We report the case of a lip epidermoid cyst, caused by piercing in a 23-year-old Japanese woman. She had an exophytic lesion in the lower lip associated with the piercing which was initially diagnosed as a mucous retention cyst. The lesion was resected under local anesthesia, and pathological examination revealed an epidermoid cyst, likely caused by piercings. Piercing-induced epidermoid cysts frequently occur in the tragus. There have been no reports of piercing-induced epidermoid cysts developing in the oral cavity. To our knowledge, this is the first report of a lip epidermal cyst caused by piercings. Six months have passed since the operation, and it has not recurred. Body piercings have emerged as a component of recent fashion trends. They are worn on the ears and oral region, specifically the tongue and lips . EpidermThe patient was a 23-year-old Japanese woman with unremarkable medical and family histories. Five years prior, she had her lower lip pierced, such that it penetrated the left side of the lip and the skin. She stopped wearing her piercings after a few months, and the piercing holes closed spontaneously. Wound indurated or swelling was not noted.When she was 22 years old, she had her left lower lip pierced again. The earrings were inserted twice. However, the pierced hole from the first set of piercings had been occluded. A mass appeared on the lower lip two months later, and the patient reported to our department due to its persistence.Intraoral examination revealed a palpable mass, measuring approximately 4 × 4 mm, on the left lower lip. The piercing was in contact with the mass and penetrated the skin and mucosa of the lower-left lip Figures  and 2.She was clinically diagnosed with a mucous retention cyst of the lower lip. She was instructed to stop using her piercings two weeks before undergoing the lesion resection. The pierced hole was closed intraoperatively. The lesion and the scar on the pierced hole were resected under local anesthesia. Histopathological examination revealed a keratin-containing cyst covered with keratinized stratified squamous epithelium. Therefore, the patient was pathologically diagnosed with an epidermoid cyst .One year has passed since the operation, and the wound has resolved without infection or recurrence Figures  and 5.Piercings has been often applied to the tragus. Piercing complications in the tragus reportedly occur in 35% . PiercinEpidermal cysts are soft tissue cysts that commonly develop in the head and neck regions. Congenital causes are associated with invasion and residual embryonic ectoderm. These causes acquired epithelial tissue invasion, such as trauma and inflammation .Kim et al. reported that 14 out of 132 people with tragus piercing complications have experienced epidermoid cysts . EpidermEpidermoid cysts are attributed to epithelial invasion and remnants at the ectodermic fusion in the congenital and to the implantation of keratinized epithelium by trauma in the acquired cases , 8. EpidChen et al. were the first to report the complications of oral piercings in 1992, and several cases have been reported after that . The majThe process of receiving piercings is invasive, but the publicity materials on its complications have been few.Since piercings have emerged as a component of the recent fashion trends, cases like the present case may become more common in the future. Thus, dentists and oral surgeons should consider this a differential diagnosis. Moreover, people should be informed regarding the potential complications and risks associated with oral piercings.


Gastric neuroendocrine tumors (GNETs) are rare and subdivided into type I, type II, and type III. Types I and II are gastrin-dependent and are usually benign, whereas type III is gastrin-independent and more aggressive. Type I accounts for 70-80% of all GNETs. Most of them are asymptomatic and incidentally detected on endoscopy. It can sometimes present with iron and B12 deficiency, dyspepsia, and less commonly with an upper GI bleed.We present a case of type I GNET who came to the hospital with melena and esophagogastroduodenoscopy (EGD) showing a 3-cm bleeding polyp and histopathology revealing a well-differentiated neuroendocrine tumor with angioinvasion. Gastric neuroendocrine tumors (GNETs) are rare tumors with a prevalence of 0.17 per 10,000 in the United States .Based on etiology, pathogenesis, and histopathological behavior, GNETs are divided into three subtypes - type I, type II, and type III. Both types I and II arise from enterochromaffin-like cells (ECL cells) and are related to hypergastrinemia. The basis for the elevation of gastrin levels in type I is hypochlorhydria secondary to chronic atrophic gastritis (CAG). In type II, the hypochlorohydria is due to Zollinger-Ellison syndrome (ZES) and multiple endocrine neoplasia type 1 (MEN1) -5. Type A 63-year-old female with a history of hypothyroidism, hypertension, and ductal carcinoma in situ status post right partial mastectomy presented to the hospital with melena of three days. Upon admission, she stated generalized weakness and fatigue for two weeks but did not report nausea, vomiting, abdominal pain, hematochezia, diarrhea, or constipation. The patient had orthostatic hypotension on presentation. The laboratory tests were pertinent for hemoglobin of 6.3 g/dl (no baseline available); mean corpuscular volume of 108.7; red cell distribution width of 30. Vitamin B12 (135 pg/ml), iron (12 µg/dl), and ferritin (23.4 ng/ml) were low with normal folate levels. She received one unit of packed red blood cells, after which repeat hemoglobin increased to 7.4 g/dl. The patient had elevated serum gastrin (1988 pg/ml) and chromogranin A (CgA) levels (300 ng/ml) and normal 5-hydroxyindoleacetic acid (5-HIAA) level in urine (8.4mg/ml). Esophagogastroduodenoscopy (EGD) and colonoscopy were performed to localize the source of bleeding. Colonoscopy was unremarkable. EGD showed a 3 cm polypoidal, ulcerated, friable, bleeding mass lesion in the body of the stomach Figure . EGD alsSnare polypectomy was done, and to control bleeding, two clips were applied, and an epinephrine injection was given. Gross appearance showed a 3.5 x 3.0 x 2.8 cm mass with a 0.9 x 0.8 cm base (deep resection margin). Microscopically, the mass was composed of tumor cells, which were relatively monotonous and arranged in predominantly glandular structures Figure . This tuCT scan of thorax and abdomen showed no evidence of metastasis. The patient was discharged on cyanocobalamin 1000 mcg weekly for four weeks and then monthly, with follow-up endoscopy in three months. Type I GNETs account for 70-80% of GNETs, arise from the ECL cells hyperplasia, and are associated with hypergastrinemia due to CAG. Type II accounts for 5-6% of GNETs and is associated with hypergastrinemia due to Zollinger-Ellison syndrome and MEN-1. In both types I and II GNETs, the arousing factor is hypergastrinemia with different etiology. An increase in gastrin levels causes stimulation of ECL cells, which leads to cellular hyperplasia and dysplasia, resulting in GNETs ,4,6. TypType I GNETs are prevalent in older women often diagnosed in their 60s . They arGNETs typically present with non-specific symptoms and are found incidentally on endoscopy. They may present with iron and vitamin B12 deficiency .The mainstay of GNETs diagnosis is endoscopy and biopsy. Endoscopically, in about 65% of cases, type I GNETs appear as multiple, small, red, or yellow sessile polypoidal or smooth hemispherical lesions in the gastric fundus or body, involving the mucosa and the submucosa. In about 22% of patients, lesions may be found microscopically for biopsies taken for other reasons ,14. WhenEndoscopic ultrasound may help assess the exact depth of the tumor and lymph node metastasis, but its exact clinical usability and diagnostic capability are questionable ,14. CT oBiopsy of the polyp should establish the diagnosis of GNET, and biopsy of the non-polypoidal area usually establishes associated CAG . HistoloThe European Neuroendocrine Tumor Grading system is usually used to grade GNETs. This system uses mitotic activity in 10 high-power fields and a percentage of the Ki-67 index. Based on this, GNETs are divided into grades 1, 2, and 3. They are classified as grade 1 when mitotic activity is <2 and/or Ki-67 index is less than 3%, grade 2 when mitotic activity is two to 20 and/or Ki-67 percentage is 3-20%, and grade 3 (neuroendocrine carcinoma) when mitotic activity is > 20 and or Ki-67 percentage is > 20% . Our patThe management options available for type I GNETs include medical management, endoscopic surveillance, or surgical management . The medType I GNETs are usually benign, and a minority of patients develop lymph node metastasis, and very few develop distant metastasis. The risk of metastasis is <5% . TsolakiType I GNETs can present with a wide variety of symptoms, including upper GI bleed. With an increase in the incidence of GNETs, physicians should be aware of the different presentations of GNETs. For tumors more than 1 cm, exact factors to decide for surgical resection or endoscopic resection were not clearly proposed. So, we are recommending further studies to establish exact guidelines regarding management and follow-up of type I GNETs more than 1 cm while considering all the poor prognostic factors.


