Primary myoepithelial carcinoma of the lung (PMC-L) arising from the bronchial glands in lower respiratory tract is exceedingly rare. Thus far, few cases in adults and only one in a pediatric patient have been recorded. To our knowledge, this is the first report of PMC-L successfully removed in a child, focusing on the importance of multidisciplinary primary surgery for the treatment of this tumor. A 7-year-old girl was admitted for persistent cough and fever; she was unresponsive to oral antibiotics. Chest radiography showed loss of volume of left lung sustained by almost total atelectasis. After routine clinical investigations, she was referred for computed tomography scan and magnetic resonance imaging that documented the presence of a mass occupying the entire left upper lobe, infiltrating the pulmonary hilum . After multidisciplinary evaluation, the histopathologic diagnosis of PMC-L was established using ultrasonography-guided transthoracic core needle biopsy and bronchoscopic biopsies. She was then subjected to left pneumonectomy under extracorporeal circulation and positioning of a thoracic expander filled with 200 mL of saline solution. The postoperative course was uneventful. With TREP (very Rare Tumor in Pediatric Age) consent radiotherapy was performed (61.2 Gy). At the 10-month follow-up, the patient was alive, breathing normally without any oxygen support, without recurrence of PMC-L or metastasis, and without any chest deformity. To our knowledge, this is the first case where a pediatric patient was successfully operated for PMC-L involving the whole lung. Extracorporeal circulation enabled us to perform radical primary surgery. Prosthesis implant not only maintained normal chest expansion but also allowed focused radiotherapy, thus enabling us to prevent damage to vital organs. Epithelial–myoepithelial tumors are rare neoplasms that originate from the salivary glands and comprise 1% of all primary tumors. Epithelial–myoepithelial carcinoma was first described in the salivary glands in 1972. The World Health Organization has classified this carcinoma as a malignant tumor composed of variable proportions of two cell types that typically form duct-like structures.Chlamydia pneumoniae,Mycoplasma pneumoniae, and QuantiFERON test for tuberculosis were negative. A computed tomography (CT) scan showed an extended mass that occupied the entire upper lobe with axial dimensions of 70 × 47 mm and assumed discreet enhancement in all the study phases. The bronchi for the upper lobe were no longer patent with endobronchial projection affecting the middle third of the main left bronchus. The mass caused posterior dislocation of the pulmonary arterial vascular axis and inferior dislocation of the superior pulmonary vein. Based on the radiological reports, the patient was referred to our pediatric surgery unit. To better define the characteristics of the lesion, a magnetic resonance imaging was performed. The pictures confirmed the presence of an expansive pulmonary lesion with a probable origin from the upper left lobe with transverse diameters of 57 × 45 mm and longitudinal extension of 85 mm. The lesion infiltrated the pulmonary hilum and invaded the bronchial structures up to the left main bronchus ∼2 cm from the carina. It appeared adherent to the common trunk of the pulmonary artery and to the pericardium at the level of the left atrium and ventricle with infiltration of the superior pulmonary vein. The mass appeared to be surrounded by a thin rim of consolidated lung parenchyma; therefore, it does not seem to infiltrate the thoracic wall (FUSgene in 16p11,EWSgene in 22q12, andSS18gene in 18q11.2. The case was discussed among pediatric surgeons, oncologists, and radiologists who concluded that the nature of the cancer was not sensitive to neoadjuvant treatment, thus indicating elective radical surgery.Chest radiography was performed for a 7-year-old girl with persistent cough and fever who was unresponsive to oral antibiotics and showed loss of volume of left lung sustained by almost total atelectasis. The patient was then admitted to the pediatric ward to begin intravenous antibiotic therapy. Serological tests foric wall . For a After the performance of sternotomy and opening of the pleura bilaterally, the left thoracic mass was revealed. The mass infiltrated the entire left lung and was attached to and infiltrated the pericardium, the left pulmonary artery and veins, as well as the left bronchus. We proceeded to release the left lower lobe by making selective distal ligation of the pulmonary arterial and venous vessels and of the left lobar bronchus. The lobectomy was completed with a mechanical stapler. The lower lobe appeared infiltrated by the mass at the level of the fissure. After resecting the lingular lobe, it was necessary to proceed under extracorporeal circulation to isolate the left pulmonary artery and veins. We isolated the pulmonary artery trunk as well as tied and dissected the Botallo's duct and the left branch of the pulmonary artery. The two left pulmonary veins and the main left bronchus were dissected and sutured. The mass was isolated from the remaining pericardium, from the vagus nerve, and from the phrenic nerve. Once the left pneumonectomy was completed and hemostasis was achieved, the interatrial defect was surgically closed, and a temporary pacemaker was implanted. A thoracic expander of 11 × 6 cm was applied and filled with 100 mL of saline solution. The expander reservoir connector was placed outside of the chest wall, and the reservoir was placed in a subcutaneous pocket. A left thoracic drain was placed dorsal to the expander. The postoperative course was uneventful. The temporary pacemaker was removed after 5 days, and the drain was removed after 8 days. The expander was gradually filled up to 200 mL with saline in three different infusions over 3 weeks . The paMyoepithelial carcinoma primarily arises from the salivary glands, rarely from the soft tissue.PMC-L is exceedingly rare. To our knowledge, our case represents the first pediatric case with surgical treatment of PMC-L that involved the whole lung. Surgery is the main treatment for operable patients. In our case, surgical excision was successful and can be expected to be curative.


Salivary gland tumors are uncommon in children. They consist of variable histopathological subtypes of benign and malignant tumors. EMC is a discrete entity among the WHO classification of salivary gland tumors since 1991. EMC is considered a low-grade malignant salivary gland tumor arising from intercalated ducts. Typically, it affects an adult female individual. Surgical resection with a negative margin is the mainstay treatment option. EMC has a potential for metastasis with a high rate of recurrence. Based on the available English literature, two cases of EMC diagnosed in a pediatric age group have been reported. Therefore, we describe the third EMC that developed in the left parotid gland of a young child. The diagnosis of EMC was established through histopathological examination of the total parotidectomy specimen and neck lymph node dissection, together with ancillary studies. Later, the patient suffered from cervical lymph node enlargement due to metastasis in which FNAB was taken. Metastasis from the known EMC was suspected with cytomorphological features in smears and cell block. Immunohistochemistry markers for the biphasic components were supportive of EMC. Due to advanced disease, the patient necessitated a concomitant treatment of radiochemotherapy. Besides, there was radiological evidence of bilateral multiple lung metastatic nodules. However, a biopsy was not sent for pathological confirmation. Epithelial-myoepithelial carcinoma (EMC) is a rare low-grade biphasic  malignant salivary gland tumor . It accoA 13-year-old boy not known to have any medical illnesses presented to King Abdul-Aziz University Hospital (KAAUH) complaining of progressive, painless left facial swelling accompanied by facial nerve palsy since few months before admission. By palpation, the left facial swelling was a solid mass in nature, irregular in shape, and adherent to deep soft tissue. A computerized tomography (CT) scan of the neck and soft tissue was performed and found to have a large heterogeneous soft tissue density involving both superficial and deep portions of the left parotid gland associated with multiple foci of calcification . The lesth decade of life, two reported EMC cases have been described in the parotid gland of a young child followed by recurrence and lung metastasis after three years [Head and neck EMC is a rare low-grade neoplasm, representing less than 1% of salivary gland tumors . Moreoveee years . Similaree years . One stuee years . Microscee years . Since Eee years . Adequatee years . On the ee years .Despite EMC having female predominance with the peak incidence in the sixth and seventh decade of life, it has been described in young children and male individuals in many studies. A high index of suspension is valuable, especially when evaluating a parotid gland mass in children. Careful histopathological examination for features defining the aggressive behavior of EMC is important. Patients with advanced disease and nodal involvement need more aggressive therapy. Close periodic follow-up is necessary since EMC has an increased rate of recurrence and has a potential for metastasis.


