 2023), aiming to clarify whether early intervention  leads to better pregnancy outcomes as compared to later intervention . The results of this study should be available to the public within the next months.However, to date, there is no consensus about timing for intervention in this pathology. Since TRAPs are almost always diagnosed in the second trimester of pregnancy, most of them underwent treatment at 16 weeks or more. Nowadays, early diagnosis is more and more frequent, so it is fundamental to understand whether immediate intervention could and should be taken after diagnosis. Several studies seem to suggest that interstitial laser ablation (ILA) is a technically feasible treatment for the TRAP in the first or early second trimester (before 16w) ,60,61. ORegardless of the gestational age, unexpected death of the pump twin, iatrogenic premature rupture of the membranes, and preterm birth are some of the complications that can occur after mini surgery . FurtherFinally, some authors suggested that a conservative approach should be the first choice, with the possibility of shifting to intervention to stop the reversed perfusion in case signs of fetal impairment develop, for example in the case of polyhydramnios appearance, in case the abdominal circumference of the acardiac twin becomes equal to or greater than that of the pump twin, or in the case of abnormal blood flow into the pump twin ,63,66.n = 14) of the pump twins were born healthy.All of Tang’s  TRAP patwhen to shift to treatment, Wong and Sepulveda [To assist with the decision of epulveda  suggesteMalone and D’Alton  suggesteClifton O. Brock. et al. , in theiHowever, the couples who decide to take a conservative approach should know that there are no clear and unequivocal data yet indicating the right frequency of clinical checks and the right parameters to analyze during each one.The choice between the two main approaches is not simple, since on the one hand there is the risk of the possible progressive deterioration of the cardiac function of the pump twin, as well as the risk of preterm birth in the case of polyhydramnios and the risk of intrauterine fetal demise; on the other hand, the fetal complications from mini-surgery  and all maternal risks  must be considered.Both our cases were managed in compliance with the patients’ preferences, though these latter were not consistent with the most recent scientific data. The first patient was extensively informed that the prognosis would have been good and, anyway, she would have been eligible for the mini-invasive surgery; despite explaining that her choice was not aligned with the recent literature evidence, she was still determined to achieve an elective TOP, thus we respected her desire. Regardless of the estimated prognosis, the second patient was unmovable in her decision of a conservative-only approach, based on ethical reasons.The Twin Reversed Arterial Perfusion (TRAP) Sequence is a rare, severe condition, which should always be suspected in monochorionic twin pregnancies if one of the twins is acardiac.The goals should be early diagnosis and good clinical counselling in order to ensure, in compliance with the patients’ preference, an earlier and more adequate treatment to reduce the otherwise extremely high risk of intrauterine fetal demise for the pump twin, and to improve the prognosis.Early diagnosis can be more easily achieved in second-level centers by operators with remarkable sonographic skills and by means of the transvaginal technique and 3D ultrasound. Although not indispensable to achieve a TRAP diagnosis, these latter may be extremely useful and complementary to the traditional transabdominal ultrasound.Parents should be immediately informed about the estimated prognosis of the donor fetus and all possible management modalities in order to allow them to choose the fate of their pregnancy freely and consciously.Due to negligible and poor-quality evidence, which prevents guidelines from being drawn up, future carefully designed randomized controlled trials and prospective studies comparing diagnostic modes, prognostic indicators, and management approaches are still needed.


Colon cancer is a common malignancy and is often encountered initially as locally advanced disease. However, there are many benign clinical entities that may masquerade as complicated colonic malignancy. Abdominal actinomycosis is one such rare mimic.A 48-year-old female presented with a progressively enlarging abdominal mass with skin involvement and clinical features of partial large bowel obstruction. Computed tomography (CT) revealed a mid-transverse colonic lesion at the centre of an inflammatory phlegmon. At laparotomy, the mass was found to be adherent to the anterior abdominal wall, gastrocolic omentum, and loops of jejunum. En block resection was performed with primary anastomosis. Final histology showed no evidence of malignancy, but mural abscesses containing pathognomonic sulphur granules and actinomyces species.Abdominal actinomycosis, particularly of the colon, is rare and exceptionally so in immunocompetent patients. However, the clinical and radiographic presentation often mimics more common conditions such as colon cancer. Accordingly, surgical resection is typically radical to clear margins, and diagnosis is made only on final histopathology.Colonic actinomycosis is an uncommon infection but the diagnosis should be considered particularly in colonic masses with anterior abdominal wall involvement. Oncologic resection remains the mainstay of treatment and the diagnosis commonly made retrospectively given the rarity of the condition. •Most locally advanced colonic masses are treated as presumed adenocarcinoma.•Cross-sectional imaging is usually performed and may reveal features of luminal masses or invasion.•Multi-visceral en block resection is then typically performed to clear margins.