Staphylococcus aureus infection. Here, we present a rare case of a female patient who presented to N.N. Burdenko Neurosurgical Center for treatment of an extradural tumor in the lower lumbar spine. She complained of acute lower back pain, lower limb muscle spasms, progressive lower limb weakness, numbness in toes, and increased frequency of defecation (five to six times per day). Intraoperatively, we discovered that the epidural space was clear and a subdural abscess was located and removed. The patient was started on antibiotics and recovered 29 days later. This case report illustrates an atypical SSA mimicking an extramedullary tumor on MRI.Spinal subdural abscesses (SSAs) are rare pathologies presenting as encapsulated pus located intradurally and extramedullary. Although there is no uniform opinion on the cause of this pathology, approximately 50% of cases are attributed to  Staphylococcus aureus infection, they present as demarcated collections of pus located intradurally and most commonly in the lumbar spine [S. aureus (50% of cases), although other pathogenic organisms can also cause SSAs [Spinal subdural abscesses (SSAs) are considered an extremely rare pathology in spinal surgery. Mostly attributed to ar spine -3. Patieuse SSAs -4.Although MRI is the study of choice, imaging characteristics of SSAs on MRI are not well described. Basic findings include a space-occupying, variably enhancing mass in the spinal canal. Fat-suppression and diffusion-weighted images (DWI) aid in diagnosing SSAs ,5.S. aureus that was treated at our facility.The treatment of choice for SSAs is decompressive surgery (laminectomy) with antiseptic irrigation and drainage of the subdural space followed by appropriate antibiotic therapy. Cultures should be obtained before wound irrigation for the definitive diagnosis of the pathogenic organism ,3,6,7. HA 49-year-old female was referred to our department for the surgical treatment of an extradural tumor, with complaints of acute lower back pain, lower limb muscle spasms, progressive lower limb weakness, numbness in toes, and increased frequency of defecation (five to six times per day). Symptoms manifested approximately 1.5 months prior to admission with an acute onset of lower back pain, for which she was treated conservatively with no clinical effect. An MRI scan of the lumbar spine revealed an extensive extradural tumor at the level of Th12-S2 vertebrae, covering the dural sack and roots with a right-sided presacral paravertebral spread at the S2-S3 level. She had no surgical history and was hospitalized with right lower limb venous thrombosis, mild urinary infection, and chronic colitis, which were not considered a surgical risk.Upon admission, secondary MRI scans revealed an extradural mass-like lesion at the level of Th12-L5 vertebrae and another lesion at the S2-S3 level . This was initially attributed to the patient’s urinary tract infection (UTI). Urinalysis on admission showed an increased WBC count  and bacteria in urine sample . The patient was started on factor Xa inhibitors for thrombosis, stopped 12 hours prior to surgery, peroral baclofen for lower limb muscle spasms, and peroral norfloxacin for her UTI. Urinalysis performed on the morning before surgery showed a marked decrease in WBC count  and no bacteria in the urine sample.On laboratory tests, inflammatory markers were elevated  daily for 15 days. Intravenous (IV) vancomycin 1 g every six hours was administered for 12 days, followed by IV amoxicillin 1.2 g every eight hours for 14 days based on antibioticogram results. After the surgery, the preoperative MRI was thoroughly analyzed. One large and one small abscess in the pelvis were found, which we missed preoperatively and considered being an extension of the spinal abscess into the pelvis , and bowel dysfunction regressed completely. The patient was discharged 22 days after the surgery, with two consecutive microbiological examinations of wound content taken from the drainage system verified as sterile. Upon discharge, a control MRI scan was obtained. No pelvic abscess was found on the MRI scan . To our knowledge, its exact incidence is unknown ,7. It isS. aureus (over 50% of reported cases). Other pathogenic organisms include various Staphylococcus species, Streptococcus, Escherichia coli, Pseudomonas aeruginosa, S. pneumoniae, and Peptococcus magnus [S. aureus that caused the SSA that spread into the pelvis. To our knowledge, there are no reported cases of spinal intradural abscesses associated with abscesses in the pelvic region.The lumbar spine is the most common region for SSAs which are typically attributed to s magnus -3,5. In Clinical signs and laboratory findings of spinal infections can be subtle and misleading . Fraser A key diagnostic feature of SSA is the absence of spinal muscle tenderness on spinal percussion, which helps differentiate this process from the more common spinal epidural abscess; however, Levy et al. found 14 of the 47 patients they reviewed to have spinal tenderness ,9. In ouLeukocyte count, ESR, and CRP are not sensitive indicators of spinal infection but are usually elevated . In our The definitive diagnostic study of choice is a contrast-enhanced MRI. It allows good visualization of the spinal cord, bony and ligamentous tissues, intervertebral discs, the extent of lesion, and compression. Because there are only a few published cases on imaging characteristics of SSAs, exact MRI findings are not well described. Although MRI is the study of choice, SSA is a surgical diagnosis as it may be difficult to differentiate subdural from epidural infection. Fat-suppression sequence and DWI can be useful tools in differentiating abscesses from tumors ,3,5.In accordance with the aphorism “ubi pus, ibi evacua,” surgery followed by appropriate antibiotic therapy is considered the mainstay of treatment. Prompt decompression (laminectomy) with antiseptic irrigation and drainage of the subdural space, followed by antibiotic therapy is considered the conventional treatment approach. Pus cultures for identifying a definitive pathogenic organism are mandatory and should be obtained before wound irrigation. Most studies advocate primary water-tight dural closure. In regards to placing external drains for postoperative irrigation, this has not been adopted as a part of the conventional treatment approach. Although there is some data concerning successful conservative treatment, overall prognosis is considerably better for patients who undergo surgical treatment. Bartels et al. reviewed 45 patient treated for SSAs. In the surgical group, 82.1% completely recovered or improved and 17.9% died. In the conservative group, 80% died and 20% improved. These numbers correlate with the current treatment mainstay for aggressive surgical treatment followed by antibiotic therapy ,7.In our case, the patient had no obvious evidence of SSA and was misdiagnosed with an IDEM tumor. We consider this to be caused by an atypical presentation of SSA associated with an abscess in the pelvic region. A thorough inspection is needed in the presence of heterogeneous diffuse lesions on MRI in the lumbar region.


Skenitis refers to the infection of the Skene's glands. Skene's glands are paraurethral glands localized on the upper wall of the vagina. The diagnosis of Skene's glands abscess or infection is usually made based on the history and physical examination, but half of women with para-urethral gland symptoms present with non-palpable lesions and necessitate further evaluation with imaging. Patients may present with chronic urethral pain, recurrent urinary tract infections, unexplained dyspareunia, and dysuria. At imaging Skene's glands are typically located on the anterior vaginal wall, at symphysis level and paramedian to urethra. Clinicians should consider Skenitis in the differential diagnosis of lower urinary tract symptoms. We report a case of a 48-year-old woman with acute lower urinary tract symptoms with a final diagnosis of Skene's glands abscess. Skene's glands are paraurethral glands localized on the upper wall of the vagina; infectious process of Skene's glands (Skenitis) can cause the obstruction of paraurethral ducts A 48-year-old woman referred at our hospital complaining urgency dysuria, dyspareunia, and discharge. She was under antibiotic therapy for the last 5 days (ciprofloxacin 500×2) with no relief of symptoms, urinalysis was negative. On examination, she was febrile with lower abdominal tenderness.3/mm3 , neutrophils 84,9% , creatinine 0,54 mg/dl , C reactive protein 12,64 mg/dl . A Foley catheter was inserted into the bladder to drain urine. Catheter was clamped and transabdominal ultrasound was performed. Left kidney calico-pelvic mild dilatation was detected . During pelvic ultrasound examination, the patient referred intense pain. The bladder was mildly distended  , and a fluid filled mass with a thick central septum was visualized . The fluid mass content was slightly inhomogeneous, the fluid mass presented thick walls and the perilesional fat was inhomogeneous , the lesion was placed inferiorly to the bladder After emptying the bladder, the catheter seemed to pass through the middle septum , hematocrit 39.9 % , white blood cell count 13,2 10e septum . An ultrAt transvaginal ultrasound, a bilocular cyst with a non-vascularized septum, low level content and regular walls, below the bladder and anterior lateral to the urethra was visualized. There was no communication between the cyst and urethra .Fig. 3  with contrast was performed. The fluid filled mass was appreciable lateral to the external urethral meatus and inferior to the pubic symphysis. At MR imaging, the lesion was oval, hyperintense on T2-weighted images. The walls were thick and there was perilesional fat stranding. The infectious was suspected on the basis of lower T2 signal, higher T1 signal and wall enhancement  and 5. AAt surgery, the abscess was treated with the technique of marsupialization. A vertical incision was made on the anterior vaginal wall, the abscess drained spontaneously, the cavity was copiously irrigated with betadine. Sutures were positioned to evert the cyst wall. The cultural exam revealed infection sustained by Escherichia Coli and Staphyloccoccus Haemolyticus.The normal female urethra is 3–4 cm in length, suspended to the pelvic sidewall and “pelvic fascia” by the urethropelvic ligament, which is composed of two layers of fused fascia. Masses that present adjacent to the urethra or at the meatus between the “fascia” layers, arise from the vaginal wall,or the urethra itself In female patients with lower urinary tract symptoms, S S Skene's glands abscess and cyst should be included in the differential diagnosis. Although rarely reported, the disease can be underestimated. Characteristically imaging appearance and location can help to rule out this diagnosis.Patient's consent not required as patient's identity is not disclosed or compromised.