Epiploic appendagitis (EA) is a rare clinical entity caused by an inflammatory/ischemic process involving the serosal outpouchings of the colon. Its clinical presentation of acute, localised, lower abdominal pain often mimics more common conditions like diverticulitis or appendicitis. The diagnosis of EA is challenging due to the lack of pathognomic clinical features. The definitive diagnosis primarily relies on cross-sectional imaging modalities like abdominal ultrasound or computed tomography (CT). Being a benign and self-limiting condition, it can be managed conservatively with analgesic and anti-inflammatory drugs. We present two cases to highlight EA as an important differential diagnosis for cases of acute lower abdominal pain, crucial to prevent unnecessary antibiotic therapy and surgical interventions. Epiploic appendagitis (EA) is a benign, mostly self-limiting, inflammatory/ischemic disorder of the epiploic appendages, which are fat-filled serosal outpouchings of the colon. Clinically, it often mimics the more common causes of acute lower abdominal pain such as acute appendicitis or acute diverticulitis -3. Owing2, who presented to the emergency department with a three-day history of an acute onset right iliac fossa pain with no other associated symptoms. Her past medical history included hypertension and a previous laparoscopy for ovarian cyst. On admission, her vital signs were stable. Abdominal examination revealed an extremely tender right iliac fossa, with guarding and no rebound tenderness. Blood investigations showed normal inflammatory and biochemical markers. Abdominal CT revealed a normal appendix with some inflammatory stranding seen in the mesoappendix  of 42 kg/mx Figure .With the clinical diagnosis of an early acute appendicitis, an emergency diagnostic laparoscopy was performed. On laparoscopy, the appendix appeared normal, although a diverticulum of the appendix was noted with a tortuous and infarcted appendage in the mesoappendix Figure .The specimen was retrieved and sent for histopathology that showed a normal appendix with hemorrhagic infarction and fat necrosis of the EA Figure .2 who was admitted with an acute onset right iliac fossa pain. Her past medical history was unremarkable. On examination, she had marked right iliac fossa tenderness and guarding with positive rebound tenderness. Rovsing and psoas signs were negative. With a clinical diagnosis of acute appendicitis, she underwent an emergency diagnostic laparoscopy that revealed a macroscopically normal-looking appendix. There was minimal serosanguinous fluid in the pelvis and no pelvic pathology was visualised on inspection. On further exploration, attached to the parietal peritoneum in the right iliac fossa, there was a pedunculated appendage that appeared infarcted and was therefore excised (Figure The second case is of a 22-year-old female with a BMI of 32 kg/md Figure .The patient was symptom free and comfortable on discharge. The histopathology report revealed a normal appendix.Epiploic appendages are pendulous adipose outpouchings protruding from the serosal surfaces of the large bowel . A normaThese were anatomically first described in 1543 by Vesalius, but their clinical significance was not known until 1853 when a source of free intra-peritoneal loose bodies was questioned, and Virchow postulated that their detachment from the bowel surface might be the source ,4. VaryiEA can be either primary or secondary. The primary cause is either due to torsion or due to spontaneous venous thrombosis. Due to the pedunculated shape and tenuous blood supply, they are prone to spontaneous torsion. Torsion of epiploic appendages was first noted by Payr in 1902 . It can The incidence of EA ranges from 2% to 7% in cases of provisional diagnosis of acute diverticulitis and 0.3% to 1% in suspected acute appendicitis cases . Acute EClinically, EA presents with acute colicky or constant abdominal pain mimicking diverticulitis, appendicitis or cholecystitis  dependinGiven the non-specific laboratory investigations, imaging modalities are vital for diagnosis . The halAlthough rare, EA should be an important differential diagnosis for the acute onset of localised abdominal pain without raised inflammatory markers. If suspected, an appropriate imaging modality, either abdominal ultrasound or CT scan, should be ordered to rule out EA. Early pre-operative diagnosis can prevent unnecessary hospitalisations, antibiotic therapy and surgical interventions. On diagnostic laparoscopy, in presence of serosanguinous free fluid in the abdomen and no associated pelvic pathology, a thorough examination of the colon should be done to look for any evidence of EA. Additionally, conservative management with non-steroidal anti-inflammatory drugs should be considered as its initial management in the absence of other complications.


Meckel’s diverticula are a rare cause of small intestinal strangulation, diagnosed at laparotomy or necropsy. This congenital anomaly of the gastrointestinal tract originates from a remnant of the vitelline duct. In reported equine cases, they present as a full-thickness diverticulum on the antimesenteric border of the distal jejunum or proximal ileum.On laparotomy a Meckel’s diverticulum positioned at the mesenteric side was found to be the cause of small intestinal strangulation. This position is very uncommon and to the best knowledge of the authors there is no unambiguous description of another case.Meckel’s diverticula should be on the list of differential diagnoses in cases of small intestinal strangulation. As in humans, equine Meckel’s diverticula can have the standard antimesenteric as well as a more exceptional mesenteric location. This case adds to the series of anecdotal reports of anomalies with regard to Meckel’s diverticula in the horse. Vitelline anomalies are a rare and often overlooked cause of small intestinal strangulation in horses , 2. DuriThis report describes the case of a 7-year old warmblood mare with an atypical mesenteric positioned Meckel’s diverticulum as the cause of small intestinal strangulation diagnosed at exploratory laparotomy.A 7-year-old, 495 kg Dutch warmblood mare developed signs of acute colic  after riding. The horse did not respond to intravenous analgesia with flunixin meglumine given by the referring veterinarian and was referred to the Utrecht University Equine Clinic . The mare arrived at the university clinic 2.5 h after the onset of symptoms.On presentation, the mare continued showing signs of abdominal pain. A general physical examination was performed, which revealed a heart rate of 48 beats/min, a respiratory rate of 10 breaths/min and a rectal temperature of 37.2 °C. Oral mucous membranes were slightly pale and tacky with a prolonged CRT. The abdomen was slightly distended. On abdominal auscultation borborygmi were absent on the left and reduced in frequency on the right side. Upon nasogastric intubation no reflux was obtained. Rectal examination revealed a mildly impacted pelvic flexure, no distended loops of small intestine could be palpated or seen on transcutaneous abdominal ultrasonography at this timepoint. Results of a hematological assessment and biochemical panel were still within normal limits.Based on these clinical findings and particularly on the severe persisting signs of colic, which were unresponsive to repeated analgesia and sedation, a tentative clinical diagnosis of a small intestinal strangulation was made. The mildly impacted pelvic flexure was assumed to be secondary. An exploratory laparotomy under general anesthesia was recommended.A) at 20.000 IU/kg body weight (BW) intravenously (IV) and gentamycin (Gentamycine 5%B) at 6.6 mg/kg BW IV. The horse was premedicated with 1 ml of detomidine (Domosedan 10 mg/mlC) IV and morphine (Morfine 10 mg/mlD) at 0.1 mg/kg BW IV, induced with ketamine (Narketan 100 mg/mlE) at 2.2 mg/kg BW IV and midazolam (Midazolam Aurobindo 5 mg/mlF) at 0.06 mg/kg BW IV. Anesthesia was maintained with isoflurane (IsoFloG) in oxygen. At the end of the surgery procaine penicillin (Procapen 300 mg/mlH) at 20.000 IU/kg BW was injected intramuscularly (IM).Pre-operatively the horse received benzylpenicillin  with its own mesentery Figure . The lumI) USP 0. The one-layered anastomosis was created with an interrupted Lembert pattern of polydioxanone (PDSJ) USP 3–0. The mesentery was closed with a simple continuous suture of polyglactin 910 (VicrylI) USP 0. At the end of surgery 1 L of carboxymethyl cellulose (Carmellose gel 2%K) was deposited intra-abdominally and the horse received dalteparin  subcutaneously to prevent intestinal adhesions. The abdominal wall was closed in four layers: the peritoneum was sutured with a simple continuous suture pattern of polyglactin 910 (VicrylI) USP 0, the linea alba with a simple continuous suture pattern of polyglactin 910 (SurgicrylM) USP 6, the subcutis with a simple continuous suture pattern of polyglactin 910 (VicrylI) USP 2–0 and finally the skin with a continuous intradermal suture pattern of poliglecaprone (MonocrylN) USP 2–0. A rolled gauze stent was sutured over the wound with interrupted cruciate sutures of nylon (EthylonO) USP 0. Recovery from anesthesia was uneventful.Intestinal motility appeared to be decreased orally and normal aborally of the strangulation. All parts of intestine were considered viable based on their motility, wall thickness and color. However, to prevent reoccurrence of a strangulation or other complications caused by the diverticulum (e.g. impaction), the decision was made to perform ‘en bloc’ resection of the anomaly and the associated jejunum of approximately 1 m. An end-to-end jejuno-jejunostomy single-layer anastomosis as described by Freeman (2019)  was perfHistopathological examination of the resected intestine was performed. The lumen of the diverticulum was covered by a stratified squamous epithelium. The second layer consisted of loose fibrous tissue, followed by a layer of adipose tissue and finally at the periphery a mesothelial, serosa-like layer. There was no lamina muscularis present in the diverticulum. The histological examination of the neighboring jejunum showed that all expected anatomical layers were present.P, lidocaine; 50 mcg/kg/min), antibiotics  NSAIDs , low-molecular weight heparin  and gastroprotectants . The horse was regularly checked for reflux by nasogastric intubation. The first 24 h after surgery the horse was fasted and allowed to drink 2 L/2 h, after which silage and grass were slowly reintroduced.Following surgery, the horse was admitted to the intensive care ward with treatment consisting of continuous infusion of fluids  did not resolve the condition. Based on these findings, and as colic persisted, the decision was made to perform a re-laparotomy. During repeat laparotomy, the anastomosis was checked and assessed to be patent and viable, with no impacted ingesta and a normal luminal diameter. The small intestines were decompressed to the cecum and the impaction in the ascending colon was resolved through an enterotomy at the pelvic flexure.In the early post-operative period, the horse developed post-operative ileus with enterogastric reflux and mild colic signs . On rectal examination, the previously encountered mild colonic impaction had increased in size, consistency was much firmer as a result of dehydration. Medical treatment with laxatives and metoclopramid CRI (EmepridQ) at 1.1 mg/kg BW q12h was followed by 5 days of oral meloxicam (MetacamU) at 0.6 mg/kg BW q24h. The amount of roughage and soaked feed was gradually increased until the horse was back to full ration 8 days after the second surgery. The horse was discharged after 14 days of hospitalization.Post-operative course after the second laparotomy was favorable. Supportive therapies were gradually discontinued based on clinical findings and bloodwork. Infusions and Dalteparin were stopped after 3 days. Antibiotics were discontinued after 5 days. Gastroprotectants and NSAIDs were given for 10 days after surgery; 5 days of intravenous flunixin meglumine  are a congenital disorder of the gastrointestinal tract found in several species like humans, pigs and horses , 2, 12. In literature a Meckel’s diverticulum is usually characterized by an origin at the antimesenteric aspect of the small intestine, however in humans there are a few cases known to have had a mesenteric positioned diverticulum , 15, 16.Just like a Meckel’s diverticulum, a mesodiverticular band is a kind of vitelline anomaly . A mesodMeckel’s diverticula can be an incidental finding; however, they are most often found to be related to the cause of colic , 8, 9. TSurgical intervention is straightforward for symptomatic diverticula, however a prophylactic surgical intervention for asymptomatic incidental diverticula is debatable , 12, 26.Although there was a mild secondary impaction palpated during the initial surgery, the decision was made not to empty and flush the colon through a pelvic flexure enterotomy at that time. It was assessed that this impaction could be resolved on its own, based on the large amount of fluid decompressed from the small intestines into the cecum; also, this decision helped minimize surgery time. However, in the first 36 h after surgery a larger and firmer impaction developed, probably in part secondary to ileus causing fluid retention in the small intestinal lumen. A re-laparotomy was performed to resolve the impaction and from that point the horse recovered well.Small intestinal strangulations carry a poor to guarded prognosis, with highest mortality in the peri-operative period . Short-tIn conclusion, Meckel’s diverticula are a rare cause of small intestinal strangulation encountered in horses of a wide age range. In literature, they are often defined as an anomaly of the vitelline duct, presenting as a full-thickness diverticulum on the antimesenteric border of the distal aspect of the jejunum or proximal aspect of the ileum . This ca