•Uncommonly, final histology may show rare benign findings such colonic actinomycosis. However, whether from biopsy or surgical resection, final histopathology remains the gold standard for diagnosis of colonic adenocarcinoma. Interestingly, it is not uncommon for this histology to show other results such as inflammatory bowel disease or non-adenomatous neoplasms. In the absence of specific patient risk factors or strongly atypical history other differential diagnoses such as infectious masses are typically considered esoteric.Herein, the authors present a case of one such rare cause of a locally advanced colonic tumour, actinomycosis. This manuscript was prepared in accordance with the SCARE 2020 guidelines 2A 48-year-old female with no known chronic illnesses presented to the emergency department with a 1-month history of an epigastric mass. The mass had been progressively increasing in size and was associated with intermittent abdominal pain, early satiety and new onset constipation. However, the patient continued to pass flatus and reported no vomiting, spurious diarrhoea or haematochezia. There was no personal or family history of malignancy, no constitutional symptoms and no history of prior colonic or upper gastrointestinal evaluation, with no previous surgeries. The patient had now presented acutely due to a 2-day history of worsening and now constant abdominal pain.Physical examination revealed an afebrile well-nourished middle-aged woman in mild painful distress. Significantly, the abdomen was obese and tender over an obvious 10 cm × 10 cm firm immobile epigastric mass with associated guarding and rebound. The mass was fixed to overlying skin which itself was indurated, erythematous and oedematous. The remainder of abdominal and other systemic examinations was unremarkable. A clinical diagnosis of locally advanced and complicated colon cancer was made and the patient investigated with CT-abdomen after commencement of empiric antibiotics.Apple Core” lesion to the mid-transverse colon which extended into the greater omentum and anterior abdominal wall forming a complex 7.7 cm × 4.8 cm × 4.5 cm inflammatory mass with an associated solitary enlarged mesenteric lymph node  was performed in an uneventful procedure , Fig. 4.Surprisingly, final histopathology found no evidence of malignancy but instead showed an inflammatory mass comprising of multiple transmural abscesses of the involved small and large bowel. Interestingly, these abscesses contained the characteristic sulphur granules with embedded bacterial colonies reminiscent of actinomyces , Fig. 6.3Actinomycosis is a rare chronic suppurative infection caused by the commensal filamentous gram-positive anaerobic bacteria of the Actinomycetaceae family, most commonly Actinomyces israellii Clinicians need to remain cognisant of alternative diagnoses to malignancy and have a heightened index of suspicion in patients with large colonic masses with multi-organ involvement. Confirmation of a benign diagnosis, such as actinomycosis, may reduce surgical morbidity by affording less radical resection when possible. Interestingly, non-operative therapy with long course antibiotics (6–12-months) is well described for actinomycosis but has limited utility when unable to effectively rule out malignancy The clinical and radiographic features of this presentation, as is commonplace with colonic actinomycosis, strongly overlapped with complicated malignancy. However, closer analysis of the case highlights evidence that could have heightened suspicions of an ulterior diagnosis. For example, the relatively young age of the patient and short history in conjunction with the rapid progression and locally advanced nature of the lesion. Particularly the anterior abdominal wall involvement and abscess formation, that is a well-documented characteristic of actinomyces infection, is rarely seen in colon cancer Further delineation from malignancy maybe done by careful evaluation of cross-sectional imaging. Firstly, due to the size of the bacterium it does not easily spread via lymphatics Finally, in the non-emergent setting, colonoscopy also aids in differentiation from neoplastic disease. Most commonly a luminal mass is not appreciated and mucosal changes, present in only 50 % of cases, are usually minimal 4Actinomycosis is a rare cause of a locally advanced colonic tumour with clinical and radiographic features that closely resemble malignancy. Pre-operative diagnosis is ideal but difficult. It relies heavily on a high-index of suspicion in conjunction with cross-sectional imaging, percutaneous biopsy and when possible colonoscopy. Accordingly, given inability to rule out malignancy, surgery is often indicated and the diagnosis made in retrospect. Response to surgery may be variable and the ideal adjuvant antibiotic regime is likely patient specific and hinges on good clinical judgement.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.This anonymised case report is exempt from ethical approval.This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.Matthew-Anthony Lyew.Not applicable.Matthew-Anthony Lyew: Conceptualization, Visualization, Writing – original draft. Conrad Morris: Writing – review & editing. Kevan Smith: Writing – review & editing. Memory Stennett: Resources.None to declare.


Do transcranial approaches still play a role for giant pituitary adenomas, given the marked evolution of endoscopic endonasal trans-sphenoidal skull base surgery? This narrative paper reviews the key arguments through a critical appraisal of the personal series of the senior author (O.A.-M.). Traditional indications for transcranial approaches include the absent pneumatization of the sphenoid sinus; kissing/ectatic internal carotid arteries; reduced dimensions of the sella; lateral invasion of the cavernous sinus lateral to the carotid artery; dumbbell-shaped tumors caused by severe diaphragm constriction; fibrous/calcified tumor consistency; wide supra-, para-, and retrosellar extension; arterial encasement; brain invasion; coexisting cerebral aneurysms; and separate coexisting pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after trans-sphenoidal surgery require individualized considerations. Transcranial approaches still play a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and the encasement of neurovascular structures.The evolution of endoscopic trans-sphenoidal surgery raises the question of the role of transcranial surgery for pituitary tumors, particularly with the effectiveness of adjunct irradiation. This narrative review aims to redefine the current indications for the transcranial approaches for giant pituitary adenomas in the endoscopic era. A critical appraisal of the personal series of the senior author (O.A.