We present the case of pleiomorphic liposarcoma in the medial compartment of the thigh of a 59-year-old female patient. The lump was noticed eight months prior to presentation and had gradually increased in size, leading to pressure symptoms in her thigh. Although painless initially, the lump eventually became tender prompting her to seek surgical attention. At the plastic surgery clinic, she was advised to get an MRI, which revealed an irregular but well-defined mass lesion measuring 8.2 x 6.6 x 4.3 cm. The mass did not have any manifestations in the surrounding structures. A wide excisional biopsy was then performed, and multiple sections were processed for histopathological analysis, confirming a diagnosis of epithelioid variant of pleomorphic liposarcoma. Liposarcoma is the most common malignant soft tissue tumour in adults. They are mesenchymal in origin and are usually large, occurring most frequently in the lower extremities , retroperitoneal, perineal and mesenteric region and shoulder area . The comA 59-year-old female patient presented to a plastic surgery clinic with a lump on her right medial thigh. She noticed the lump eight months ago and it was gradually increasing in size. It was painless initially; however, the lump gradually became tender. The patient was otherwise fit and well with no co-existing morbidities. Closer examination of the right thigh revealed a high consistency mass, with reduced mobility. There was no right inguinal lymphadenopathy or lymph nodes enlargement. Laboratory blood tests were unremarkable. An MRI scan was requested to further assess the mass, which was irregular but well-defined in the medial compartment of the thigh, measuring 8.2 x 6.6 x 4.3 cm in size. The mass showed an intermediate signal on both T1 and T2-weighted imaging, appearing hyperintense compared to the adjacent muscular tissue, which also persisted on fat-suppressed imaging. The mass invaded the intramuscular fat planes and caused compression and displacement of the adductor muscles. There was no evidence of intra-muscular invasion. Normal cortical outline and medullary signal intensity of the femur were seen in the right thigh. There was no evidence of bone contusion, marrow oedema, fracture line, or cortical discontinuity. Other muscles of the thigh had a normal outline and signal intensity with no evidence of focal or diffuse oedema. Neurovascular structures were unremarkable. Overall, MRI findings were suggestive of soft tissue neoplasm, with a possibility of a neurogenic tumour. A wide excisional biopsy was then performed to further assess the tissue histologically by the pathologist and confirm the diagnosis. The removed mass measuring 8.5 x 6.5 x 5.4 cm and is shown in Figure Histopathology of the mass revealed a tumour arranged in sheets and fascicles composed of round to oval cells along with variably sized adipocytes Figure . NumerouThe patient was also referred to the Department of Nuclear Medicine & Molecular Imaging for post-surgical restaging and assessment for possible metastases using 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) scan. The abdominopelvic section showed the liver measuring within normal limits; however, the scan revealed an ill-defined hypermetabolic hypodense lesion seen involving segment VI measuring approximately 2.8 x 1.8 cm suggestive of hepatic metastases with concurrent fatty liver. The scan was also remarkable for the musculoskeletal system, revealing multiple hypermetabolic osseous lesions involving the skull base, right iliac bone, and few vertebrae (predominantly T7-L1); which was suggestive of skeletal metastases. A non-hypermetabolic pulmonary nodule in the right lung field was also detected; it was considered to be likely benign, but interval scanning is suggested to monitor further progress. Finally, there was also evidence of diffuse subtle hypermetabolism at the site of surgery which is suggestive of postsurgical inflammatory sequelae; however, microscopic residual disease cannot be completely ruled out. These multi-organ lesions were due to be biopsied to examine their immunohistochemical findings to confirm metastatic lesions of primary pleiomorphic liposarcoma. However, the patient did not attend the follow-up appointments.PLS represents the rarest type of liposarcomas . Due to Several differential diagnoses were excluded following our IHC. Pleomorphic lipoma, for instance, which usually presents as a well-circumscribed mass shows strong immunoreactivity to CD34 (reported negative in this case). Furthermore, other closely resembling carcinomas such as renal cell carcinomas were excluded owing to the negative epithelial membrane antigen test. MFH and other pleomorphic non-lipogenic sarcomas were excluded based on the presence of lipoblasts in this case. Furthermore, as this case demonstrated a significant degree of pleomorphism, myxoid liposarcoma was safely excluded. DLS is another closely related differential; however, the abundance of lipoblasts associated with bizarre nuclei and irregular nuclear membranes pointed towards PLS. Furthermore, the location of the lesion in the extremities is far more common in PLS than in DDLPS, which is mostly found retroperitoneally . As repoThe mainstay of treatment for soft tissue sarcomas remains complete surgical resection to minimize the risk of recurrence ,13-15. TPLS has the highest mortality rate among the four subtypes of liposarcomas, highlighting the importance of early and accurate diagnosis. Although IHC can be used in excluding other diagnoses, careful microscopic examination of the lipoblasts demonstrates that lipoblasts are indeed “in the eye of the beholder”. In terms of management, low-grade liposarcomas (well-differentiated and myxoid) can be largely managed with surgery alone provided the surgery is carefully planned and adequate clean margins are achieved. However, high-grade liposarcomas (round cell and pleomorphic), especially in extremities need to often be managed with neoadjuvant/adjuvant chemotherapy and radiation. Metastasis remains a considerable concern in high-grade liposarcomas, however, the paucity of literature in the area shows the need for more extensive research to develop more standardized guidelines for management as such malignancies mostly have poor outcomes.


The aim of this study was to report a case study on gastrointestinal lipoma with GIB.Lipomas are common harmless tumors that are created in the colon in the gastrointestinal tractA 38-year-old man was admitted to the hospital because of gastrointestinal bleeding for two months in December 2017. He had abdominal pain, dyspeptic disorders, vomiting, melena, and intermittent hematemesis without significant weight loss. Upper gastrointestinal endoscopy indicated a large subepithelial lesion in the antrum of the stomach with near-normal mucosa. Endoscopic ultrasound (EUS) showed a large well-defined heterogeneous mass-like lesion in the antrum of the stomach. A subtotal gastrectomy was done in the patient. The histology results of the separated samples presented a gastric lipoma.Gastric lipoma is often yellowish. It might ulcerate and bleed, but it does so, only rarely. It most frequently occurs as a solitary and smooth mass in the gastric antrum. Lipomas comprise 3% of gastrointestinal tumors with a prevailing spot in the colon 60-75%) and the small intestine (30%) . Lipomas% and theA 38-year-old man was admitted to the hospital because of gastrointestinal blood loss for two months in December 2017 . He had abdominal pain, dyspeptic disorders, vomiting, melena, and intermittent hematemesis without significant weight loss.His past medical history indicated no related conditions but reported a history of smoking 10- pack-years and alcohol consumption. On physical examination, his height was 178 cm, weight 124 kg (BMI: 39/2 KG/M2), blood pressure was 100/60 mmHg, and his pulse rate was 80/min. There was also no intake of nonsteroidal anti-inflammatory drugs. There were no unusual findings in the chest x-ray, and no icterus existed. The abdomen was noticeably full of fat, but a common intestine sound was heard. Epigastric pain was felt in the stomach. Laboratory results showed leukocytosis , and other test results were normal. Upper gastrointestinal endoscopy disclosed a large subepithelial lesion in the antrum of the stomach with near-normal mucosa that causes a partial obstruction of the lumen, so the scope was passed with caution . BecauseAccording to endoscopic results, we decided to perform surgery. The patient underwent midline supraumbilical laparotomy. Intraoperatively, a yellowish, smooth surface subserosal wound with a linear diameter of around 5 cm was detected in the antrum of the stomach. Subtotal gastrectomy was performed for removing the mass with the appropriate margin. Pathology examination of specimens confirmed gastric lipoma consists of a stomach segment measuring 13×6×4 cm with two pieces of separated adipose tissue measuring 20×10×3 cm. A submucosal well-defined creamy-colored mass with the greatest dimension, measuring 7 cm, was detected with a distance of 2.5 cm from the closest surgical margin. The patient was discharged on the sixth postoperative day with a stable vital sign and appropriate feeding. Gastric lipomas are detected marginally more often in women than in men and commonly affect the population between 40 to 70 years of age . LipomasOn the contrary, if a gastric tumor cannot be recognized as a lipoma or be in the vicinity of a hemorrhagic ulcer should be removed surgically 15. The In a study conducted by Machado et al., 37% of the cases were diagnosed with either chronic or acute gastrointestinal bleeding, obstruction, or dyspepsia. In this study, most of the large stomach lipomas that have been presented were cured by primary gastric resection . In anotIn this case report study, a 38-year-old man presented with hematemesis, pain, and melena. So, the surgical excision was performed with subtotal gastrectomy. An intramural mass was found in the antrum, causing a degree of lumen structure. There was an ulcer on the surface of this tumor. In our case, a large intramural lipoma of the stomach with areas of reactive fibrosis, the ulcerated area of tumor with mild inflammation, and small hyperplasia of the gastric mucosa near the ulcer was recognized. The remaining gastric mucosa appears with no substantial lesions. Microcystic dilation of the gastric glands is recognized .


The complication of duplication of alimentary tracts and pancreas divisum (PD) is a rare malformation and the development of pancreatic ductal adenocarcinoma (PDAC) in this malformation is also extremely rare. There have been some reports of complication of malignancy in a gastric duplication cyst (GDC) and PD. However, there have been no reports of complication of PDAC in cases with GDC and PD.A 54-year-old woman was followed up at the previous hospital due to a history of ovarian endometrial adenocarcinoma. She also had a surgical history of partial excision for a GDC and pancreatic tail of PD in her childhood. A gynecological follow-up computed tomography (CT) examination revealed the pancreatic body tumor and the bifurcated main pancreatic duct dilatation. Furthermore, magnetic resonance cholangiopancreatography also revealed that the ventral main pancreatic duct communicated with the GDC. The initial levels of tumor markers were high, but we could not achieve preoperative histopathological diagnosis. The preoperative diagnosis was PDAC occurring in a case with PD and GDC. She received two courses of neoadjuvant chemotherapy with gemcitabine and nab-paclitaxel. A CT examination after neoadjuvant chemotherapy revealed the shrinkage of the tumor, and then we performed distal pancreatectomy with splenectomy and GDC resection. A histopathological examination revealed invasive PDAC and lymph node metastases; pathological staging was T1N1M0, stage III. Furthermore, PD and GDC were also histopathologically detected. The postoperative course was uneventful, and she was discharged on the postoperative day 25. She received S-1 monotherapy for 6 months, and no recurrence has been detected at 1 year after radical resection.We herein presented an extremely rare combined case of PD, GDC and PDAC. We successfully treated it by neoadjuvant chemotherapy and distal pancreatectomy with GDC resection, and postoperative chemotherapy. Duplication of the alimentary tracts is a rare developmental anomaly that may occur anywhere between the mouth and rectum, with 4–9% occurring in the stomach . DuplicaThe combination of PD and GDC is a rare condition. Furthermore, complication of pancreatic ductal adenocarcinoma (PDAC) is an extremely rare condition. We herein report an extremely rare case of PDAC that occurred in a patient with PD and GDC.A 54-year-old woman was followed up by the gynecological department of the previous hospital due to a history of left ovarian endometrial adenocarcinoma. She also had a history of partial excision for GDC and PD in her childhood, but there was no detail of the surgical record. A follow-up computed tomography (CT) examination revealed a cystic nodular lesion beside the crus Fig. a. At firGDCs are a congenital malformation that can occur in the entire gastrointestinal tract, with a reported incidence of 1 in 4500 to 10,000 births . TherefoOn the other hand, PD is also a rare anatomical abnormality, and its frequency has been reported to be 6–10% in patients with a history of endoscopic retrograde cholangiopancreatography and in autopsy cases , 8.In addition, PDAC appeared at the junction of the PD and the fistula of the GDC.Duplicated stomach has been found to be continuous with the main pancreatic duct in 78% of cases . TraversWe experienced an extremely rare case of PDAC with PD and GDC. Detailed image retrieval is required for the diagnosis of PD and GDCs, and if the patient is diagnosed with PD, surgical resection may be considered due to the possibility of malignant changes. In this case, asymptomatic chronic pancreatitis due to pancreatic-associated GDC triggered the carcinogenesis of PDAC, and PDAC occurred at the junction of the PD and the fistula to the GDC.