Pilonidal sinus usually arises in the area of natal cleft in young men. Hair accumulation in the wound in the perianal region is very rare. Although pelvic magnetic resonance imaging (MRI) is used in the differential diagnosis of perianal region diseases, it is not possible to diagnose perianal pilonidal sinus by MRI.A 24-year-old male patient presented with the complaint of swelling and itching in the anus for several months. On physical examination, the area giving endure and fluctuation was detected in the perianal region. An area of 2 × 2 cm hyperintense in T2 was seen in pelvic MRI. In the surgical exploration, collection of hair was seen at 7 o’clock at perianal region with pus discharge. After the cavity was cleaned, crystallized phenol was applied to the area and the wound was left to secondary healing. Granulation was observed after 4 weeks.Perianal pilonidal sinus is very rare in the literature and is often confused with other perianal diseases such as perianal abscess or anal fistula. In this respect, when examining perianal diseases, especially in young men, perianal pilonidal sinus should be kept in mind in the differential diagnosis. It is defined as a granulomatous lesion with dense hair, usually located on the sacrum in young men with hair . Here, w2A 24 year-old young male patient applied to the clinic with a 2-month history of itching and swelling around the anus in 2018. A physical examination in the prone position showed presence of left sided indurated and fluctuated approximately 2 × 2 cm diameter area of perianal region. He had no history of any previous anal surgery. MRI demonstrated that 2 × 2 cm  hyperint3Pilonidal sinus typically derives in the space of natal cleft in young men. Diagnosis may be mixed up with the other perianal diseases like as perianal fistula or hidradenitis suppurativa. Pilonidal sinuses are usually present in sacrococcygeal area of young men. The presence of pilonidal sinus in association with anal canal is a quite rare situation. Less than 20 perianal pilonidal sinus have previously been reported .Aggarwal K et al. presented the case of pilonidal sinus arose in the intersphincteric area in the anal canal . In thisAlthough there were similarities between the scheme of 3 cases published by T. H. Walsh and C. V. Mann in 1983 and our case, anal fistula did not develop in our case, and its location was suprasphincteric, not intersphincteric. On the other hand, Doll D et al. reported that when the anal canal was opened in their case, they encountered a very small amount of hair under the anal mucosa and submucosa .Moreover, the etiopathogenesis of this case was more like anal abscess formation based on cryptoglandular theory. In the literature, several cases have been reported that presented with complicated anal fistula, a complication of anal abscess, and the etiology of which was found to be anal pilonidal sinus during surgery . In our This case demonstrated a suprasphincteric located perianal pilonidal sinus abscess. In the treatment, a surgical approach such as the approach to anal abscess was applied, the abscess was drained, the hair in the cavity was removed, the cavity was washed with saline and crystallized phenol was applied to the cavity. Today, although the application of crystallized phenol to pilonidal sinus cases located in the sacrococcygeal area is common in the literature, no post-drainage phenol application was observed in the literature, similar to this case .The limitation of this case report is that the patient's pictures after granulation have not been presented.4Anal pilonidal sinus is a very rare condition in clinical practice. When diagnosed, abscesses such as perianal abscess should be drained and the cavity should be cleaned and the wound should be left to secondary healing. However, as seen in this case, successful results can be obtained with crystallized phenol application after cleaning the cavity. We predict that with the spread of perianal pilonidal sinus cases in the literature, it will be easier to determine the treatment algorithm of perianal region diseases that are difficult to manage.The author has no conflict of interest.None.The study is exempt from ethical approval.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.1Name of the registry: not applicable.2Unique identifying number or registration ID: not applicable.3Hyperlink to your specific registration (must be publicly accessible and will be checked):not applicable.Ozlem Zeliha Sert, MD, Haydarpasa Education and Research Hospital, General Surgery Department, Istanbul, Turkey.Not commissioned, externally peer-reviewed.


Emergency department physicians should incorporate point-of-care-ultrasound (POCUS) in the assessment of patients presenting with acute scrotal pain for rapid identification of the time sensitive urologic emergency, testicular torsion.A 20-year-old otherwise healthy male, with a history of monorchism, presented to the emergency department with vague testicular pain. A POCUS was performed, which demonstrated attenuated arterial flow of the patient’s single testicle as well as twisting (“whirlpool sign”) of the spermatic cord, both highly specific ultrasonographic findings of testicular torsion.These findings expedited definitive management resulting in the salvage of the single ischemic testicle. Scrotal and testicular complaints comprise at least 0.5% of all emergency department (ED) visits. Of the various etiologies of testicular discomfort, only testicular torsion is seen as a true, time-sensitive urologic emergency.3The congenital absence of one testes, monorchism, is considered rare.A 20-year-old male with a past medical history of monorchism presented to the ED with one hour of sudden onset, cramping-like, progressively worsening, 10 out of 10 testicular pain that woke him from sleep. The pain had been present for approximately four hours. He denied any trauma, dysuria, or concerning sexual history. When questioned on the medical history of his single testis, he reported having only one testicle from birth, without understanding the etiology or ever having been evaluated for it.His vital signs upon presentation demonstrated a heart rate of 79 beats per minute, systolic blood pressure of 145 millimeters mercury, respirations of 18 breaths per minute, oxygen saturation of 99% on room air, and an oral temperature of 97.7° Fahrenheit. Physical exam demonstrated a single, firm, edematous testicle with a horizontal lie that was significantly tender to palpation. There was also a tender, firm spermatic cord. There was no surrounding scrotal edema. His abdomen was soft and nontender, and there was no evidence of inguinal hernia. A point-of-care ultrasound was performed, which demonstrated a heterogenous, single right testicle located within a surrounding simple hydrocele . The tesThe epididymis appeared unremarkable. The spermatic cord was identified, and when tracked proximally had an abrupt change in its course with a spiral twist in the scrotal sac, referred to as the “whirlpool sign” .Unfortunately, since the patient had a history of monorchism there was no contralateral testicle for comparison of vascular flow or echotexture. Given the patient’s complaint, exam, and sonographic findings, a diagnosis of testicular torsion was made. Urology was emergently consulted, and the patient was scheduled for immediate surgery. A formal comprehensive ultrasound was performed pending the consultant arrival, which reiterated findings described in the POCUS. The patient was taken to the operating room and had a successful detorsion and orchidopexy, and was ultimately discharged home. Outpatient follow-up evaluation performed by urology five weeks after surgery demonstrated a preserved, single viable testicle.Ultrasound is the imaging modality of choice for the diagnosis of testicular torsion. A definitive sign, as observed in this case, is twisting of the spermatic cord, also called the “whirlpool sign.”11What do we already know about this clinical entity?Testicular torsion is a time sensitive emergency.What makes this presentation of disease reportable?The use of point-of-care ultrasound to expedite definitive management of torsion in a patient with one viable testicle to preserve fertility.What is the major learning point?Point-of-care ultrasound can help confirm testicular torsion rapidly at the bedside.How might this improve emergency medicine practice?Point-of-care ultrasound should be utilized in patients who present with acute testicular pain to facilitate earlier diagnosis, surgical consultation, and definitive management.When performing a scrotal ultrasound, the testicle in question can be compared to the contralateral testicle. Differences in echotexture, testicular size, and vascular flow can aid in the diagnosis of testicular torsion. What makes this case unusual is the patient’s history of monorchism; thus, the ultrasonographic findings could not be compared to a healthy testicle. The appearance of the twisted spermatic cord and absence of testicular flow as visualized by POCUS made the diagnosis of testicular torsion extremely likely even without the ability to compare our findings to a contralateral testicle.Point-of-care ultrasound helps emergency physicians improve the accuracy of their diagnoses and provides better overall patient care. If a patient presents with testicular or scrotal pain, using POCUS to examine for attenuated or absent vascular flow with the “whirlpool sign” of the spermatic cord may aid in confirming the diagnosis of testicular torsion, thus preventing delay in care and providing consultants with more objective data, especially in resource-poor settings where formal imaging may not be readily available.