-M.) was performed to characterize the patient factors and the tumor’s pathological anatomy features that endorse a cranial approach. Traditional indications for transcranial approaches include the absent pneumatization of the sphenoid sinus; kissing/ectatic internal carotid arteries; reduced dimensions of the sella; lateral invasion of the cavernous sinus lateral to the carotid artery; dumbbell-shaped tumors caused by severe diaphragm constriction; fibrous/calcified tumor consistency; wide supra-, para-, and retrosellar extension; arterial encasement; brain invasion; coexisting cerebral aneurysms; and separate coexisting pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after trans-sphenoidal surgery require individualized considerations. Transcranial approaches still have a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and the encasement of neurovascular structures. The historical evolution of pituitary surgery is fascinating. The name Galen of Pergamon is derived from "pituita" from the Greek “ptuo” (to spit) and the Latin “pituita” (mucus). Andreas Vesalius modified it to mean “glans in quam pituita destillat”, describing it as a small anatomical structure at the base of the brain at that time believed to secret products from the brain into the nasal cavities . Based oThe recent explosion of endonasal endoscopic surgery and neuronavigation has made the trans-sphenoidal route overwhelmingly popular. At the same time, it is deficient in some instances, requiring a transcranial approach.This article attempts to define the transcranial approaches that can be used for pituitary tumors.Pituitary adenomas have a prevalence ranging between 15% and 17% in the general population and are the third most frequent type of intracranial tumor in adults ,32,33. TPituitary adenoma surgery has three goals: the decompression of optic pathways, the preservation or restoration of the pituitary function, and the prevention of malignant transformation. The latter is known to significantly, but not exclusively, affect syndromic and sporadic ACTH-secreting tumors and prolactinomas, and can be characterized by a poor prognosis ,36,37,38The sellar region is a party wall between the neurocranium and splanchnocranium. Giant pituitary adenomas represent a complex clinical entity whose surgical management often imposes the choice between a trans-sphenoidal versus transcranial approach. The evolution of endoscopic transnasal trans-sphenoidal surgery and its good results in pituitary tumors have overshadowed the need for transcranial approaches in particular circumstances, mainly for giant pituitary adenomas. This narrative review aims to define the contemporary indications for transcranial approaches in giant pituitary adenomas by analyzing specific anatomical factors related to the patient and anatomopathological aspects associated with the tumor. In addition, technical innovations associated with future directions of the surgical management of giant pituitary adenomas are also discussed.“distribution and mode of origin of septa and walls of the sphenoid sinus” [In 1920, Congdon first highlighted the surgical relevance of the d sinus” . The pned sinus” ,48. It pd sinus” . Differed sinus” ,51. Hambd sinus” . Similard sinus” ,51,53,54d sinus”  in a mord sinus” ,51,53.Conchal-type sinuses and other mixed patterns of the coronal non-pneumatized sphenoid sinus are generally believed to be less favorable for a trans-sphenoidal approach, especially in children and large tumors. Flat sellar-type and complex sphenoid sinus configurations, with incidences of 11% and 29%, respectively , are als"Kissing" internal carotid arteries (ICAs) may touch each other within the sphenoid sinus, sphenoid bone, or sella ,58,59. T“considerable enlargement of the pituitary may be unobservable roentgenologically” [American Journal of Roentgenology [3) = 0.5 (length × width × depth in mm)/1000 [Ten years before the advent of the CT scan, Sir Godfrey Hounsfield, Di Chiro, and Nelson reported the measurement of the sella turcica based on conventional radiography, noting that gically” . This megenology . The sizgenology . The femgenology . A smallgenology  and the genology . Criticagenology . In contmm)/1000  . Purely infra-diaphragmatic tumors are easily managed with a trans-sphenoidal corridor. Conversely, adenomas with a large and giant dumbbell shape impose a trans-tubercular extension of the trans-sphenoidal approach. It should involve trans-diaphragmatic access to reach the suprasellar area since, regardless of the consistency, the likelihood of a descent supradiaphragmatic component has been reported to be considerably lower in the case of significant diaphragmatic constriction ,93,95. AA 39-year-old female suffering from headache, right-sided facial pain and numbness, and hyposmia was diagnosed with a non-functioning giant pituitary adenoma extending bilaterally into the cavernous sinus (CS). The mass also significantly thinned the dorsum sellae and eroded bilateral petrous apices . Because of a competent diaphragm (Rhoton type A), the tumor was mostly infra-diaphragmatic. However, a non-negligible mass component involved the right middle fossa through the roof of the CS. A staged resection of the adenoma was planned, where an extended trans-sphenoidal corridor with right medial maxillotomy was used to remove the sellar component of the lesion .Six months later, the second stage was performed after the a new MRI scan which showed a volumetric increase in the known intracranial residue . The patient underwent gross total tumor resection through a cranio-orbito-zygomatic (COZ) approach .The consistency of a tumor is a crucial factor impacting the EOR, complication rate, and outcome of giant pituitary adenomas ,97,98,99Other promising techniques include MRI elastography, and high-resolution ADC achieved with 7 tesla diffusion-weighted MRI imaging ,115.