Superior mesenteric arteriovenous fistulae (SMAVF) are a rare complication from trauma or iatrogenic surgical intervention. There are less than 50 cases reported in the literature and no clear guidelines as to the best practices for diagnosis and treatment. SMAVF are often asymptomatic but can present with nonspecific abdominal symptoms ranging from nausea and vomiting to gastrointestinal bleeding and mesenteric ischemia. Symptom onset, when present, is often delayed years after the inciting event, further complicating the diagnosis. We present a case of a 71-year-old man presenting with mesenteric ischemic symptoms secondary to a large SMAVF that was successfully treated with coil embolization. We describe our approach to treatment and describe the classical imaging findings. We, then, review the current literature and management recommendations. We present a case of a patient presenting with postprandial abdominal pain secondary to a giant superior mesenteric arteriovenous fistula (SMAVF). The arteriovenous connection was successfully treated with coil embolization. There were no complications. Patient symptomatology resolved by discharge, and follow-up imaging demonstrated complete thrombosis of the SMAVF.Arteriovenous fistulae (AVF) are communications between the arterial and venous system that bypass the high-resistance arteriole system. Blood is shunted away towards the low-pressure venous system. In the mesenteric vessels, this can result in vague, nonspecific abdominal symptoms among other symptoms.The most common causes of mesenteric AVF are iatrogenic or trauma-related. For example, an errant stitch or suture line that crosses through an artery and vein may result in the formation of an abnormal communication between the two. The inciting incident, however, may have occurred years ago, making diagnosis challenging. Furthermore, the AVF is often detected incidentally for imaging performed for other reasons. Only once other etiologies for the patient’s symptoms have been ruled out, should the AVF be treated as the cause. Due to the rarity of SMAVF, there are no clear guidelines for treatment. Management options range from surveillance, open surgery, or minimally invasive endovascular interventions.A 71-year-old man presented to the emergency department with chief complaint of cramping abdominal pain, which he rated 10 out of 10. Symptoms have been on and off for the past two months. In addition, he admitted to nausea, vomiting, and mild non-bloody diarrhea. Vital signs were within normal limits. Past medical history included hypertension, midline anterior abdominal wall hernia, and a remote small bowel obstruction for which he underwent partial small bowel resection and anastomosis 25 years ago. He had a recent colonoscopy that revealed tubular adenomas.Pertinent positives on physical exam included abdominal tenderness to palpation without rigidity, guarding, or distension. Labs demonstrated mildly decreased hemoglobin (12.1 g/dL) and mild elevation of liver functional enzymes . Lipase, white blood cell count, lactate dehydrogenase, and lactic acid were within normal limits.The primary care team's initial concern was for an infectious or inflammatory process. A contrast-enhanced CT scan was ordered, which revealed diffuse atherosclerotic disease and a high-grade superior mesenteric artery (SMA) to superior mesenteric venous (SMV) communication with enlargement of the SMV to 3.4 cm Figure . No otheThe following day, the patient went to the angiographic suite. A 4 French micropuncture kit was used to access the right common femoral artery and upsized to a 5 French vascular sheath. Using standard catheter and guidewire technique, a 5 French Omni Flush catheter was advanced to the suprarenal abdominal aorta, and digital subtraction angiography was performed. The aortogram demonstrated normal patency of the celiac and superior mesenteric artery origins. A large, early draining vein, the SMV, was identified arising from the third-order jejunal branches Figure . The SMAThere was complete resolution of symptoms by the time of discharge. A follow-up ultrasound examination in three months demonstrated satisfactory thrombosis of the previously seen SMAVF without any residual flow Figure .SMAVF are a rare source of ischemic mesenteric complications, with less than 50 cases reported in the literature -3. SMAVFSMAVF are often asymptomatic, which may partially contribute to the low reported incidence. Symptom onset is often delayed and ranges in days to decades after the inciting event (if an inciting event is found) ,4. SymptSMAVF is a diagnosis made primarily through imaging. Physical exam findings are generally nonspecific. The most-reported physical exam finding is an abdominal bruit from the rapid flow of high-pressure arterial blood directly into the low-pressure venous system. These are hard to distinguish from other bruits from arterial occlusive disease ,5. WhileSMAVF were traditionally surgically excised or ligated, but the current preference is endovascular embolization due to comparable results and fewer complications. The mortality rate for surgical treatment of SMAVF has been reported at up to 18% [Coils are metallic vascular-occluding devices that assume a coiled-configuration when deployed in the target vessel. Multiple coils are densely packed to achieve vessel occlusion. As the vessel is packed more tightly, however, the higher the chance that any additional coil may prolapse into a nontarget vessel due to incorrect sizing or catheter kickback. Detachable, rather than pushable, coils alleviate some but not all of the associated risks. In a high-flow, arteriovenous fistula, distal migration through the venous outflow is another potential complication. A flow-reducing device such as a vascular plug can help secure the coils if needed. Immediately post-coiling, slow blood flow is expected, and one should wait three to five minutes before reassessing residual flow within the vessel .Symptomatic SMAVF are quite rare, so there is limited data set to define optimal management. There is no formal recommendation for treating arterioportal fistulae with management dictated by operator familiarity and comfort. While endovascular options traditionally include coiling, there have been reports of success employing covered stents. There has been a global shift to minimally invasive endovascular techniques, and these techniques show comparable results to open surgical repair with less overall morbidity.


Benign brain tumors largely affect the brain and can lead to reversible dementia, which can be resolved following the treatment of the primary etiology. Herein, we report three cases of relatively large frontal meningiomas in patients who presented with cognitive impairment as initial symptoms. The three participants demonstrated notable dementia alongside frontal meningioma. Following resection, all patients showed dramatic cognitive function improvement, and they successfully returned to society. Our cases illustrate the benefit of active surveillance with neuroimaging in selected patients, especially those who present with acute or subacute dementia. Reversible dementia is a form of dementia that is resolved following the treatment of the primary etiology. The early detection of hidden treatable causes is important for physicians treating reversible dementia.Brain tumors can cause dementia due to the mass effect on the adjacent brain tissue. Meningioma, a benign brain tumor, has been found to cause reversible dementia if it is located in the frontal region of the brain -3. MeninCase 1A 79-year-old man with a history of hyperuricemia and hypertension developed incontinence and apathy two days before admission and presented to his primary care physician. His head CT images showed an approximately 5 cm mass lesion in the frontal region, and he was transferred to our department. On admission, his cognitive examination results were as follows, suggesting cognitive impairment: Japan Coma Scale (JCS) I-1, Glasgow Coma Scale (GCS) E4V4M6, Mini-Mental State Examination (MMSE) 25/30, Hasegawa Dementia Rating Scale-Revised (HDS-R) 22/30, Frontal Assessment Battery (FAB) 8/18, and Trail Making Test . Contrast-enhanced MRI revealed a homogeneously enhanced 4.8x4.0x4.0 cm mass with peritumoral edema at the midline of the frontal region, consistent with falx meningioma Figures , 1B. We Case 2Six months prior to visiting our department, a 42-year-old woman presented with memory disturbances, anorexia, weight loss, and apathy. Initially, she assumed that these symptoms were caused by the menopausal syndrome. Five months later, following the lack of symptom improvement, she visited a psychiatric clinic and started using antidepressants after being diagnosed with depression. She complained of headaches and visited a neurosurgical clinic. MRI revealed a 7 cm lesion in the right frontal region, and she was referred to our department. Upon admission, her cognitive examination results were as follows, suggesting severe cognitive impairment: JCS I-1, GCS E4V4M6, MMSE 7/30, HDS-R 3/30, FAB 6/18, and Behavioral Assessment of the Dysexecutive Syndrome (BADS) 4/24. Contrast-enhanced MRI revealed a heterogeneously enhanced extra-axial mass of approximately 7 cm in the frontal region with peritumoral edema, which is consistent with right frontal convexity meningioma Figures , 2B. PreCase 3Three months prior to admission, a 47-year-old man presented to a psychiatric clinic with apathy and restlessness. He started using antidepressants after being diagnosed with depression by psychiatrists. Later, he developed headaches and left hemiparesis and became ambulatory with a walking cane. He had a history of surgical procedures for lumbar canal stenosis seven years prior to admission, and his orthopedic surgeon had planned lumbar canal restenosis. Conversely, a head CT was performed by the doctor to address the headache complaints, which revealed a large mass in the right frontal region. The patient was then referred to our department. He had mild cognitive impairment and his neurological examination results on admission were: JCS I-1, GCS E4V4M6, mild lift hemiparesis , MMSE 25/30, HDS-R 26/30, FAB 13/18, and TMT . Contrast-enhanced MRI revealed an extra-axial approximately 7 cm homogeneously enhanced mass with a dural tail sign in the right frontal lobe Figures , 3B. We We report three cases of relatively large meningiomas in the frontal region that initially manifested as psychiatric symptoms. All patients, including an elderly patient, showed dramatic recovery of cognitive function following tumor resection. Most meningiomas occur between the ages of 30 years and 70 years and rarely occur in children ,6. As shIn terms of age, approximately 15% of Japanese patients who were aged 65 years and older were affected by dementia in 2012 . Thus, dMoreover, middle-aged women are more than twice as likely as men to develop meningiomas . As showLarge frontal meningiomas tend to affect the motor cortex, Broca’s area, and the large branch/main trunk of the anterior and middle cerebral arteries. Patients with large frontal meningiomas can depict not only psychiatric symptoms but also paralysis and aphasia. Thus, early diagnosis and surgical treatment are required. In Cases 2 and 3, headache, which is caused by elevated intracranial pressure, triggered neuroradiological examinations. Although headache is a common symptom in daily medical practice, the neuroradiological examination should be performed in patients who present with both psychiatric symptoms and headaches. According to the Japanese Ministry of Health, Labor and Welfare, in 2018, there were approximately 320,000 physicians, and approximately one-fifth (19.4%) were general physicians . ApproxiSurgical removal is the first-line treatment for symptomatic meningiomas. Even in elderly patients, surgical removal of the tumor is a safe and effective treatment option while preserving performance status . In all General physicians should recognize that benign brain tumors can cause cognitive impairment and with proper treatment, remission is probable. In addition, neuroradiological examinations should not be hesitated, especially in patients with acute or subacute dementia to detect the treatable causes.