Abdominal pain is a common chief complaint that can represent a wide breadth of diagnoses, ranging from benign to life-threatening. As our diagnostic tools become more sophisticated, we are able to better identify more causes of potentially life-threatening diseases. One such disease that is relatively unfamiliar to clinicians is spontaneous isolated celiac artery dissection (SICAD).We describe a case of a 46-year-old man who presented to our emergency department with a chief complaint of abdominal pain and was found to have a SICAD and was successfully treated with anticoagulation, antihypertensives, and observation.It is important for emergency physicians to keep this potentially life-threatening condition in mind and to know the appropriate first steps once identified. Abdominal pain is one of the most common presenting chief complaints of patients in the emergency department (ED).9 thousands (K) per microliter (mcL) (range 3.6–10.6 K/mcL), with a normal lipase, normal liver function tests, and negative troponin. Given the history and exam, a CT angiogram of the chest, abdomen, and pelvis was ordered, which revealed SICAD  to be universally fatal. With the increased utilization of computed tomography imaging, it is being detected more frequently.What is the major learning point?This rare, but potentially fatal condition should be considered in the differential diagnosis for abdominal pain; particularly in male smokers with a history of hypertension.How might this improve emergency medicine practice?It is important for emergency physicians to consider this potentially fatal diagnosis. Knowledge of this condition, risk factors and presentation will increase the likelihood of detection resulting in life-saving therapies.Abdominal pain as a chief complaint can vary from benign to catastrophic. Spontaneous isolated celiac artery dissection is relatively rare, and can present from asymptomatic incidental finding to severe pain with bowel ischemia and peritonitis. Early diagnosis is critical to reduce morbidity and mortality and is typically detected on a contrast-enhanced CT. SICAD has a wide presentation range, but often resolves with conservative management. It is important for emergency physicians to keep this potentially life-threatening condition on their differential, and to know the appropriate first steps to take once identified.


Osteoclastic giant cell tumor of the pancreas is a rare aggressive tumor, counting for 2–7% of all pancreatic cancers. Surgery is considered the most appropriate treatment. We report a case of a 84-year-old man with incidentally detected 11cm tumor in the pancreatic tail and another 6 cm tumor located in the jejunum on abdominal computed tomography. The patient underwent distal pancreatectomy with splenectomy along with segmental resection of the tumor bearing part of the jejunum. On histological examination, osteoclast-like giant cells with some areas of metaplastic bone were observed which confirmed the diagnosis of osteoclastic tumor of the pancreas. The jejunal tumor was strongly c-kit positive on immunohistochemistry which confirmed the diagnosis of GIST. On the last follow up at 2 years after surgery, there is no evidence of recurrence or distant metastasis. Pancreatic OGCT has a better prognosis after resection than pancreatic adenocarcinoma. Its co-existence jejunal GIST, as seen in the index case, has not been reported in the English literature till date. •Osteoclastic giant cell tumor of the pancreas is a rare aggressive tumor, counting 2–7% of all pancreatic cancers.•Surgery is considered the most appropriate treatment.•Pancreatic OGCT has a better prognosis, after resection than pancreatic adenocarcinoma.•Its co-existence jejunal GIST, as seen in the index case, has not been reported in the English literature till date. In 20102A 84 -years –old lady with presented with epigastric pain and vomiting for 3 months. The pain was dull aching in nature, paroxysmal, unrelated to food and without radiation. There was no history of associated hematemesis, or weight loss. She had past history of myocardial infarction 3 years back for which she was taking oral antiplatelet therapy, Physical examination revealed an epigastric intra-abdominal mass measuring around 4 × 4 cm, firm in consistency with rounded borders. Routine blood investigations and tumor markers  were within normal range. Upper gastrointestinal endoscopy was unremarkable. Abdominal ultrasound (US) showed a 10 × 7 cm well-defined, round-like, mixed cystic and solid mass in the body of the pancreas. On contrast enhanced computed tomography of the abdomen (CT), a well-defined solid-cystic mass of 11 × 7 × 6 cm was found involving the body and tail of the pancreas . The cysMacroscopically, it was 11-cm well-defined tumor involving the body and tail of the pancreas. On cut section, areas of necrosis could be observed. On histological examination, the tumor cells were fusiform, epithelioid or polygonal in appearance with atypical nuclei. Osteoclast-like giant cells were observed within the stroma, consisting the major component of the tumor. . Some arOn the last follow up at 2 years after surgery, there is no evidence of recurrence or distant metastasis on CT abdomen and pelvis.3Osteoclastic giant cell tumor (OGCT) is a rare, distinctive, malignant pancreatic tumor that is typically large, frequently has a pancreatic ductal adenocarcinoma component, and has 3 classical cell types: osteoclastic, pleomorphic, and mixed. Pancreatic OGCT is more frequent in women with mean age of 58 years . The symGIST are the most common mesenchymal tumors of the gastrointestinal tract and usually show cKIT and DOG1 positivity on immunohistochemistry. The existence of pancreatic OGCT and jejunal GIST, as seen in the index case, has not been reported in the English literature till date. However, there are some reported cases of the co-existence of GIST having osteoclastic –like giant cells associated with other abdominal tumors ,7. There4Pancreatic OGCT are rare tumors, their association with jejunal GIST is even rarer. This is the first case to be reported in literature associating these two tumors. Its prognosis is better than pancreatic adenocarcinoma and its evolution is generally favorable after total surgical resection.Not commissioned, externally peer reviewed.This study has not received any funding.The study was approved by Ethics Committee.Study concept or design – MBM, HA.Data collection – HA, WF, RG.Data interpretation – MBM, AB, EH.Literature review – WF, SL, EH,ABA.Drafting of the paper – HA, MBM, SL.Editing of the paper – MBM, WF,AM.1. Name of the registry:2. Unique Identifying number or registration ID:3. Hyperlink to the registration (must be publicly accessible):As this was a case report and not a clinical trial, this study does not require registration.Waad farhat.None.The patient provided informed written consent prior to submission of this manuscript.The authors declare no conflict of interest.Informed consent was taken from the patients for this study.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee.The authors declare that they have no conflict of interest.


Introduction. Juvenile polyposis syndrome is a rare autosomal dominant disorder in children characterized by multiple polyps in the gastrointestinal tract. A variety of clinical features manifest, including prolapse of a polyp or entire rectum, gastrointestinal bleeding, anaemia, and intussusception. This condition if left unmanaged promptly leads to fatal complications including the development of cancer of the bowel. Case Presentation. A 13-year-old girl with a history of mass protrusion per anus associated with bloody diarrhea. Colonoscopy showed multiple polyps in her large bowel. She underwent total colectomy with ileorectal anastomosis and did clinically well post surgery with no complications. Conclusion. Juvenile polyposis syndrome is an inherited condition with significant morbidity and a high risk of colon malignancy. It is important for early screening and diagnosis and hence management in its early stages as there are no specific standard guidelines for children. Juvenile polyposis syndrome is a relatively rare autosomal dominant condition where hamartomatous polyps are found in the entire gastrointestinal tract but usually predominantly in the colon , 2. ThosA 13-year-old girl was referred to our center with a main complaint of generalized body swelling and difficulty in breathing for three months. The swelling started with both lower extremities and gradually became generalized. The girl also reported of awareness of heart beats and headache. The mother reported the child to have had several admissions due to mass protrusion through the anus with on and off history of bloody diarrhea since June 2018. She is the first born in the family of four, and her other siblings are well. Her maternal aunt also was reported to have had a history of a mass protruding through the anus.9 and moderate anaemia of 8.7 g/dl (microcytic hypochromic in nature). Serology for Hepatitis B and C surface antigen, ASOT, and blood for culture and sensitivity were negative.Upon admission, the girl had bilateral lower limb grade three pitting edema with anasarca, finger clubbing, tinge of jaundice on the sclera, tanner stage two, and marked conjunctival pallor. Abdomen was tender with hepatosplenomegaly of 4 cm below the costal margins and a loose anal sphincter tone on digital rectal examination. On the cardiac examination, heart sounds one and two were heard with a grade two diastolic murmur, nonradiating. Initial complete blood count revealed leukocytosis of 26.7 × 10Abdominal ultrasound was done and revealed free fluid in the abdomen and right lung pleural effusion. Doppler ultrasound of the right leg showed valvular insufficiency and cellulitis. Echocardiogram concluded a pericardial effusion of 12 mm and mild mitral and tricuspid valve regurgitation. The child was prescribed vitamin K intramuscular injection, intravenous Ceftriaxone, Captopril tablets, and Furosemide tablets and given multiple blood transfusions of whole blood.During her stay in the wards, she was reviewed by the gynecology team whereby sexual abuse was ruled out. The progress in the ward was good with a decrease in oedema, but after a few days, the patient developed a bullae lesion on the right leg which progressed into an ulcer. Doppler ultrasound was done which showed occlusive thrombus from the distal third of the superficial femoral vein, including the popliteal vein and extending into the posterior tibial vein, and concluded deep vein thrombosis and cellulitis, and there was no feature of bone involvement. She was kept on thrombolytics and managed accordingly.Colonoscopy was done under general anesthesia which showed multiple polyps throughout her entire large bowel, highest concentration of polyps at the sigmoid . Biopsy Juvenile polyposis syndrome is a rare disorder of the gastrointestinal tract described by the presence of hamartomatous polyps which are benign and have the tendency to become malignant, hence colon cancer . The conβ signal transduction pathway, and these genes are found in 50-60% of the patients [Those with the condition have 50 to 200 polyps throughout the colon and sometimes in the stomach and small intestines. The polyps are few centimeters in size, smooth head with a stalk. Microscopically, they contain abundant lamina propria and tubules lined by a normal columnar epithelium . Two parpatients , 3, 4, 7patients .Management outline of the condition is genetic screening for the genes specified along with genetic counseling giving importance to family pedigree. Surveillance is equally recommended for bowel cancer by endoscopic means . If few Juvenile polyposis syndrome is a rare condition featured by the presence of benign polyps in the gastrointestinal tract of pre- and school-aged children. They can present with anaemia from rectal bleeding, prolapsed of the rectum, or polyps per anus and if large enough can cause bowel obstruction. Genetic knowledge allows genetic diagnosis in about 40% with family pedigree screening.