“unpredictable”. The development pattern is affected by several factors, such as tumor progression, the state of fixation of the chiasm, the pituitary fossa’s shape, and the sellar diaphragm’s specific anatomy [Based on his roentgenographic studies, in 1940, Geoffrey Jefferson defined the extrasellar growth of giant pituitary adenomas as  anatomy . Jules H anatomy ,118,119. anatomy . The vol anatomy ,90,96,98 anatomy ,121,122.Type D tumors involving the anterior cranial fossa deserve further consideration regarding the possible encasement of the optic chiasm and optic nerves. It is without a doubt that trans-sphenoidal surgery allows for an effective decompression of the optic apparatus, which is responsible for improving visual function in visually symptomatic patients. Nevertheless, a wider working corridor and a greater microscopic magnification are required in those cases where a circumferential encasement of the optic nerves is ascertained preoperatively to avoid surgical dissection, which may be a potential source of iatrogenic damage if the arachnoid plane is absent. The encasement of optic apparatus is a recognized potential source of visual loss after trans-sphenoidal surgery for dumbbell-shaped suprasellar tumors . Tumors A 43-year-old male patient suffering from headache, progressive visual loss in the left eye, decreased libido, fatigability, and an intolerance of cold was diagnosed with a giant Hardy type D non-functioning pituitary adenoma involving the subcallosal area and the anterior cranial fossa. The lesion encased the optic apparatus and pushed the anterior cerebral artery complex upward. On the FLAIR MRI, the tumor also showed a partial parenchymal invasion of the basal forebrain . A gross total resection of the tumor was performed through a right COZ approach, where a meticulous microneurosurgical dissection of the encased optic nerves and chiasm was performed. A small remnant invading the ventrostriatum was left, followed by neuroimaging . No recurrences occurred after 24 years and the remnant remained stable. A 28-year-old male had a giant Hardy type D growth hormone and a giant pituitary adenoma involving the left CS and a substantial suprasellar, retrosellar, and left parasellar middle fossa extension. The lesion invaded the left cerebellar peduncle and showed cystic degeneration at its apical portion, compressing the ipsilateral temporal horn of the lateral ventricle . A right COZ approach was executed and the tumor was resected . Ten days later, the patient was discharged without deficits .The medial wall of the CS is formed by a thin sellar part and a thicker sphenoidal part that, contrary to the lateral wall, are not easily separable. The sphenoidal part is frequently interrupted so that the intracavernous carotid is in direct contact with the pituitary gland in 52.5% of cases ,126. ConUsually, the remnant in the CS is treated with medical therapy or radiosurgery ,147,148.A 51-year-old female underwent a brain MRI for visual loss (R>L) that worsened over the last 2–3 months. MRI revealed a giant pituitary adenoma with a significant parasellar, suprasellar, retrosellar, and parenchymal extension . Not surprisingly, by considering the laterality of the lesion, the patient had lateral homonym hemianopsia . A staged resection was planned to entail a sublabial trans-sphenoidal resection of the intrasellar part and a left COZ approach aimed at a gross total resection . Postoperatively, the patients had a partial deficit of the left third and fourth cranial nerves that improved after one month . A 58-year-old female was affected by a giant Hardy type D pituitary adenoma with an asymmetrical growth pattern. The patient suffered from severe nausea, vomiting, left hemiparesis, and right third nerve palsy. The mass invaded the CS that was significantly extended beyond its lateral wall in the middle fossa. The cavernous carotid and right P1 segment of the posterior cerebral artery were encased, and the lesion also involved the right tentorial incisura and the petroclival region .A transcranial approach was indicated in this case and a COZ approach was performed.A 52-year-old female asymptomatic patient was incidentally diagnosed with a giant pituitary adenoma. The tumor showed a significant extra-sellar component in the suprasellar and sphenoid region and the left CS. The posterior communicating and anterior choroidal arteries were encased due to the involvement of the supraclinoid segment of the ICA . A left pterional approach was performed, achieving a near-total (>90%) resection of the tumor . The patient had a partial third cranial nerve deficit that recovered after three months . PatholoNot infrequently, sellar invasion Hardy grade IV and suprasellar extension Hardy grade C or D adenomas may involve the retrosellar or retroclival area. Grade IV tumors are characterized by extensive sphenoid bone erosion and dura erosion. This aspect is considered a feature of aggressive behavior   is associated with this occurrence ,225. WheDespite the popularity and outcomes achieved over the last two decades by endonasal trans-sphenoidal endoscopic techniques, transcranial approaches continue to hold a critical role in managing giant and more complex pituitary adenomas characterized by a wide intracranial extension, allowing gross total resection with good outcomes.As dopamine agonist treatment has offered a breakthrough in the treatment of prolactinomas, fostering the hope and anticipation that similar medical treatments will be as effective in the treatment of other hypersecreting adenomas which will mark another triumph in the management of pituitary adenomas and make surgery unneeded but for particular circumstances. Future directions of giant pituitary adenoma surgery involve improvements in preoperative evaluation, planning, intraoperative courses, and postoperative management. The advancement of neuroimaging techniques will allow us to precisely estimate the consistency of the tumor and the invasion of the CS, dura, leptomeningeal, and brain parenchyma . The bet