Bezoar is described as a swallowed, extraneous, and indigestible mass located in the gastrointestinal system; it accounts for 0.4-4.0% of all cases of mechanical intestinal obstruction. Intestinal obstruction is the most frequent complication of bezoar formation. Apart from intestinal obstructions, bezoars may also exhibit clinical symptoms such as abdominal pain, nausea, vomiting, weight loss, upper gastrointestinal bleeding, and gastric perforation. However, a considerable number of cases tend to be asymptomatic. Of note, its clinical symptoms cannot be differentiated easily from intestinal obstructions caused by other factors. As such, preoperative CT examination can provide invaluable information about the level of obstruction, etiology, and the existence of additional pathology and thereby help plan the type of surgical procedure required. If prompt diagnosis and timely treatment are not carried out, the condition may lead to significant morbidity and mortality. Bezoars account for approximately 0.4-4.0% of all cases with mechanical intestinal obstruction. The word “bezoar” originates from the Arabic word “bedzehr” or the Persian word “padzhar,” which means “protecting against a poison.” Bezoars, defined as a swallowed, extraneous, and indigestible mass in the gastrointestinal system, are classified into different types according to undigested accumulative agents that they originate from: (i) pharmacobezoars, developing due to certain medications, (ii) phytobezoars, caused by the indigestible components of fibrous foods and fruits, (iii) lactobezoars, originating from lactoproteins, and (iv) trichobezoars, developing due to swallowed hair, pilar, and cilium. Some bezoars occur due to the swallowing of plastic and metal pieces. In addition, Rapunzel syndrome has been determined to be an unusual form of bezoar extending from the stomach to the small intestine or beyond -3.PhytoThe patient was an 82-year-old female who presented to the emergency service with complaints of stomachache, nausea, abdominal swelling, and inability to defecate for the last three days. On review, her personal medical history was remarkable for cholecystectomy and acromphalus. On physical examination, tenderness in the abdomen and abdominal distension were recognized. Imaging studies revealed intestinal air-liquid levels on the abdominal X-ray and a mass-like formation that filled the lumen in the distal ileal segment leading to the dilatation in the proximal loops (raising suspicion for intussusception or bezoar) on contrast-enhanced abdominal CT. She underwent emergency surgery and the laparotomy exhibited a mass compatible with bezoar that completely obstructed the intestinal lumen, approximately 50 cm proximal from the ileocecal valve Figures , 2. The It has been reported that the rates of obstruction due to the bezoars are between 0.4 and 4%. Bezoars tend to develop in both the stomach and the small intestine. Moreover, intestinal obstruction is the most common type of complication of bezoar formation ,8. AdditEven though regional and seasonal variations can be observed, bezoars might affect people all around the world. Obstruction is generally seen in the narrow part of the small intestine, particularly 50-70 cm distant from the ileocecal valve since the intestinal lumen is narrow at that level. The second most common region is jejunum . The patAbdominal roentgen, barium enema, ultrasound, and endoscopy can be performed in order to establish a diagnosis of obstruction due to a bezoar. However, those methods may be inadequate and have several limitations . In intePhytobezoar-induced intestinal obstruction remains an uncommon etiology of small bowel obstruction. This phenomenon, per se, may appear in the absence of previous gastrointestinal surgery and might easily be overlooked without a high index of clinical suspicion. Physicians should focus on a detailed dietary history, contributing factors, and imaging features. The rates of mobility and mortality may be attenuated in these cases through a rapid and effective approach, which involves immediate decision-making and opting for an appropriate surgical procedure. Bene diagnoscitur, bene curatur.


Glomus tumor is an uncommon soft tissue tumor. However, as the tumor causes significant disability, its early diagnosis is essential. It involves subungual areas of fingers and toes in most cases, and its extra-digital involvement is rarely seen. To the best of the authors' knowledge, only a few chest wall involvement cases have been reported in the literature.In this paper, we describe a 63-year-old patient with a chest wall glomus tumor presenting with axillary paroxysmal pain and limitation in his shoulder range of motion that had been missed for nearly 15 years. His symptoms were relieved immediately following surgical excision.Glomus tumors may involve any part of the human body. It is curable with surgical excision in most cases. Therefore, a correct early diagnosis has paramount importance. A high index of suspicion is needed for early diagnosis, especially when the tumor involves uncommon anatomic areas. Glomus tumor (GT) is a mesenchymal neoplasm that originates from modified smooth muscle cells of the glomus body known as glomus cells . Less thThe lesion is mostly benign, and its excision has a cure rate of around 90 percent . HoweverThe tumor mostly involves the hand and foot digits especially the subungual area . HoweverIn this article, we report a case of chest wall GT with an uncommon presentation of chronic axillary pain. This article highlights a precise history taking and a high index of suspicion to recognize an unusual presentation of GT. We obtained informed consent from our patient for the publication of this case report.The patient was a 63-year-old male who presented to our clinic with left axillary pain and significant shoulder movement limitation. His symptoms started 15 years ago and did not subside despite using several pain killers. Initially, his pain was vague and sensed over the entire left shoulder. However, after 7 years, his pain changed in nature to a paroxysmal and lancinating one localized to the left axilla. He did not state any history of trauma. He had undergone radiologic and cardiologic work-ups several times without achieving a definite diagnosis. From 6 years ago, he noticed an axillary lump, assuming it to be an insignificant lesion unrelated to his chief complaint. According to the patient, the mass was sensitive to cold temperature and obliged him to wear warm clothes. As the mass size became larger and the pain was exacerbated, he became worried and came to our clinic for further evaluation.Upon physical examination, his lump was revealed to be a fixed and painful mass located at the patient's left chest wall (in the mid-axillary line). No enlarged axillary lymph nodes were detected. His left shoulder's passive motion was in full range, but his active range of motion, especially active forward elevation, was limited.The chest X-ray and shoulder X-ray of our patient were insignificant. His left shoulder magnetic resonance imaging (MRI) revealed a 5-cm (in the largest diameter) left axillary soft tissue mass at the mid-axillary line. The tumor was deep to the fascia and over the posterolateral chest wall extending from third to fifth ribs with no visible rib cage involvement Fig. .Fig. 1DiOur differential diagnoses were schwannoma, hemangioma, glomus tumor, lipoma, and their malignant counterparts. Thus, we decided to perform an open biopsy. The histopathology report was in favor of a GT. At the next step, the excision of the mass was planned. We approached the tumor through the mid-axillary longitudinal incision. The previous incision for biopsy was included in the surgical approach. During the operation, the lesion was observed to be an encapsulated mass situated between the scapular body and chest wall. There was no gross adhesion between the tumor and the surrounding tissues. Therefore, it was separated by blunt dissection. After ligating its main vascular pedicle, the mass was excised completely and sent for histopathologic assessment.Macroscopically the lesion had an irregular red–purple tissue and sized 5 × 4 × 2 cm ., 12.2, 1The GTs frequently (90%) present solitary. Multiple GT presentation known as glomangiomatosis is seen mostly in children and is associated with either autosomal dominant inherited mutation in chromosome 1 or neurofibromatosis type 1 , 11. TheThe average presenting age of GT is usually between 30 to 50 years old and the tumor starts to become atrophied after the age of 60 , 15. ItsThe GTs can be found in any location, even in visceral organs. There are reported cases of GT affecting breast , thyroidVan Geertruyden et al. demonstrated that the average time between the beginning of GT’s symptoms and its diagnosis is 10 years . This tiHistory of paroxysmal pain, which appears spontaneously or following direct compression and exposure to cold temperature, is the main clue to reach the diagnosis . Upon phPlain radiography generally does not show any abnormality unless in chronic lesions, in which bony erosion may be seen. Although ultrasonography can help in the diagnosis, the imaging modality of choice is MRI . Like ot.Surgical excision remains the management of choice with a 10–30% recurrence rate in the literature . Laser aThe GT mostly has a benign nature, and it has less than 1 percent risk of transformation into malignancy . HoweverIn our case, the histopathologic findings were in favor of glomangioma, and no significant nuclear atypia or mitosis was identified. However, the size and deep location of the tumor overlapped with the malignancy criteria. Close observation of the patient and 19-month follow-up has shown neither metastasis nor relapse.In conclusion, a glomus tumor may affect any part of the human body and be associated with significant functional impairment. Meanwhile, the tumor is curable with surgical excision in most cases. Therefore, early correct diagnosis is of paramount importance. A high index of suspicion would be needed in order not to miss GT cases.


Primary penile malignancy is a rare occurrence in the United States, with squamous carcinoma being the most common aetiology. Non-squamous penile cancers are scarcely reported in the literature. We present a unique case of a 65-year-old male with a history of Waldenström macroglobulinemia (WM) previously in remission complaining of a painless subcutaneous bump on the base of the penis. Biopsy with histological and immunohistochemical analysis confirmed the recurrence of WM. This novel case illustrates an unusual presentation of the disease after being successfully managed with chemotherapy and immunotherapy in an asymptomatic individual. There is only another reported case in the literature of a patient with a similar presentation. We highlight the clinical features and presentation of this condition, including a consensus for the approach and management of non-Hodgkin’s lymphomas of the penis. Penile malignancy is rare and accounts for less than 1% of male cancers within the United States . The mosA 65-year-old male with a medical history significant for scleroderma, Raynaud’s phenomenon, benign prostatic hyperplasia status post-transurethral resection of the prostate, low-grade appendiceal mucinous neoplasm, and WM diagnosed six years ago and in remission since 2017 presented to outpatient urology with a right painless mass at the base of the penis that had been slowly increasing in size over six months. He was previously treated for WM with bendamustine that was completed in 2015, along with maintenance rituximab therapy until 2017. An ultrasound was performed that showed a 1.6 cm soft tissue nodule overlying the medial aspect of the right corpus cavernosum, near the base of the penis  B-cell lymphoma that occurs in less than 2% of patients with non-Hodgkin lymphoma with an incidence rate of three per million . The mosAll cutaneous presentations of WM are characterised in a 2001 report, describing the lesions as infiltrative papules and plaques with red-brown discolouration . CutaneoPenile presentation of WM is extremely rare, with only one case identified by our literature search . AdditioEven though non-squamous penile malignancy is rare, it is imperative to understand the treatment for these non-Hodgkin lymphomas, typically consisting of chemotherapy and immunotherapy, with surgery reserved as the last option. From our literature review, the management varies between initiating systemic therapy and delaying surgery as the last option or utilising surgery to remove most of the penile mass and starting systemic chemotherapy ,11,12. TWM with subcutaneous penile involvement is extremely rare, and there have been no other reported cases. This case provides a clinical example of why clinicians should consider lymphoma relapse in a patient who presents with a mass on the base of the penis and has a history of lymphoma. While much less common than squamous cell carcinoma of the penis, WM should be kept on the differential diagnosis.