Kerion is an inflammatory type of tinea capitis characterized by swelling and alopecia of the scalp, which could be mistaken as bacterial infection. It occurs most frequently in children. We report a 10-year-old child whose kerion was misdiagnosed as bacterial abscess and unnecessarily incised. Later, her condition was rediagnosed as kerion based on clinical appearance and potassium hydroxide wet mount. The lesions resolved completely with systemic antifungal treatment, griseofulvin, leaving residual scarring alopecia. The delay in the proper diagnosis and inappropriate treatment of this patient resulted in permanent scarring alopecia. Thus, clinicians must have a high index of suspicion for tinea capitis when dealing with inflammatory scalp lesions. Kerion is an inflammatory fungal infection of the hair follicle of the scalp, characterized by boggy swelling, purulent discharge, alopecia, and lymphadenopathy. It is more common among children. Different pathogens have been implicated to cause kerion, and the predominant are dermatophytes of genus Trichophyton and Microsporum . BecauseWe report a case of kerion of a child which was misdiagnosed and mismanaged as pyoderma with incision and drainage under local anesthesia, resulting in delayed specific treatment, unnecessary economic burden, risk of anesthesia and surgery, and severe morbidity of scarring alopecia. Thus, we recommend that patients especially children who present with boggy swelling on the scalp should be seen by dermatologists for its appropriate management.It is a story of a 10-year-old female child who presented with mild, tender, itchy, and boggy swelling of the scalp for one-month duration. The lesions started as a small tender nodule over the vertex which gradually increased in size to cover a larger area of vertex. It was associated with areas of hair loss and easily pluckable hairs and infrequent purulent discharge. For this, she visited a nearby surgeon who mistook it as a bacterial abscess and underwent incision and draining under local anesthesia. During surgical procedures, the scalp tissue was very friable to leave a chunk of depression, which could not be sutured and was referred to us for further management.Examination revealed a localized area of hair loss at the vertex of scalp (6 × 5 cm) with dispersed multiple boggy nodules and polygonal incised ulcer (3 cm × 1.5 cm) with friable edges at the middle of alopecia. Areas of purulent discharge and patchy hair loss were also noted at the periphery of lesions . The lefMicrosporum and Trichophyton, which are zoophilic dermatophytes. Potassium hydroxide (KOH) wet mount, Wood lamp examination, and dermoscopy aid in diagnosis, whereas the fungal culture helps to identify species which might not be always positive [Tinea capitis is a common and easily transmitted childhood fungal scalp infection. Kerion is a type of inflammatory tinea capitis associated with tender boggy swelling, purulent discharge, alopecia, and regional lymphadenopathy . It is cpositive . BecauseOur diagnosis was based on typical clinical features and KOH mount. Fungal culture and species identification were not possible because of unavailability of advanced laboratories facilities. The standard treatment of tinea capitis is systemic antifungal therapy for two to six weeks with oral terbinafine, griseofulvin, or itraconazole, whereas with griseofulvin, mycological cure and efficacy rates are generally high, so it is commonly preferred . The durAs illustrated in this case, kerion could easily be misdiagnosed as a bacterial infection due to its clinical presentation. Only the systemic antifungal therapy is the foundation of treatment, and surgical incision is unnecessary and is associated with hazards. In the absence of laboratory facilities, a trial of oral antifungal agents is justified while monitoring the treatment response. Clinicians should have a high index of suspicion for tinea capitis when dealing with inflammatory scalp lesions.


Chiari I malformation is the herniation of cerebellar tonsils below the level of the foramen magnum due to congenital or acquired pathologies. Acquired Chiari I malformation (ACM) may occur secondary to space-occupying lesions (SOLs), such as intracranial tumors due to elevated intracranial pressure (ICP), and can be accompanied by syringomyelia. ACM and syringomyelia have been shown to resolve after resection of the SOL, without the need for adjuvant posterior fossa decompression. The vast majority of SOLs leading to ACM have been reported in the posterior fossa, thus exerting a direct mass effect on the cerebellum. Supratentorial SOLs leading to ACM are much less frequent but, when present, are most commonly parieto-occipital. We report a rare case of a large anterior left frontal, parasagittal meningioma causing ACM and syringomyelia. These findings resolved following the resection of the meningioma, with no further surgical intervention. Our case demonstrates that ACM can occur secondary to an anterior supratentorial mass and further supports the idea that decompression of the posterior fossa is not required for the resolution of intracranial tumor-associated ACM and syringomyelia. Chiari I malformation (CIM) refers to the caudal herniation of the cerebellar tonsils for a variable distance below the foramen magnum. This displacement may restrict the flow of cerebrospinal fluid (CSF), resulting in syringomyelia . CIM mayAcquired Chiari I malformation (ACM) may arise secondary to space-occupying lesions (SOLs) such as meningiomas. In these patients, the SOL may be resected, resolving the ACM and syringomyelia without the need for posterior fossa decompression. In the majority of reported cases, SOLs are located in the posterior fossa or parieto-occipital region . Here, wThe patient is a 39-year-old, right-handed female with no significant medical history, who presented with progressive bi-frontal headaches for four months. She stated that her headaches were worse in the evening and frequently woke her up at night. She also complained of blurry vision. There were no focal findings on neurological examination.Her symptoms prompted an ophthalmologic examination, which was notable for papilledema. Magnetic resonance imaging (MRI) showed a large, left, medial-frontal enhancing extra-axial tumor, consistent with meningioma, which measured 7.1 cm in its longest diameter and invaded the frontal calvaria Figure . There w3 , we measured the size of the tumor, excluding the intraosseous component, as 44.715 cm3 Figure . When ac3 Figure .Our patient underwent gross total resection of the meningioma with excision of the involved superior sagittal sinus. We also performed titanium mesh cranioplasty to repair the craniectomized calvaria that was involved with the tumor. Pathology was consistent with World Health Organization (WHO) grade II atypical meningioma. Postoperative MRI seven months later demonstrated near-complete resolution of the peritumoral edema around the resection cavity Figures -3B, as wCIM is classically thought to be a congenital anomaly in which hydrocephalus was originally implicated in the tonsillar herniation . Other sWang et al. conducted a systematic review of surgical management of ACM secondary to SOLs . SpecifiIn the same systematic review of 44 patients, 36% of lesions were meningiomas while 32% were arachnoid cysts . In manyACM secondary to an intracranial tumor is a rare finding, with a lack of large prospective studies and only one systematic review on the topic. Furthermore, specific measurements of the size of SOLs causing ACM, as well as precise measurements of tonsillar descent, are not consistently reported in the literature. While the majority of reported cases involve infratentorial masses, our case demonstrates that a large anterior frontal tumor with significant vasogenic edema may increase the ICP enough to shift the craniospinal gradient and cause tonsillar herniation. Our case is also consistent with the notion that an adjuvant posterior fossa decompression surgery is not required for the resolution of ACM and syringomyelia secondary to tumors.