Branchial cleft cysts are birth defects that happen when the first through fourth pharyngeal clefts do not close properly and most of these cysts develop from the second cleft. Second branchial cleft cysts are almost always in the neck, so it is rare for them to present in the nasopharynx. We report an extremely rare case of a branchial cleft cyst that is located in an unusual site in the nasopharynx in a 36-year-old male with no prior medical history. Computed tomography scan findings showed non-enhancing thickening of the right side mucosal-pharyngeal space, obliterating the fossa of Rosenmuller with no invasion or erosion. The patient was admitted for nasopharyngeal mass excision, and the mass was sent for histopathology. When a cystic lesion is noted in the lateral nasopharynx, branchial cleft cysts should be on the list of possible diagnoses. Surgery is primarily the treatment. The marsupialization approach is a simple way to treat nasopharyngeal branchial cleft cysts as it is safe and has limited complications Branchial abnormalities are the result of aberrant branchial apparatus development during embryogenesis, which occurs between the second and sixth-seventh weeks of fetal life. Branchial remnants that are still present can result in the growth of cysts, sinuses, fistulas, or cartilage islands . BranchiBCC are frequently asymptomatic; however, they have tendency to grow, become tender, or become inflamed during episodes of upper respiratory tract infections, leading to the development of an abscess or secondary infections. In such circumstances, the patient may exhibit purulent sinus discharge to the skin or throat. Due to cyst compression of the upper airway, dysphagia, dyspnea, and stridor are the most alarming symptoms . BCC migCongenital BCC of the nasopharynx is quite rare and typically develops from the lateral nasopharynx with inferior and medial extension. The cysts often have a single, unilateral location and exude mucus. By means of their histopathologic presentation, imaging features, and particular nasopharyngeal localisation, they can be distinguished from other nasopharyngeal cancers . We repoA 36-year-old male patient suffering from allergic rhinitis visited the ENT clinic for regular check-up and medication refill. He was on PRN (administration as per need) treatment and had no other prior significant medical or surgical history. A nasopharyngeal scope was done for the patient, showing bilateral hypertrophy of the inferior turbinate and a nasopharyngeal mass on the right side of the nasopharynx obliterating the fossa of Rosenmuller. An enhanced CT scan of the neck with intravenous iodinated contrast was done for the patient. CT scan was preferred as the patient was claustrophobic and it was a faster procedure to follow. It showed non-enhancing thickening of the right side mucosal-pharyngeal space, obliterating the fossa of Rosenmuller with no adjacent soft tissue invasion and no erosion or vascular invasion Figure .The assessment of the ear was normal with bilateral intact tympanic membranes. Additionally, the hearing sensitivity as per pure tone audiogram was also normal and type A bilateral tympanogram was observed. The patient was admitted for nasopharyngeal mass excision which was performed through cold steel straight forceps and direct nasopharyngeal scope zero degree under general anesthesia and removed with straight cup forceps and microdebrider. An incision into the cystic lesion under the view of rigid zero degree telescope through the nasal cavity was made. Multiple punch biopsies including full thickness of the cystic wall were taken for histopathological examination and the entire remaining lesion was cleaned out with the assistance of microdebrider. Grossly, the mass consisted of two fragments of grey-tan soft tissue. The first measured 2x0.5x0.5 cm and the second fragment measured 1x0.4x0.4 cm. Microscopic examination showed that the cystic cavity was lined by pseudostratified columnar epithelium underlying the connective tissue exhibiting lymphoid tissue and the cystic lumen was lined by ciliated pseudostratified epithelium . No clear complications or recurrences were seen after the surgery. Transoral marsupialization is a way to treat nasopharyngeal BCC that is easy, effective, and less invasive . SimilarNasopharyngeal BCC is a rare lesion that can be observed as an incidental finding however it can also present with nasal obstruction symptoms. Histopathological findings confirmed the diagnosis of nasopharyngeal BCC in our case. Therefore, the location of the lesion and histopathological diagnosis is crucial for the diagnosis of nasopharyngeal BCC. CT scan is sufficient for assessment and diagnosis while MRI can be used for pediatric patients. Surgical excision is the most effective treatment for management and to rule out serious differential diagnoses.


Duodenal hemangiomas are benign vascular tumors caused by haphazard vascular proliferation within the duodenal wall. Although rare, duodenal hemangiomas could lead to rapidly progressive life-threatening gastrointestinal (GI) bleeding that requires urgent intervention. The diagnosis of duodenal hemangioma often requires direct visualization of the lesion either endoscopically or surgically, as well as histopathological examination. Treatment options include endoscopic resection, laser coagulation, sclerotherapy, or in a specific subset of patients, open or laparoscopic surgical intervention.We herein report a case of a 46-year-old female presenting with signs and symptoms of chronic GI bleeding. The patient underwent upper endoscopy and was found to have an ulcerated mass in the proximal duodenum consistent with the diagnosis of duodenal hemangioma. This case highlights the importance of including duodenal hemangioma in the differential of upper GI bleeding. It also underscores the significance of surgical intervention in treating duodenal hemangioma, as well as the crucial role of employing endoscopy in the diagnostic and therapeutic management of this condition. Hemangiomas are benign vascular tumors that typically originate from the submucosal layer of blood vessels . They teWe describe a case of a 46-year-old patient presenting with weakness, fatigue, and melena. Endoscopy revealed the presence of an ulcerated oozing duodenal hemangioma. The tumor was resected using an open surgical technique leading to the complete resolution of the patient's condition.A 46-year-old female presented to the emergency department complaining of generalized weakness for one-week duration. Her past medical history was significant for hypertension and heart failure with a preserved ejection fraction (EF) of 50%, both of which were diagnosed seven months ago. Her medications included candesartan, furosemide, and multivitamins. On physical examination, the patient looked pale and fatigued. She was conscious, alert, and oriented to time, place, person, and situation. Her abdomen was soft with no