Dissecting intramural hematoma is a rare complication of acute myocardial infarction (AMI) and has been associated with increased mortality. There has been paucity of literature to establish protocols and guidelines for management in such cases.We hereby report the case of a 45-year-old male patient with left ventricular intramural dissecting hematoma (LV-IDH) who presented with chest pain and breathlessness and diagnosed as non-ST-elevation myocardial infarction (NSTEMI). Transthoracic echocardiography (TTE) was performed showing LV-IDH, confirmed with cardiac magnetic resonant imaging (cMRI). Selective coronary arteriography (CAG) was performed showing significant obstructive coronary artery disease (CAD). Further management with conservative approach involved discussion with patient, cardiothoracic surgeon and cardiology team including heart failure specialist and interventional cardiology.This case describes a rare complication of AMI and also focuses on utility of TTE and cMRI in the diagnosis of this rare complication. Both diagnosis and management are challenging and have to be individualized in similar cases. Multidisciplinary care coordination is important in management of patients with this diagnosis.The online version contains supplementary material available at 10.1186/s12872-022-02523-x. Intramural dissecting hematoma (IDH) is a rare complication after AMI. It has been variously termed as intramural dissecting hematoma, intramural hematoma, intramyocardial dissecting hematoma in literature. It can also occur spontaneously after percutaneous coronary intervention (PCI) or chest trauma and can extend in to left ventricular (LV) free wall, interventricular septum, or the right ventricle. It can be considered to be a part of the spectrum between ventricular septal and free wall rupture where the dissection plane does not extend to epicardium, but rather extends into myocardium. However, similar to ventricular septal rupture, it carries high mortality and treatment options can vary between conservative management to surgical evacuation and LV repair. Management of IDH must be individualized based on size of the hematoma, LV function and clinical and hemodynamic status of the patient, after detailed discussion with the patient.A 45-year-old male who presented to the emergency department (ED) with one month history of intermittent chest pain worsening for one day before presentation. He also had associated breathlessness on exertion for the same duration. His past medical history was significant for diabetes mellitus, hypertension, dyslipidemia, active cigarette smoking and established ischemic heart disease (IHD) with CAD for which he required PCI four years before presentation. He had family history of premature CAD. He denied any other recreational drug use. He has history of medication non-adherence and has not used any medications in past two years including the recommended antiplatelet agents, statins, anti-hypertensives, and anti-diabetic medications.In the ED, patient continued to have anginal chest pain. He was diaphoretic and had breathlessness at rest. The temperature was 98.6-degree Fahrenheit, blood pressure 162/122 mmHg, heart rate 100 beats per minute, respiratory rate 16 per minute and oxygen saturation 99% on room air. On physical examination he appeared anxious, diaphoretic and tachypneic. Cardiopulmonary examination showed raised jugular venous pressure, mild pedal edema and crepitations involving less than one-third of both lung fields. Rest of the physical examination was unremarkable. His 12-lead electrocardiogram (ECG) showed sinus tachycardia and right bundle branch block (RBBB) with borderline ST-segment elevation in precordial V4 and V5 leads with q waves in inferior leads II, III, aVF as shown in Additional file The initial laboratory findings in ED were significant for hemoglobin of 14.7 g per deciliter (reference range 12.0–16.0), white blood cell count of 13,300 per cubic millimeter . The serum creatinine was 1.9 mg per deciliter (reference range 0.5–1.5), and troponin level was 349 nanogram per liter  which increased to 417 nanogram per liter over four hours. The hemoglobin A1C value was 6.9% (reference range 4.7–6.4). The Pro-B-Type-natriuretic peptide (ProBNP) level was 25,951 picogram per milliliter (reference range 0–125).He was admitted in cardiac care unit (CCU) with the diagnosis of NSTEMI and started on continuous intravenous infusion of unfractionated heparin in accordance with NSTEMI management guidelines. He was also started on intravenous diuretics. The TTE showed reduced LV ejection fraction and dyskinesis in left anterior descending (LAD) territory in apical region. The LV apex showed echogenic lucent area with endomyocardial border as shown in Additional file The cMRI was done for viability assessment and showed transmural infarct involving 49% of the LV mass involving inferior, apical, mid-ventricular septum , inferolateral and anterior walls. It confirmed large intramural hematoma involving apical segments with myocardial rupture involving epicardium but with intact endocardium with viable tissue in LCX territory and partially viable tissue in LAD territory as shown in Additional file The LV-IDH is a rare and dreaded mechanical complication that occurs after AMI. In majority of cases, hematoma involves LV, followed by left atrial wall (after ablation procedures) , or RV . The mosIn a necropsy study by Vargas-Barŕon et al., septum was the most common region involved followed by the LV free wall. Anterior wall AMI accounts for majority of the cases, with only small percentage contributed by inferior wall AMI . Most caThe IDH comprises of myocardium, epicardium and pericardium in its outer wall and myocardium and endocardium in its inner wall facing ventricular cavity. The pathophysiologic mechanism of IDH is dissection of myocardial tissue contributed by poor support from infarcted tissue, remodeling of small vessels in infarcted tissue, and raised intra-cavitary pressure.The ECG may show bundle branch blocks in more than half of cases and may show persistent ST-segment elevation. TTE remains the cornerstone of diagnosis as in our case. It can show varying patterns of IDH, in varying stages of resorption, and formation of thrombus. Our case also showed intramural areas of resorption reflected by significant echo-lucent regions within IDH. Echocardiographic features include a thin layer of freely mobile endocardium or myocardium on one side and pericardium along with thicker layer of myocardium on the other side with doppler demonstration of color flow in the cavity. Occasionally entry point can be seen as in our case, where entry point was the junction of normal and infarcted IVS. Other imaging modalities such as cardiac MRI are especially useful as LV cavitary thrombus and LV aneurysm can closely mimic IDH  figure shows echocardiogram in parasternal long axis view demonstrating echo lucent space suggesting intramural hematoma involving apical region with entry point along interventricular septum. b) echocardiogram in parasternal short axis view (angulated to include maximum width of IDH) showing intramural hematoma, in apical segments extending from mid cavity level. Figure 3: a) Echocardiogram in parasternal short axis view shows no flow across endocardium to intraventricular region. b) Echocardiogram with perflutren lipid microsphere (DEFINITY ®) injectable suspension contrast agent showing no communication between LV cavity and intramural space. Figure 4: Cardiac MRI showed intramural dissecting hematoma with communication with the LV apex.


Autoimmune hypophysitis is the consequence of an immune-mediated inflammation of the pituitary gland, which is rare, and most frequently occurs in females during postpartum periods. It usually responds well to corticosteroid treatment with reported resolution of the pituitary mass lesion.A 51 years male presented with a one-month history of lethargy, headache, nausea, proximal muscle weakness with intermittent flushing. He was a diabetic with metformin 500mg twice daily. No other remarkable medical history or family history of autoimmune disease. On examination, he had no neurological deficit with a normal visual field. His initial biochemical evaluation showed features of secondary hypothyroidism as evidenced by low free FT4 and suppressed TSH with normal electrolytes. The subsequent evaluation of his hormonal profile revealed panhypopituitarism. Contrast MRI of pituitary showed an enhanced homogenous mass and minimal stalk thickening with a dural tail and preserved posterior bright spot. He was managed with glucocorticoid 20 mg once daily for two weeks along with levothyroxine and testosterone replacement. After two weeks of treatment, he improved clinically. Repeat MRI imaging of the pituitary showed complete resolution of the homogenous mass.Although autoimmune hypophysitis is rare in males, a careful clinical history with necessary hormonal investigations is required for the suspicion about the inflammatory pituitary disorders This current case highlights glucocorticoid as the primary modality of treatment and the need for long-term follow-up with periodic clinical assessment. Hypophysitis is an inflammation of the pituitary gland of acute or chronic onset. Hypophysitis can be further classified based on its cause, involvement of various parts of pituitary glands, and/or histology characteristics. Primary hypophysitis (lymphocytic or autoimmune) refers to isolated lymphocytic inflammation and infiltration of the pituitary not associated with other known causes of pituitary inflammation .Anatomically hypophysitis is classified according to involvements of various parts of pituitary glands such as involvement of the anterior pituitary gland (adenohypophysitis), posterior gland, and stalk (infundibuloneurohypophystis), or entire gland (panhypophysitis) ,3. HistoAutoimmune hypophysitis (AH) is an uncommon inflammatory disorder, mostly encounters young females, especially in the peripartum period. It was first recognized in 1962 by Goudie and Pinkerton  therapy with a complete resolution of mass lesion in the pituitary  with theThere are three modalities of treatment for AH; medical treatment with oral GC or pulse methylprednisolone, immunosuppressive therapy for the GC resistant case, and finally surgery is reserved for those patients who require diagnostic confirmation or decompression of the optic chiasm.A 62.5%, and 44% response to treatment rate with a pharmacological dose of prednisone equivalent to >10 mg/day, and <10 mg/day was reported respectively . We starThere is another form of intervention in AH that has been tried such as stereotactic radiosurgery and radiotherapy in a few cases who show recurrence after surgery and are resistant to glucocorticoids ,5.Our case demonstrates the importance of clinical history and hormonal investigation for the suspicion about the inflammatory pituitary disorders of autoimmune nature which is a diagnosis of exclusion of other inflammatory disorders of the pituitary gland. The current case highlights glucocorticoid as the primary modality of treatment and the need for long-term follow-up with periodic clinical assessment; if deem necessary an MRI imaging to find out the progression of a mass lesion.