Anterior mediastinal masses are generally asymptomatic until they grow and compress surrounding structures. Chest X-rays only suggest a mediastinal abnormality and contrast-enhanced CT scan and MRI are necessary for a better definition of the lesion. The classification of the anterior mediastinal masses is based on their etiology and it is sometimes a challenge to have an accurate differential diagnosis based only on radiological examinations: therefore, only the histopathological examination makes the correct diagnosis. Surgeons generally agree that symptomatic masses or those with progressive growth should undergo surgical resection. We report a case of an accidental finding of an organized thymic hematoma in a 46-year-old female. At first totally asymptomatic, the hematoma was misdiagnosed for a thymic cyst and resected when it increased in size and compressed surrounding mediastinal structures. A detailed anamnesis highlighted a minor thoracic trauma which turned out to be the cause. Retrosternal hematoma generally grows several months after trauma and initial stabilization; therefore, it is mandatory to include an organized hematoma in the differential diagnosis of the retrosternal neoformations. It extends from the diaphragm, inferiorly, to the thoracic inlet, superiorly, and contains thymus, mediastinal fat, lymph nodes, internal mammary arteries and veins.Mediastinal cysts are well-marginated round lesions that contain fluid and are lined with epithelium. They represent 12–30% of all primary mediastinal masses, more than half of which are located in the anterior compartment.Mediastinal masses are most frequently asymptomatic, but they may cause cough, dyspnea, chest pain, Horner syndrome and other symptoms due to the compression they apply on surrounding structures.In the diagnostic process, it is of primary importance to take into account chest radiography findings suggestive of a mediastinal abnormality, since chest X-rays are the most common imaging examination performed. Although small lesions may not be visible, large lesions often may manifest with loss of the normal mediastinal contours or a mass in the retrosternal space in lateral chest projection. Therefore, chest X-rays can only be considered a screening examination.2,3Once an abnormality is identified at chest radiography, CT with intravenous contrast agent is the first choice imaging modality. MRI and PET/CT scan can be used in selected cases and offer additional information that can further refine the differential diagnosis.Since it is difficult to make an accurate diagnosis relying on radiological examinations only, surgeons generally agree that symptomatic cysts or those with progressive growth should undergo surgical resection.We present the case of a patient with a neoformation of the anterior mediastinum, treated with a feasible, safe and mini-invasive thoracic surgical technique for the mediastinum pathology: robotic-assisted thoracoscopic surgery (RATS).We report the case of a 46-year-old female, with a family history of Familiar Dilative Cardiomyopathy, admitted to the Thoracic Surgery Department of our Hospital for an unusual massive neoformation of the anterior mediastinum. The patient had no significant comorbidities and was a smoker of five packs of cigarettes/year.In 2018, the patient was subjected to a contrast-enhanced CT of head and neck because of persistent hemicrania. Accidentally, the upper thorax section images documented the presence of a neoformation of the anterior mediastinum. A thoracic high-resolution CT (HRCT) was then performed and documented the presence of a fluid oval lesion (77×47 mm) in the right-middle mediastinum, positioned between the right anterolateral tracheal wall and the carina and with no contrast enhancement of its thin walls. Therefore, the diagnosis of a cystic neoformation of the thymus was suggested and in consideration of the Hounsfield Unit (HU) scale of the cyst content, it was defined as a complicated cyst. Differential diagnoses also led to the suspect of a thymic cystic neoplastic lesion.Laboratory tests, performed to rule out cyst superinfection, were in the normal ranges with negative phlogosis indices. The possibility of characterizing the mediastinal neoformation through fine needle aspiration biopsy (FNAB) was excluded due to its cystic component. The removal of the neoformation through a sternotomy was therefore suggested, but the patient refused. The female was therefore offered a close follow-up.In January 2019, both chest X-ray and chest CT documented an increase in size (91×73 mm) . After aAnother thorax CT examination was then performed, revealing extension of the lesion in the upper and middle mediastinum (10×8×11 cm) with contrast enhancement of its walls. Medially, the lesion was close to the aortic arch and the brachio-cephalic trunk (Natsis type-I); cranially, it was close to the right subclavian vein; caudally, it was adjacent to the right pulmonary artery, which appeared slightly compressed. The mass was also very close to the superior cava vein (SCV) and the anonymous veins, sharply compressed and dislocated . The maiIn consideration of the increase in the size of the mediastinal neoformation and the initial symptomatic compression of the mediastinal structures, the patient was hospitalized and prepared for surgery.The main diagnostic hypotheses were complicated thymic cyst or germ cell tumor with a cystic component, but different types of anterior mediastinum masses exist and may have similar clinical features. Therefore, it is important to distinguish one from another:Bronchogenic cysts: result from abnormal ventral budding of the tracheobronchial tree during embryological development. Their CT attenuation values can vary from water-to-soft tissues. Most of them are localized in the subcarinal or right paratracheal region;Neuroendocrine tumors: composed of small, uniform and round cells. The most common one is thymic carcinoid, the onset of which is observed in Cushing Syndrome;Mediastinal thyroid: enlarged gland distorted by multiple nodules and surrounded by a fibrous capsule. It causes displacement and compression of the trachea;Germ cell tumors: on CT, teratoma contains a prominent cystic component, small dense localized areas of calcification, fat or mixed low-density material;Thymolipoma: composed of lobules of fat and thymic tissue;Thymoma: composed of thymic epithelial cells mixed with lymphocytes. Almost half of the patients with thymoma suffer from Myasthenia Gravis;Thymic cysts: they fall into three main categories, congenital, acquired and neoplastic. On CT, congenital ones appear as well-defined water-attenuation masses with imperceptible walls;Pericardial cyst: pericardial cysts are rare entities and comprise 7% of all mediastinal masses. They are commonly congenital, but traumas, bacterial or parasitic infections, pericarditis and cardiac surgery may also result in the formation of pericardial cysts.4,5Lymphomas: 15% of the mediastinal masses are lymphomas . Chest CT generally documents a lobulated or smooth soft tissue attenuating mass of the anterior mediastinum with paratracheal involvement. Presentation with low-density cystic areas are common.6As a first step, to decide the best following surgical approach, exploration of the anterior mediastinum was performed using the right robotic approach with the Da Vinci Si. On 30th January 2019, the patient underwent robotic surgery under general anesthesia.The exploration of the anterior mediastinum confirmed the presence of giant neoformation of brownish color starting from the thymus, with dislocation of the surrounding structures. In consideration of the dimensions and to avoid the execution of a sternotomy, a biopsy of the mass was obtained and sent for a fresh frozen examination. The tissue resulted in negative for neoplasm and documented the presence of fibrous tissue containing blood cells. Therefore, an additional utility incision was performed at IV intercostal space to allow the decapitation of the mass.Its fluid content was aspired  and the neoformation was then cautiously moved from the vena cava and the pericardium, but it presented tenacious adhesion to the thymic tissue and the pericardium in its most caudal portion. For this reason, the lesion floor remained in place and was not removed due to its non-neoplastic nature. After the removal of the neoformation, all the structures that were found to be dislocated returned to their natural anatomical sites.The postoperative course was regular with a resolution of the symptoms. Following radiological examinations documented on-axis mediastinum  and pleuThe definitive histological examination documented fibro-adipose tissue with hemorrhagic content covered by hemosiderophages, compatible with outcomes of chronic hemorrhaging, mixed with lymphoid tissue containing thymic lymphocytes . The presence of cystic epithelium was not documented, therefore conclusive diagnosis of chronic intrathymic hemorrhage was made.The patient was therefore called for the communication of the outcome of the histological examination and she was asked to refer to any previous thoracic traumas. She reported having a small thoracic trauma years ago caused by a car crash, that did not require hospitalization or performing in-depth examinations but that was followed by a few days of retrosternal pain.Our final diagnosis was an organized thymus hematoma.Follow-up at 3 months with chest X-ray and at 6 months with thorax CT with contrast documenting no recurrence of the disease .7–10Despite the advancement of technological innovation, the most important action that a doctor has to accomplish is an accurate anamnesis. In our case, if a detailed medical history had been collected, an organized hematoma would have been probably taken into consideration for the differential diagnosis. On the other hand, it must be considered that the clinical trend of the retrosternal hematoma was particular because of its slow increase in size, which occurred several months after the trauma. An examination that, if carried out, would probably have given clinicians additional imported data is MRI. MRI could have provided important information regarding the content of retrosternal collection and probably allow a distinction between complicated thymic cysts and hematoma. Today, minimally invasive surgery represents a valid option. The robotic-assisted thoracic surgery (RATS), as demonstrated in many articles, allows an ideal approach to the diseases of the anterior mediastinum.In our clinical case, robotic surgery allowed an optimal exploration of the mediastinum without needing to perform a sternotomy. The robotic technique approach first allowed to make a diagnosis and subsequently to assess the relationship between neoformation and mediastinal structures. Thanks to a high-definition three-dimensional view and more precise and flexible robotic arms, the surgeon can assess the actual operability of the patient and decide to continue the surgery with a minimally invasive robotic technique.The medical history and the physical examination of the patients are fundamental instruments in the hands of a medical doctor.The first investigation is a chest X-ray, that helps detecting a loss of normal mediastinal contours, followed by chest contrast-enhanced CT, which represents the best choice to study mediastinal masses.Hematoma should be included in the differential diagnosis of retrosternal neoformations, considering its characteristic growth, even several months after the initial stabilization following a trauma.In case of indeterminate pathologies of the anterior mediastinum, an MRI could be very useful, providing complementary and additional information to the CT scan.In cases of undetermined or doubtful pathologies of the anterior mediastinum, a minimally invasive exploratory robotic approach must be evaluated in order to obtain a diagnosis and to assess the effective operability of a patient before proceeding with a sternotomy.