palpable masses or organomegaly.On further questioning, the patient reported generalized weakness and fatigue that developed sub-acutely over the course of a few days. She also had palpitations, bilateral lower limb myalgia, and tar-colored stools for the past month. During that time, laboratory investigations including a complete blood count (CBC) revealed a hemoglobin of 6 g/dL (N=12.1-15.1 g/dL). Subsequently, the patient was admitted to the hospital and had two packed red blood cell transfusions. The patient's symptoms and hemoglobin subsequently improved leading to discharge five days post-admission.Three days post-discharge, the patient developed hematemesis of dark-colored blood, which was intermittent and estimated as one full cup in amount. Furthermore, the patient complained of recurrent generalized weakness, fatigue, and anorexia. She was readmitted to the hospital and stabilized with aggressive intravenous (IV) fluid therapy and proton pump inhibitors. A complete metabolic workup including electrolytes, liver, and kidney function tests was unremarkable. Abdominal computed tomography (CT) with IV contrast revealed focal polypoidal non-enhancing wall thickening seen at the second part of the duodenum, along with multiple non-enhancing cystic lymph nodes seen in the retrocaval, para-aortic, and the right peri-renal spaces. In addition, a small homogenous liver mass was detected. Put together, the findings were suspicious for a duodenal malignancy with metastatic lymphadenopathy. Consequently, an upper endoscopy was performed and revealed a 2 cm ulcerated actively bleeding mass located on the post-bulbar lateral wall of the duodenum opposite to the ampulla of Vater Figure .On the second-day post-admission, a right subclavian central line was applied and the patient was started on total parenteral nutrition (TPN). Input-output charts were recorded along with an order to repeat CBC every 12 hours to monitor for deterioration. On the fifth day post-admission, a pre-operative assessment was done and two units of packed RBCs were transfused. The patient subsequently underwent explorative laparotomy, during which a small firm non-mobile lesion was found at the antimesenteric border of the second part of the duodenum measuring about 1×2 cm. Small preduodenal cystic lymph nodes were also observed. The surgeon then performed wedge resection of the duodenal mass and the preduodenal lymph nodes, after which an abdominal drain at Morrison's pouch was inserted. The specimens resected were sent for histological examination, which confirmed a venous hemangioma involving the submucosa, muscularis propria, and surrounding adipose tissue Figures -2F. AddiPostoperatively, the patient was transferred to the surgical ward for observation. She was kept on nothing-by-mouth (NPO) status. A nasogastric (NG) tube was inserted, and IV fluids along with antibiotics and analgesics were administered.The patient continued to improve leading up to the removal of the central line and the NG tube. Oral feedings were then attempted with good tolerance. She was discharged with an abdominal drain on day six post-operatively in good general condition with no complaints. The patient was counseled to follow-up at an outpatient clinic and showed marked improvement over the next few months with no signs of recurrence.Intestinal hemangioma is a rare benign overgrowth of the submucosal vessels characterized by vascular and endothelial proliferation of the submucosal vascular bed in the intestine. It most commonly presents in young adults in their 20s, however, there are a few cases reported in the pediatric population . ConversOn histopathological examination, small intestine hemangioma is classified into three types according to the type of vessel involved. These include cavernous hemangioma, which is the most common type, as well as capillary and mixed types . The hisThe clinical presentation of duodenal hemangioma varies broadly. The mass can be discovered incidentally during the performance of an endoscopic procedure, or have non-specific non-localizing signs and symptoms. Similar to our patient, most cases typically present with signs and symptoms related to chronic GI bleeding and anemia. While other cases present with life-threatening GI bleeding that requires hemodynamic stabilization and urgent management with aggressive fluid therapy and blood transfusions . On the The differential diagnosis of duodenal hemangioma is wide and includes the whole differential of upper GI bleeding. Thus, the implementation of a comprehensive history and physical examination, as well as radiological imaging and endoscopy, is crucial for differentiating between the various etiologies and reaching a final diagnosis .One of the important modalities utilized for diagnosing duodenal hemangiomas is upper endoscopy which provides a gross and microscopic visualization of the lesion, as well as therapeutic options including hemostatic clipping, endoscopic sclerotherapy, end loop snare, and endoscopic mucosal resection ,21. As sThe mainstay therapy for duodenal hemangiomas after stabilization is open or laparoscopic surgical resection. Poor surgical candidates and patients with active GI bleeding typically undergo upper endoscopy with electrocoagulation, sclerotherapy, endoscopic mucosal resection (EMR), or argon plasma coagulation (APC) . CurrentIt is important to point out that the differential diagnosis for our case is broad, including more common etiologies of upper GI bleeding such as peptic ulcer disease, esophagitis, gastritis, varices, and angiodysplasia among other causes . This hiDuodenal hemangioma is a rare cause of upper GI bleeding that commonly presents with non-specific signs and symptoms, often rendering the diagnosis delayed and difficult. Comprehensive clinical and radiological investigations, as well as microscopic examinations, are often needed to establish a definitive diagnosis. The diagnostic and therapeutic utility of minimally invasive procedures such as endoscopy makes it a preferable choice in the management of duodenal hemangiomas in a specific subset of patients. However, large lesions, as well as those with transmural involvement, and/or those with nodal and extra-nodal involvement, often prompt the need for open or laparoscopic surgical intervention.