Persistent primitive hypoglossal artery (PPHA) is a rare and permanent carotid-vertebrobasilar anastomoses. Patients with PPHA usually have higher changes of developing intracranial aneurysms due the high intracranial hemodynamics. Although cases of PPHA alone and PPHA with aneurysms have been reported in literature, cases of fenestrated PPHA harboring a ruptured aneurysm have seldomly be reported in literature. We present a rare occurrence of a fenestrated PPHA harboring a reputed aneurysm.A 43-year-old woman was presented with a sudden-onset severe headache and nausea.Computerized tomography scan showed third, fourth, and bilateral ventricular hemorrhages. Computed tomographic angiogram showed a PPHA with fenestration malformation and a cystic protrusion consistent with an aneurysm.The patient underwent a successful stent-assisted coil embolization via the trans-arterial route under general anesthesia.Two years follow-up revealed no recurrence of her symptomatology and she is currently well and go about her normal daily life.Fenestrated PPHAs harboring aneurysms may be more prone to rupture because of the fenestration and connective tissue weakness of the artery as well as changes in hemodynamics of the already malformed and weak artery. Patients with PPHA usually have higher changes of developing intracranial aneurysms due the high intracranial hemodynamics.–8 Most often than not, the aneurysms are often found on other arteries and not the parent artery with the PPHA.,9 However, a few cases of commitment occurrences of aneurysms on the parent PPHA artery have been reported.,9Persistent primitive hypoglossal artery (PPHA) is a rare and permanent carotid-vertebrobasilar anastomoses with an incidence rate of about 0.02% to 0.26%. Surgical evaluation as well as clipping of the aneurysms on the parent PPHA in the posterior circulation is often very difficult. Thus, endovascular coiling is the currently the safest and easier treatment option for acutely ruptured intracranial arterial aneurysms with decreased morbidity as well as morbidity in complex PPHA harboring aneurysms as compared with open surgery.–9 We report a rare case of a fenestrated PPHA harboring a ruptured aneurysm which we successfully treated with stent-assisted coil embolization. Although cases of PPHA alone and PHHA with aneurysms have been reported in literature, cases of fenestrated PPHA harboring a ruptured aneurysm have seldomly be reported in literature.Computed tomographic angiography (CTA) is usually the gold standard radiological modality for the diagnosis as well as accurate evaluation of the persistent anastomoses.2A 43-year-old woman was admitted at our neurosurgery department due to sudden-onset of severe headache and nausea. Her past medical history was unremarkable. Cranial nerves examination revealed no focal neurological findings. General physical examination did not yield much. Routine laboratory investigations were grossly normal. Also, routine chest x-ray and electrocardiogram did not show any abnormalities.Head computerized tomography (CT) scan showed third, fourth, and bilateral ventricular hemorrhages Fig.  A and B.The patient underwent stent-assisted coil embolization via the trans-arterial route under general anesthesia. She was given oral aspirin and clopidogrel (300 mg each) on the day of the surgery and 40 mg heparin (approximately 2/3 of her 60 kg weight) intraoperatively. Intraoperatively, we observed a ruptured aneurysm in a fenestrated PPHA on the left ICA. The aneurysm was located along the blood flow at the proximal bifurcation of the fenestration. The neck of the aneurysm was relatively wide. The aneurysm was successfully embolized with low-profile visible intraluminal support (LVIS) stent-assisted coils  , to be specific, are capable of adequately displaying the PPHA without any contrast medium.,21 However, surgical approach is always challenging for these aneurysms in the posterior circulation. Surgical unreachability, unsuccessfulness of clipping, wide or absent aneurysm neck, and a medical illness impeding craniotomy were the initial potential indications of endovascular intervention for the treatment of PPHA.,22 In our case, the bilateral posterior inferior cerebellar arteries originated from the fenestrated malformed vessels. The aneurysm was located along the blood flow at the proximal bifurcation of the fenestration, which suggested involvement of hemodynamic forces during the development of aneurysm. The neck of the aneurysm was relatively wide. Thus, we selected LVIS stent-assisted embolization, which had a high metal coverage, in order to reduce the recurrence of the aneurysm and avoid the risk of PPHA stenosis.Surgical treatment via either wrapping or clipping of the aneurysm was the initial treatment for PPHA with aneurysms.,24 These devices are flexible, braided microstent made purposely for the stent-assisted coiling of wide-necked intracranial aneurysms.,25 They have demonstrated to be effective as well as efficient embolization treatment option for intracranial aneurysms.,24 They have good compliance as well as vascular accesses.LVIS device is a new brand of intracranial stent in recent years.4Fenestrated PPHAs harboring ruptured aneurysms have seldomly been reported in literature. Fenestrated PPHAs harboring aneurysms may be more prone to rupture because of the fenestration and connective tissue weakness of the artery as well as changes in the hemodynamics of the already malformed and weak artery.All authors contributed toward data collection, drafting, and critically revision of the paper and agree to be accountable for all aspects of the work. Seidu A. Richard wrote the final paper.Conceptualization: Sen He, Ming-Li Wei, Fei Xie, Seidu A. Richard.Data curation: Sen He, Ming-Li Wei, Fei Xie, Seidu A. Richard.Formal analysis: Sen He, Ming-Li Wei, Fei Xie, Seidu A. Richard.Methodology: Sen He, Ming-Li Wei, Fei Xie, Seidu A. Richard.Resources: Sen He, Ming-Li Wei, Fei Xie.Supervision: Fei Xie.Writing – original draft: Seidu A. Richard.Writing – review & editing: Sen He, Ming-Li Wei, Fei Xie, Seidu A. Richard.


Managing traumatic injuries of the gastroesophageal junction (GEJ) is infrequent due to associated lesions of adjacent highly vascularized organs. Its anatomical localization in the upper abdomen makes the repair challenging to perform. A stable 23-year-old male was presented at the emergency department with two thorax gunshot wounds. Computed tomography revealed air in the periesophageal space and right hemopneumothorax with no injury of the major vessels. A chest tube was placed and the patient was transferred hemodynamically stable to the operating. Abdominal exploration identified injuries to the left diaphragm; liver lateral segment; 1-cm transfixing perforation of the GEJ and right diaphragmatic pillar. Primary repair of the GEJ was performed and patched with a partial fundoplication. The diaphragm was repaired and the liver bleeding controlled. Finally, drains and a feeding jejunostomy were placed. The patient had an uneventful early postoperative course and was discharged home on the 12th postoperative day. Injuries of the gastroesophageal junction (GEJ) are infrequent due to associated trauma of adjacent highly vascularized organs such as the heart, liver and major vessels , 2. On-sSurgical management of these injuries has been poorly defined. Textbooks and case reports describe multiple options ranging from simple primary repair to highly complex alternative such as esophageal transection, total gastrectomy or damage control procedures. In trauma surgery, we usually prefer simple methods of repair. This report aims to present the surgical case of a patient with transfixing GEJ gunshot wound and primary repair through an anterior approach. A video of the procedure and a literature review are provided see .A 23-years-old male presented at the emergency department with a gunshot wound to the left thoracoabdominal region. After advanced trauma life support (ATLS)-based management, exposure revealed two gunshot wounds on the anterior and left lateral thorax . The patThe liver left lateral lobe was mobilized and retracted medially. To provide adequate exposure of the GEJ posterior wall without complete mobilization of the stomach and esophagus, an anterior transgastric approach through the anterior wall penetrating injury was performed . PrimaryTraumatic injuries of the GEJ are infrequent at the emergency department. A series of 28 cases, reported that the main etiology were penetrating traumas (96%), whether by gunshot (81%) or by stabbing (19%) . The morIn order to achieve the GEJ exposure, transection of the triangular ligament and mobilization of the lateral segment of the liver left lobe is often described . For expet al. describe 28 cases and summarize the procedures accomplished in a single US center. Of these, 21 patients undergo primary sutured repair either on a one-layer fashion (n = 8) or a two-layer (n = 13). Other patients followed a damage control approach and had the GEJ injury stapled off for delayed reconstruction (n = 4) . Tex (n = 4) .The surgical approach can be performed by laparotomy, thoracotomy or thoracoabdominal incision and is decided upon the injury location or trayectory and the suspected associated injuries . In the In conclusion, GEJ injuries are rare and multiple management options have been described. We present a case with successful anterior primary repair and a literature review to provide more alternatives for effective management of these injuries.Surgical_Repair_GEJ_injury_rjab160Click here for additional data file.