Parkinsonism is a commonly seen movement disorder syndrome with neurodegenerative and non-neurodegenerative causes. Presynaptic dopamine transporter (DaT) single‐photon emission computed tomography (SPECT) imaging is the most commonly used imaging technique in clinical practice to differentiate degenerative Parkinson’s disease (PD) and PD plus syndromes from other causes such as essential tremor and drug-induced parkinsonism. This can help identify the patients who would benefit from medical therapy due to underlying pre-synaptic dopaminergic deficits. We report a case of unilateral parkinsonism caused by ipsilateral substantia nigra micro-haemorrhage resulting in disruption of the nigrostriatal pathway. This is an unusual case of a 55-year-old male patient who presented with unilateral Parkinsonism a decade after significant head trauma where MRI plays a critical and complementary role in diagnosing complete interruption of the nigrostriatal pathway due to cerebral micro-haemorrhage. The case also beautifully demonstrates the anatomy of the nigrostriatal pathway where a small lesion in the substantia nigra caused complete loss of radioligand uptake in the ipsilateral corpus striatum. Physicians should be aware of the importance of structural imaging in atypical movement disorder cases and, in particular, the routine use of susceptibility-weighted sequences (SWI). MRI of the brain is a helpful first-line imaging tool to differentiate neurodegenerative parkinsonian disorders from parkinsonism caused by lesions involving the nigrostriatal pathway such as infarcts, mass lesions, and demyelination.3 Presynaptic dopamine transporter (DaT) single‐photon emission CT (SPECT) uses a radioactive pharmaceutical which binds to the presynaptic membranes of the terminals of dopaminergic projections. DaT is contemplated as an indicator of dopamine terminal integrity from the substantia nigra in the midbrain to the striatum in the basal ganglia (caudate nucleus and putamen).4 An abnormal DaT scan can help differentiate conditions associated with pre-synaptic dopaminergic dysfunction, such as neurodegenerative parkinsonism and vascular Parkinson’s, from essential tremor and drug-induced Parkinson’s.Parkinsonism is a movement disorder defined by the presence of bradykinesia in addition to rest tremor or rigidity.5–7 have been described. To our knowledge, this is the first case of hemi-parkinsonism caused by ipsilateral substantia nigra micro-haemorrhage resulting in disruption of the nigrostriatal pathway. This emphasises the importance of susceptibility-weighted sequences in imaging patients with parkinsonism especially in the presence of unilateral abnormal DaT scan and normal head CT or structural MRI scans.There are many case reports in the literature describing focal lesions within the substantia nigra affecting the nigrostriatal pathway DaT uptake and causing contralateral hemi-parkinsonism. The causes ranging from lacunar infarcts to Japanese encephalitisWe present a 55-year-old male patient who sustained a head injury in a road traffic accident about 13 years ago. CT scan of his head at that time showed multiple brain parenchymal haemorrhagic contusions involving the corpus callosum, bilateral frontal, and temporal lobes. He suffered right-sided hemiparesis since then. Seven years later he started to develop gradual worsening of the unilateral hemiparesis along with new onset of rigidity and hyperreflexia, symptoms which are indicative of extrapyramidal syndrome and had worsened along the course of 2 years. He was thus investigated for the possibility of idiopathic Parkinson’s disease. MRI of his head was done and showed encephalomalacia changes involving bilateral superior frontal gyri. The lesion within the left frontal lobe involves the supplementary motor cortex (area 6) which explains the post-traumatic right-sided hemiparesis that he had suffered from for years. No abnormality was seen within the basal ganglia or midbrain to explain the extrapyramidal symptoms. No susceptibility-weighted imaging was obtained at that time. The DaT scan showed complete absence of the radioligand uptake within the right striatum with normal uptake on the left . Whilst 8 However, few studies have discussed the SWI importance in evaluating unilateral parkinsonism apart from that.Structural imaging is performed in the presence of abnormal DaT scan uptake to rule out focal abnormalities involving the nigrostriatal pathway. This is of particular importance in patients not presenting with the typical clinical picture of degenerative PD. SWI should always be included in the MRI sequencesto evaluate for the presence of iron accumulation and focal haemorrhages.Our patient presented with symptoms of unilateral parkinsonism with ipsilateral absent radioligand uptake on DaT scan within the right striatum. The cause of which was found to be right substantia nigra haemorrhage from a previous head injury. Susceptibility-weighted imaging has long been used in imaging of Parkinson’s disease but was always used to detect iron accumulation in the substantia nigra. An area of particular importance is the dorsolateral substantia nigra called Nigrosome one which typically shows hyperintense signal on SWI, the so-called swallow-tail sign. Several studies have proved that the loss of the swallow-tail sign was both sensitive and specific for Parkinson’s disease.The connection between the presence of a substantia nigra lesion and unilateral parkinsonism is well recognised.9 Thus, any lesion along the pathway will cause symptoms on the contralateral side-of the body.The substantia nigra is connected to the ipsilateral motor cortex via connections with the caudate and putamen in the process of movement regulation.10 Furthermore, the radioligand uptake on DaT scan was significantly reduced in the putamen on the symptomatic side. Whereas the putamen uptake contralateral to the symptomatic side was only slightly reduced or normal. This was attributed to being due to hand dominance. This is in concordance with other studies which support the hypothesis that motor symptoms in unilateral parkinsonism are usually on the hand dominant side.11Additionally, a case report published in 1978 described a case with right-sided parkinsonism due to a right substantia nigra infarct confirmed at autopsy.12 Further studies are needed to justify the occurrence of clinical symptoms ipsilateral to the substantia nigra abnormalities.DaT scan can evaluate the integrity of the nigrostriatal pathway from the substantia nigra in the midbrain to the caudate and putamen in the basal ganglia. Nonetheless, most of the information in the literature discusses the contra laterality of the clinical symptoms in relation to the substantia nigra lesion. However, one study in evaluating patients with early-stage unilateral Parkinson’s disease found that changes in the substantia nigra correlated with clinical symptoms on the ipsilateral side-of the body.To our knowledge, this is the first case of substantia nigra haemorrhage causing unilateral absent uptake in the right striatum. Moreover, the ipsilateral symptomatology of our patient adds to the uniqueness of our case.Substantia nigra micro-haemorrhage is a rare cause for unilateral parkinsonism.The importance of utilizing structural imaging along with nuclear scans in diagnosing movement disorders.The use of susceptibility-weighted imaging in unilateral parkinsonism.


Solitary fibrous tumor is an unusual fibroblastic mesenchymal neoplasm typically described in the pleura. It may appear anywhere with a varied anatomic distribution and essentially it can develop from any soft tissue or visceral location. Its course is usually indolent and it rarely causes distant metastases, so it has a prolonged survival rate. It sometimes presents itself as a disseminate disease being the liver the most frequently involved location. In these occasions, the management should be discussed in a multidisciplinary tumor committee formed by surgeons, oncologists and radiologists. Surgery remains the gold standard for treatment.We present the case of a woman with a tumor in the left abdominal wall and bilobar massive liver metastases, both locations histologically diagnosed as solitary fibrous tumor. She receives biological treatment for a severe case of Crohn´s disease. Evaluated in a multidisciplinary committee, surgery was recommended for both the primary lesion and the liver metastases. The hepatobiliary surgeons considered a two-stage hepatectomy with portal vein embolization (PVE) as the best strategy. After the first procedure consisting in cleaning the left hepatic lobe followed by PVE the future liver remnant volume (FLRV) was considered inadequate, so the patient was also treated with right transarterial radioembolizacion with yttrium 90 (TARE-Y90) intending a double goal: to treat the tumor and to increased the FLRV. Furthermore, a severe flare of Crohn´s disease forced us to intensify the patient’s treatment with the addition of biological agents  until complete remission of the symptoms. The second stage of the liver surgery had to be postponed for more than 6 months and could finally be carried out without complications, achieving an R0 resection. The postoperative course was uneventful and the follow up has showed no recurrence to date.Solitary fibrous tumours with extensive liver metastases are infrequent but when they appear modern surgical strategies like two stage hepatectomy are the treatment of choice and must be carried out by specialised units. The therapeutic decisions should be guided by a multidisciplinary committee. Solitary fibrous tumor (SFT) is a rare fibroblastic mesenchymal neoplasm  mainly described in the pleura. Although it is commonly considered as intrathoracic, more than 50% of the SFTs arise outside the thorax , 2. TheyThe majority of SFTs follow an indolent course and do not recur after the removal. 10-year overall survival in these cases is 90%. However, between 10 and 25% of SFTs may have local recurrence or will present as a disseminate disease. These patients who recur and those who cannot be resected, have a poor prognosis , 5.Management of SFTs at all sites should be discussed in a multidisciplinary committee. The preferred treatment for locally advanced or metastatic SFT is radical surgery even if it is necessary to use aggressive surgical strategies like two stage hepatectomy as we used in this case .A 53-year-old woman with a long medical history, including Crohn's disease with two intestinal surgeries , psoriatic arthritis and mild chronic renal failure was referred for consultation because of a solid mass on the left flank. The CT scan showed a subcutaneous tumor in the left lateral abdominal wall and multiple giant bilobar liver metastases which consisted in a 13.5 cm tumor in segment VII and a 9.5 cm tumor in segment IVb Fig. . A CT sceSFT with liver metastases is an extremely rare entity with less than 30 cases reported in the literature . The mosOnce the histological diagnosis is certain, management of SFTs at all sites should be discussed in a multidisciplinary tumour committee with the participation of surgeons, oncologists, radiologists and pathologists. Although there is not a great body of scientific evidence, and these are uncommon tumours, radical surgery appears to be the treatment of choice , 8. On tThe liver involvement wether it is as a primary or secondary location, as our case, is extremely rare with only a few cases reported in the literature, and should be treated in specialized units of hepatobiliopancreatic surgery , 5. MultOur patient did not receive systemic treatment. The reported role of chemotherapy and radiotherapy in this kind of tumours is still controversial. Systemic therapies are reserved for cases where the resection has been incomplete or when there are obvious signs of aggressive behavior , 8.In conclusion, solitary fibrous tumours with extensive hepatic liver metastases are infrequent but when they occur modern liver surgery strategies like two stage hepatectomy are the treatment of choice and must be carried out in specialized units. The decision making should be done in a multidisciplinary committee.