We present the case of a 72-year-old man with a three-month history of epigastric pain. A physical examination revealed a tender, hard mass around the epigastric area. Enhanced CT showed no chest or abdominal abnormalities, except for a large xiphoid process. The diagnosis was xiphodynia caused by a large xiphoid process. Xyphoidynia should be considered a differential diagnosis for epigastric pain. The differential diagnosis for epigastric pain varies as it encompasses conditions including cardiac diseases and abdominal diseases such as gastroesophageal reflux disease (GERD) and Helicobacter pylori-related ulcers . HoweverA 72-year-old Japanese man presented with chronic epigastric, not-so-severe, dull pain and nausea that had persisted for the previous three months. His medical history revealed hypertension, for which he was taking medication (losartan 50 mg/day). The patient was of medium build and had no history of chest or abdominal surgery. He retired from work seven years ago; however, he reported undertaking do-it-yourself (DIY) projects as a hobby. During physical examination, a tender, hard mass was detected around the epigastric area. A blood examination, electrocardiography, abdominal ultrasound examination, and gastroscopy detected no abnormalities. Enhanced CT revealed no chest or abdominal findings except for a large xiphoid process, measuring 6 cm Figure . Based oThe epidemiological characteristics of xiphodynia remain unclear. Joint damage, potential subluxation, and other diseases such as OA and RA may be caused by xiphodynia . SymptomThe primary treatment for xiphodynia is conservative, involving NSAID treatment. If no improvement is observed, several local xylocaine or steroid injections may be necessary. Yet, if no improvement is observed, surgery may be effective . OlivencOccupations involving heavy lifting, childbirth, trauma to the lower chest or abdomen, and anatomical variation of the xiphisternal angle are thought to be risk factors ,7,8. StoHerein, we describe a case of xiphodynia that may have originated from a large xiphoid process in a patient without any precipitating factor or known underlying disease for this process. Our case highlights that xiphodynia should be considered a differential diagnosis after excluding other more common pathologies in cases of induration of the xiphoid process with tenderness. A large-sized xiphoid process possibly constitutes a risk factor for xiphodynia.


Extraskeletal osteosarcoma (EOSA) in dogs is a rare malignant mesenchymal tumor of somatic soft tissues or more commonly visceral organs with a poor prognosis. In dogs, EOSAs have been described as arising from multiple locations, but differently from humans, never from a main vessel. In this report, we describe the first case of an EOSA arising from the post-hepatic caudal vena cava in a 7-year-old male neutered mix breed dog. This report focuses on the description of the diagnostic challenges to obtain a preoperative diagnosis, highlights the importance of histopathology for a correct diagnosis, and introduces a new differential diagnosis for an animal presenting with a suspected thrombus of the vena cava. Extraskeletal osteosarcoma (EOSA) in dogs is a rare malignant mesenchymal tumor of somatic soft tissues or more commonly visceral organs that is characterized by the production of osteoid without involvement of bone or periosteal tissue. An exception to this definition is mixed malignant tumors of the mammary gland and thyroid (carcinosarcomas), where osteoid production is considered to be related to stromal metaplasia associated with adenocarcinomas . EOSA isIn humans, EOSA is also a rare tumor and tends to arise more commonly from the soft tissue of the extremities rather than from visceral organs . A few pThe purpose of this case report was to describe an EOSA arising from the post-hepatic caudal vena cava in a dog, adding to the list of the differential diagnoses that ought to be considered and highlighting the need to biopsy the mass for obtaining a correct diagnosis.A 7-year-old, 6.4-kg male neutered mixed-breed dog was presented to his primary veterinarian for a 5-day history of anorexia, polyuria/polydipsia, non-specific gastrointestinal signs, and a rapid onset of abdominal distension. Physical examination was unremarkable, except for moderate to marked abdominal distension and the presence of palpable fluid wave. A serum biochemistry analysis, complete blood count (CBC), canine-specific pancreatic lipase, pre-prandial bile acids, and urinalysis were performed, and findings are reported in Due to the abnormal liver values, gastrointestinal symptoms, and the suspected presence of abdominal effusion, the dog was started on supportive therapy  and was referred to a specialty hospital for an abdominal ultrasound. An abdominal ultrasound was performed by a board-certified veterinary radiologist and showed changes consistent with non-specific hepatopathy, pancreatitis, and a single small splenic nodule. The remainder of the ultrasonogram was considered normal. An abdominocentesis was performed using a 25-g needle, and 1 ml of pink, hazy fluid was collected and submitted for fluid analysis. Fluid analysis was consistent with a transudate  with a mixed population of reactive mesothelial cells, macrophages, and degenerate neutrophils. No neoplastic cells were identified.Based on the results of the tests, a tentative diagnosis of non-specific hepatopathy and pancreatitis was made.The dog was returned to the primary veterinarian 2 days after the visit to the specialty hospital to have bloodwork repeated. CBC, serum biochemistry, canine-specific pancreatic lipase, and bile acid values are reported in Due to a lack of improvement in clinical signs 3 weeks after the initial visit to the primary veterinarian, the dog was referred to Colorado State University (CSU) internal medicine service for a second opinion. On physical examination, the main abnormalities noted were a severely distended abdomen with prominent subcutaneous vessels of the abdominal wall, mild dental tartar, and soft stools on rectal examination. Bloodwork comprising a CBC, total protein, bile acids, blood gas analysis, Texas GI panel, and basal cortisol was performed. CBC showed mild regenerative anemia and mild neutrophilia. Total protein level was improved from the previous examination, making hypoalbuminemia unlikely to be the cause of the ascites. Pre-prandial bile acids were increased. The blood gas analysis showed marked hypokalemia, likely related to the chronic abdominal effusion. The Texas GI panel showed low folate, possibly indicative of proximal intestinal