Foreign Body Cutaneous Granuloma (FBCG) is a form of chronic inflammatory response of the body to various agents. From a histological perspective, it consists of a necrotic center surrounded by macrophages, epithelioid cells, and fibrous tissue. It clinically presents as a solitary infiltrated pink-reddish nodule.A 62-year-old woman came in consultation for a pink-reddish 5 mm nodule located on the sole of the right foot, at the periphery of a skin graft for an excision of a melanoma (Breslow 1.35 mm) performed 3 months earlier. Dermoscopy showed a structureless homogeneous milky-red area with vessels, a clinical diagnosis of loco-regional melanoma metastasis was hypothesized .A 70-year-old man presented with a newly arisen red painless nodule about 5 mm in diameter located in right hypochondrium, close to a surgical scar. The patient underwent cholecystectomy 20 years ago. Dermoscopic examination highlighted a homogenous bright red, roundish central area, surrounded by a scaly collarette and a violaceous halo .A 57-year-old woman sought consultation for a 4 mm pinkish painful nodule on the dorsal region of her left wrist. The nodule appeared 6 months ago, following a gardening session. Dermoscopy showed a structureless homogeneous reddish background and a central umbilication, surrounded by fine whitish scales .A 30-year-old man presented with a newly-onset, irritated, itching papule on the medial surface of left leg. He denied surgical procedures or traumas. Upon dermoscopy the lesion showed a central whitish scar-like area surrounded by a structureless pinkish ring with linear vessels .Excision and subsequent histological examination of the lesions led to FBCG diagnosis including a suture stitch (case I and II), the thorn of a rose (case III) and an ingrowing hair (case IV) respectively.To the best of our knowledge, very few reports in the literature illustrated the dermoscopic FBCG pattern, so far. Our case series highlights FBCG’s heterogeneous presentation, since it revealed reddish or bluish structureless areas, rainbow pattern, polymorphic vessels, scar-like areas, erosions, and scales.FBCG differential diagnosis basically encompasses all entities presenting as solitary pink-reddish nodules. The appearance of new lesions on a surgical scar deriving from a previous excision should immediately raise suspicion of local recurrences and a biopsy should be performed. Similarly, a biopsy procedure must be performed if cutaneous lymphomas, Kaposi’s sarcoma, Merkel cell carcinoma, or amelanotic melanoma are suspected. Conversely, dermoscopic evaluation is usually specific enough to make diagnosis of spinal and basal cell carcinoma, dermal nevus, angioma, and dermatofibroma.In conclusion, dermatologists should include FBCG in the differential diagnosis of pink-reddish elevated lesions in body sites that are compatible with their presence. FBCG lacks pathognomonic dermoscopic features. Still, dermoscopy represents a useful tool that can help clinicians when making an exclusion diagnosis, by ruling out conditions characterized by more specific patterns. Nevertheless, it is crucial to manage uncertain nodular lesions with excision and follow-up, these should never be considered as an option when dealing with fast growing or nodular lesions ,2.


We report the case of a 73-year-old male who underwent abdominal multidetector computed tomography with vascular reconstruction that highlighted a congenital variant of iliac arteries. Iliac artery anatomical variants are exceedingly rare and only a few cases have been reported in the literature. We present a case of a 73-year-old male who presented to our emergency department for abdominal trauma due to a car incident. He underwent abdominal multidetector computed tomography that excluded abdominal traumatic pathologies. Vascular coronal volume rendering reconstruction highlighted an asymptomatic congenital anatomical variant, with cranial origin of internal iliac arteries . This pCongenital variants of the iliac arteries are exceedingly rare, and only a few cases have been reported in the literature.With an increase in noninvasive diagnostic vascular imaging, thoracoabdominal vascular anomalies are seen with greater frequency,


Fibrolamellar variant of hepatocellular carcinoma (FLHCC) is a rare malignancy. Our patient presented to the hospital with increasing weight loss, decreased appetite, and night sweats. Imaging revealed a large liver mass and multiple pulmonary nodules concerning for metastasis. The patient eventually underwent interventional radiology (IR)-guided biopsy of the liver which revealed pathology consistent with FLHCC. The patient was discharged from the hospital and was scheduled for a follow up at an outpatient cancer center close to her family. Cancer is a leading cause of death worldwide, accounting for nearly 10 million deaths in 2020 . MalignaA 29-year-old female with a past medical history significant for low-grade squamous intraepithelial lesion s/p colposcopy and laser therapy in 2017 presented to the hospital with worsening upper abdominal pain, nausea, night sweats, weight loss, and decreased appetite for approximately three weeks duration. Approximately three weeks ago, the patient noticed she started to become very nauseated after meals. She thought her nausea was due to poor diet as she was eating an excessive amount of ice cream. The patient was unsure of how much weight she lost over the past several weeks, but her family stated that her weight loss was noticeable. The patient was recently deployed to Afghanistan and returned home in January 2020 after completing a tour.On physical exam, the patient was afebrile and hypotensive with blood pressure 104/73. The abdominal exam was remarkable for tenderness to palpation in the right upper quadrant. Laboratory values were remarkable for microcytic anemia, anion gap of 18, alkaline phosphatase 139, aspartate aminotransferase 76, alanine aminotransferase 74, total protein 7.3, total bilirubin 0.3, CA125 47 U/mL , CA 19-9 15.6 U/mL . Ultrasound abdomen was completed, which revealed diffuse gallbladder wall thickening up to 7 mm, trace scattered free fluid in the right upper quadrant, and a large heterogeneous mass in the right lobe of the liver, measuring 10.7 x 9.5 x 12.7 cm. Ultrasound also revealed a large mass seen towards the midline, measuring 10.4 cm maximally. CT abdomen pelvis revealed massive hepatomegaly, bilateral pulmonary nodules, very large bilobed central hepatic mass measuring 19.3 cm x 10 cm x 9.4 cm, and one enlarged portocaval lymph node below the hepatic porta  were initially consulted. Gynecology reasoned that the mildly elevated CA125 could be from the known liver mass and did not indicate ovarian malignancy. Further, an epithelial, ovarian neoplasm, or germ cell tumor was unlikely given the lack of adnexal mass on imaging. Gynecology also reasoned that patient’s history of low-grade abnormality on Pap smear three years ago was improbable to have progressed to cervical cancer as on exam cervix was grossly normal. HB surgery recommended that the patient needed interventional radiology (IR)-guided liver biopsy to evaluate further and identify liver mass.The patient underwent an IR-guided liver biopsy, and pathology revealed well-differentiated, large, polygonal tumor cells with eosinophilic hyaline cytoplasmic bodies and abundant fibrous stroma arranged in thin parallel lamellae around tumor cells consistent with hepatocellular carcinoma with features most suggestive of FLHCC.Due to pathology results, hematology/oncology was consulted and recommended the patient to undergo IR-guided biopsy of lung nodules found on imaging as this would guide treatment. The patient was discharged with a plan for an outpatient lung biopsy. Fibrolamellar hepatocellular carcinoma is a rare liver cancer that affects adolescents and young adults with no history of primary liver disease . The tumWhen symptoms are present, they are generally nonspecific and usually include abdominal pain, malaise, and fatigue . In our Microscopic evaluation of the tumor reveals well-differentiated polygonal hepatic cells with eosinophilic and granular cytoplasm surrounded by thick, fibrous stroma arranged in bands . ApproprIn regards to tumor pathogenesis, Honeyman et al. (2014) investigated the molecular basis of FLHCC and identified a chimeric transcript that was expressed in FLHCC but not in normal liver. This chimeric transcript resulted due to a deletion on chromosome 19 and was found to code for a protein containing DNAJB1  and PRKACA . Honeyman et al. (2014) performed western blot analyses and immunoprecipitation, which confirmed that the chimeric protein was expressed in tumor tissue in 15/15 patients with FLHCC, indicating a potential role of DNAJB1 and PRKACA in tumor pathogenesis. The role of the fusion protein is still being investigated at the time of this publication . More reStipa et al. (2006) performed a prospective study published in the American Cancer Society in 2006 on patients with FLHCC referred to a tertiary care center over 18 years from 1986-2003. The median age of all patients was 27 years, and 28 patients underwent complete gross resection while 13 patients had an unresectable disease. The median tumor size was 9 cm in those who underwent resection, and 36% of these patients had vascular invasion while 50% had lymph node metastasis. The study found that at 34 months, five-year survival was 76% for resected patients. Median survival for those who did not undergo resection was 12 months. Six of the patients who did not undergo resection were deemed unresectable due to extensive liver involvement or peritoneal metastases. The other seven were deemed unresectable based on preoperative imaging. In the study, 17 patients underwent a second operation after a median interval of 37 months due to recurrence. The median survival after the second operation was 26 months [Chakrabarti et al. (2019) performed a retrospective study by chart reviewing 42 patients with FLHCC treated between 1990-2017 at the Mayo Clinic . All tenFLHCC remains a rare tumor worldwide, and research is ongoing to determine potential risk factors, patient presentation, and effective treatment strategies. From the studies published regarding patient outcomes, it is evident that patients have prolonged survival if their disease is amenable to resection; however, reoccurrence is common. Our patient presented with a typical presentation of the disease and is unlikely to be a resection candidate, given the likely pulmonary involvement. Unfortunately, the patient was discharged before the biopsy of the pulmonary nodules.


Infantile perianal pyramidal protrusion (IPPP) is an uncommon and underreported benign cutaneous lesion characterized by a protrusion from the anal orifice. It is also believed to be often mistaken for other conditions. The unawareness of this lesion may be responsible for underreporting and an excessive concern both in providers and in parents. Timely diagnosis and reassurance need to be emphasized in the provider community.We report an interesting case of IPPP on the first day of life, which was erroneously diagnosed as imperforate anus at her delivery. The term infantile perianal pyramidal protrusion (IPPP) was first coined by Kayashima et al. in 1996 when they reported it for the first time . This beA full-term Caucasian female infant was delivered at 39 weeks and 1 day gestational age via normal vaginal delivery to a 28-year-old Gravida 2 now Para 2 mother. No significant maternal history except for basal metabolic index (BMI) > 30 and diet-controlled gestational diabetes was reported. Her birth weight was 2790 grams (16th percentile) and Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The infant did not require any resuscitation at birth. During the initial assessment by her nurse, the absence of an anal orifice was noted. The on-call neonatal provider evaluated the baby and diagnosed her with imperforate anus due to the absence of an anal orifice. The infant was made nil per oral and started on intravenous fluids. She was subsequently examined by the neonatologist. On examination, a fleshy pink pyramidal mass of approximately 4 mm × 2 mm was seen covering the anal orifice  and dermoscopy may aid in timely diagnosis and thus avoid unnecessary biopsy and histology ,12. US rIn conclusion, IPPP may not be as rare as it is reported in the literature, and awareness of this condition is paramount in avoiding unnecessary workup. Diagnosis can be easily made on history and a careful physical exam. Most lesions would resolve spontaneously or by treating the underlying cause. However, more studies are needed to document the natural course of this benign condition.