malabsorption, while basal cortisol was normal .The dog was discharged with the plan to continue with the diuretic therapy and to reduce the frequency of Denamarin administration.Two weeks after the initial visit , the dog returned to CSU to have an abdominal ultrasound, and liver biopsies were performed.Blood for serum biochemistry and coagulation panel was collected before the abdominal ultrasound. The results showed persistent hypoalbuminemia and a mild elevation of activated partial thromboplastin time, elevated D-dimers, and a low quantitative fibrinogen. The dog was sedated, and 1 L of serosanguinous fluid was drained from the abdomen to facilitate imaging but not submitted for analysis. An abdominal ultrasound focused on the liver and hepatic vasculature identified diffusely hyperechoic and heterogeneous liver parenchyma and a large echogenic post-hepatic thrombus in the vena cava. The absence of blood flow was identified within the thrombosed lumen on Doppler interrogation , left. CSupplementation of vitamin B12 (100 mcg/kg SID) and folates (75 mg/kg SID) and a newly selected protein diet  were started to treat the suspected lymphangiectasia. Liver metal analysis revealed an increased iron value  and normal copper value . No bacterial growth was identified on the liver biopsy culture.The dog's ascites did not improve after 2 weeks from starting the new therapy. Apixaban (0.25 mg/kg BID) was added to help resolve the caudal vena cava thrombus. Still, the clinical signs did not improve and an abdominocentesis had to be performed weekly, removing 300–500 ml of fluid each time. An abdominal ultrasound was repeated a month after initiating medical therapy and did not show any reduction in the size of the suspected thrombus. Surgical removal of the thrombus or caudal vena cava stenting was re-offered as a treatment option but declined by the owner due to financial constraints. The dog was continued on the same medical therapy previously prescribed.One month after the last appointment , because of the persistent severe ascites requiring frequent abdominocentesis, the owner elected to have a computed tomography (CT) scan of the abdomen performed in preparation for surgical thrombectomy. The dog's physical examination was unchanged. CBC, serum biochemistry, and coagulation panel were repeated. The CBC showed an increase in the reticulocyte count. The serum biochemistry showed hypoproteinemia and hypoalbuminemia and a minimally increased ALT. Activated partial thromboplastin time and prothrombin time were normal. The dog was also blood-typed and was DEA 1.1-negative. Thoracic radiographs were obtained before surgery and showed a mild diffuse interstitial pattern throughout the pulmonary parenchyma, an enlarged caudal vena cava, and no evidence of metastatic disease. The dog was anesthetized, and a CT examination with an angiogram of the abdomen revealed the presence of a large amount of mixed soft tissue/mineral attenuating material in the caudal vena cava and left hepatic vein . The thrDue to the irresectability of the mass, poor clinical condition of the dog, and the suspected neoplastic process, the owners elected to euthanize the dog under general anesthesia and consented to perform a necropsy. The gross necropsy findings revealed a slightly enlarged and diffusely congested liver with rounded edges and a 5 cm × 2 cm-firm, tan, proliferative mass expanding and completely occluding the vena cava and a branch of the left hepatic vein. On microscopic examination, the caudal vena cava mass was composed of spindle-to-stellate neoplastic cells organized in streams and whorls embedded within mildly fibrous stroma that contained multiple branched fibrillar eosinophilic material consistent with osteoid . ImmunohIntravascular neoplasia is rarely reported in the human literature, with leiomyosarcoma being the most common tumor arising from the inferior vena cava , 16. OstA definitive diagnosis of an intravascular tumor is often delayed in human medicine because of the difficulty of differentiating between the presence of mass from a bland thrombus and the rarity of these tumors making them unlikely to be considered as a differential diagnosis . The samCommonly, a combination of different imaging techniques, such as ultrasound, CT, and magnetic resonance imaging, is used to obtain a definitive diagnosis of thrombus vs. intravascular neoplasia . Bland tWhen the CT angiogram was performed, the mass was minimal-to-no contrast enhancing compared to the pre-contrast images. This is in accordance with what was noted in a case of chondroblastic osteosarcoma of the pulmonary artery , and thi18F FDG PET-CT)  . Becauseeoplasia .18F FDG PET-CT would have been a more accurate method of staging to confirm that the caval mass was the primary with no other neoplastic lesions as small osseous lesion could have been missed on necropsy.Negative prognostic factors reported for human patients affected by inferior vena cava tumors are the presence of Budd–Chiari syndrome, suprahepatic location of the tumor, intraluminal tumor growth, and inferior vena cava occlusion . The curIn conclusion, this case report describes for the first time in veterinary literature the presence of an EOSA arising from the post-hepatic caudal vena cava in a dog. Even if rare, EOSA should be added to the list of potential differentials in animals with intravascular neoplasia. The difficulty in diagnosing these EOSAs stems from the rarity of these tumors. Because of their asymptomatic nature, they remain silent for most of the disease course and are usually found due to their mass occlusive or space-occupying effect, as in human cases . Surgicagiovanni.tremolada@colostate.edu.The datasets presented in this article are not readily available because, this is a case report, no data set was produced. Bloodwork and imaging of the case can be shared upon reasonable request. Requests to access the datasets should be directed at: Ethical approval was not required for the studies involving animals in accordance with the local legislation and institutional requirements because the animal was treated according to standard of care and no experimental procedures were performed. Written informed consent was obtained from the owners for the participation of their animals in this study. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.GT prepared the first draft. GT, AM, LG, and TA managed the patient or interpreted the imaging tests or performed the necropsy/interpreted the histopathology and contributed to conception of the case report. All authors contributed to manuscript revision, read, and approved the submitted version.