Malignant spermatic cord tumors have an annual incidence of 0.3 cases/million. The vast majority of tumors in this region are benign. We present a rare case of a dedifferentiated liposarcoma of the spermatic cord successfully treated.A 59-year-old gentleman presented complaining of an enlarging painful right groin mass. On exam there was an obvious 10 cm inguinal mass. Imaging illustrated a right inguinal soft tissue mass that was not present on imaging 22 months prior.The patient underwent a right inguinal exploration, en bloc resection of the mass, and radical orchiectomy to ensure negative margins. Histopathological analysis revealed a grade 2 dedifferentiated liposarcoma that measured 9 × 6 × 5 cm, with 5 cm negative margins. The patient did well and was discharged on postoperative day one. On 6-month follow-up there was no evidence of recurrence.We present a rare dedifferentiated liposarcoma of the spermatic cord that was successfully treated with surgical resection. This case highlights the importance of maintaining a high index of suspicion coupled with a thorough history and physical examination when encountering an enlarging inguinal mass. This rare pathology is lacking level one evidence-based standardized treatment algorithms. The mainstay of treatment is surgical resection.For spermatic cord liposarcomas, the surgical approach is en bloc resection with radical orchiectomy aiming for R0 margins. Prognosis depends on tumor grade, anatomic site, and the ability to achieve a microscopically tumor negative resection. Despite our patient’s disease free status, prolonged surveillance with physical examination and cross sectional imaging is still warranted. The vasRegarding liposarcomas, five-year survival rates ranging from 15 to 85%, depending on tumor grade, anatomic site, and the ability to achieve a microscopically complete or R0 resection ,5. AccorThe inguinal canal in males is a small channel in the lower abdominal wall that contains the vas deferens, testicular artery and veins, lymphatic vessels, and nerves which compose the spermatic cord. This joins to the epididymis and testicle within the scrotum and links to the pelvic cavity. These structures can be involved in a wide array of pathologies, including neoplastic, congenital, and inflammatory etiologies which require a thorough history and physical exam to diagnosis . The cliThe initial imaging modality of choice is ultrasound for its high sensitivity to characterize intra-testicular and extra-testicular lesions, ease of performance, and relatively inexpensive cost. Despite only suggesting the diagnosis in about 50% of cases, CT or MRI imaging remain critical tools to aid in diagnosis and surgical planning for suspected malignant lesions within the inguinal region .Intraoperatively, liposarcoma typically presents as a bulky heterogeneous solid lesions that are larger and firmer compared to a simple “cord lipoma.” Tumors have been found to range from 3 to 30 cm in diameter . On gros2A 59-year-old gentleman presented to outpatient clinic complaining of an increasing right groin mass with associated pain and discomfort. The patient denied weight loss or groin injury. No family history of cancer was noted. He was afebrile and vitals were within normal limits. On exam there was a grossly apparent large right inguinal mass measuring about 10 cm in diameter with no skin changes or signs of infection. A computerized tomography (CT) scan revealed a right inguinal canal soft tissue mass measuring 5.1 × 4.87 × 4.03 cm that was not present on previous imaging 22 months prior for an episode of nephrolithiasis .Fig. 1A:Due to the size of the mass, location, associated pain, and previous CT scan there was concern for a spermatic cord malignancy and the patient was consented for a right inguinal exploration, resection, and possible radical orchiectomy. Intraoperative examination revealed a large soft tissue mass that was intimately attached to the spermatic cord. There was high concern for malignancy prompting an en bloc resection of the mass with a radical orchiectomy to ensure negative margins . Histopa3Despite literature accounts of surgeons’ experience with inguinal malignant neoplasms such as liposarcomas, this pathology is lacking level one evidence-based standardized surgical management algorithms. Most of the data published are case reports, surgeon experience, and retrospective analysis of hospital specific outcomes. This pathologic entity happens too infrequently for any single institution to accumulate enough cases to prospectively undertake randomized control trials. In one of the largest cohorts of spermatic cord tumors, investigators at Harvard Medical School analyzed 362 patients and concluded an annual incidence of 0.3 cases per million which did not change over time. Rodriguez et al. observed worse outcomes with undifferentiated tumor grade, distant disease, positive lymph nodes, and leiomyosarcoma or histiocytoma cell histology .Liposarcomas, as with most sarcomas invade through local extension of the mass and rarely spread via lymphatic routes. High grade subtypes are associated with higher rates of recurrence and hematogenous spread to the bone and lungs . It is tThe current literature regarding management is limited with only case reports and single-institution series. When a spermatic cord tumor is suspected the only generally accepted treatment entails wide resection with a radical orchiectomy and high ligation of the spermatic cord for complete tissue analysis. The utility of preoperative fine needle aspiration (FNA) cytology has not been clearly established . CompletDue to the rarity of spermatic cord tumors and the overwhelming majority being sarcomas, much of recommendations are extrapolated from the general surgical principles of sarcoma therapy and testicular tumors. According to the American Urology Association when a clinician encounters a testicular lesion suspicious for malignant neoplasm a radical inguinal orchiectomy is recommended. Testis-sparing surgery is not recommended and transscrotal biopsy or orchiectomy is discouraged.  .Regarding the sarcoma literature, tumors of all grades tend to infiltrate local tissues which increases the difficulty of completing a complete resection. An inadequate resection promotes the seeding of tumor through the operative site with recurrence rates as high as 50% in cases that employed a less aggressive, simple excision. Therefore, an aggressive surgical approach has been recommended in the management of spermatic cord tumors .The current controversy in management is in regards to the use of adjuvant chemotherapy or radiotherapy and whether these additional treatment options actually decrease recurrence and ultimately improve survival. Unfortunately, due to the rarity of this disease there is limited data into this matter with no randomized control studies available in the literature. Coleman et al. from Memorial Sloan-Kettering Cancer Center describe their 20 year surgical experience with spermatic cord sarcomas in 47 patients. In their patient cohort, 21 (45%) were treated with adjuvant radiation and 9 (19%) received chemotherapy. However, investigators were unable to demonstrate a therapeutic effect with these therapies. Interestingly, in 21 patients who underwent reoperative wide resection after a prior incomplete resection, authors concluded a trend toward improved disease-free survival (p = 0.059). Additionally, disease-free survival over time was shorter when there were positive surgical margins at first and second resection (p < 0.05), illustrating the importance of an aggressive surgical approach to achieve R0 resection. Coleman suggests that despite adjuvant radiotherapy not shown to increase long-term survival in extremity lesions but shown to decrease local recurrence perhaps there is a benefit in select cases of spermatic cord sarcomas in high-risk patients with multiple recurrences, positive margins, and high grade tumors .Based on studies of sarcomas of the extremities, adjuvant radiotherapy may play a role in recurrent or residual liposarcomas of the spermatic cord. In France, Khanfir et al. showed a significant decrease in local recurrence in patients with margins less than 10 mm (p = 0.005) and in patients with residual tumor cells after re-excision (p = 0.001). However, investigators were unable to show significant influence on 5- and 10-year overall survival .In Italy, Frustaci et al. was able to show a survival benefit for intensive chemotherapy for high grade (grade 3 or 4) sarcomas of the extremities greater or equal to 5 cm or any size recurrent tumor. Authors found a significant benefit in median overall survival of 75 months for treated and 46 months for untreated patients (p = 0.03). In addition, an absolute benefit from chemotherapy was 13% at 2 years and increased to 19% at 4 years (p = 0.04) .In an extensive literature review, Morozumi et al. found that only 326 cases of spermatic cord liposarcomas have been reported with only 15% of liposarcomas being of the dedifferentiated subtype. Authors describe a case of dedifferentiatted liposarcomas that was diagnosed at the 7th resection of recurrence, indicating the difficulty and importance of making the initial diagnosis with subsequent wide and complete resection with negative microscopic margins . Due to In only the 14th reported case in Japan, Tobiume et al. recently published a similar case of a dedifferentiated liposarcoma of the spermatic cord with a positive surgical margin. An additional wide resection to achieve an R0 resection without adjuvant therapy was successfully carried out with patient doing well 12 months postoperatively without signs of recurrence .In our case, due to the complete resection of the mass with negative 5 cm margins and this being the initial occurrence with no clear guidelines or randomized control trials recommending adjuvant therapy it was decided to conclude treatment and proceed with aggressive clinical follow-up. Authors from Johns Hopkins Hospital recently published a similar case of a well differentiated liposarcoma of the spermatic cord and showed a successful outcome through employing the same operative strategy. Despite being a relatively less aggressive tumor, uncertainty still remained in regards to optimal treatment. Chalouy et al. notes the lack of available literature with no gold standard of treatment and how the current management of this rare pathology is based on case reports of surgeons’ experiences .The accepted treatment for liposarcomas of the spermatic cord encompasses an en bloc resection of the mass along with a radical orchiectomy and high ligation of the spermatic cord with the main goal of achieving a R0 resection. Based on extrapolated data of the available studies pertaining to sarcomas of the extremities, adjuvant radiation or chemotherapy may serve a vital role in high risk situations. Further research into this matter is crucial. Despite our patient’s disease free status, prolonged surveillance with physical examination and cross sectional imaging is still warranted.4We present a rare case of a dedifferentiated liposarcoma of the spermatic cord that was successfully treated with an R0 resection. This case highlights the importance of maintaining a high index of suspicion coupled with a thorough history and physical examination when encountering an enlarging inguinal mass. Despite accounts of surgeons’ experience with liposarcomas of the spermatic cord, this rare pathologic entity is lacking level one evidence-based standardized treatment algorithms. Initial treatment encompasses an en bloc resection of the mass along with a radical orchiectomy and high ligation of the spermatic cord with the main goal of achieving a negative margin or R0 resection. More research is needed in the matter of adjuvant radiation and chemotherapy to provide surgeons with evidence-based standardized approach to ensure optimal patient outcomes.None.None.This report was conducted in compliance with ethical standards. Informed written consent has been obtained and all identifying information is omitted.Informed written consent has been obtained and all identifying information is omitted.YS, AE, DB, MM, DK, AA, JW – Conception of study, acquisition of data, analysis and interpretation of data, drafting the article, and revision of article. JW – Management of case.YS, AE, DB, MM, DK, AA, JW – Approval of the final version for submission.This is a case report study.Jason Wolf.Not commissioned, externally peer-reviewed.


Hemangioma is a benign tumor made up of blood vessels and typically occurs as a slightly elevated purplish or reddish area of skin. Hemangioma is mostly found superficially; subcutaneous hemangioma in the nasal dorsum is rare.In West Nusa Tenggara Regional Hospital, the authors found two cases of subcutaneous hemangioma in patients of very different ages. The first patient was a 2-year-old Sasak girl, and the other was a 40-year-old Sasak man. The pediatric patient was treated with an elliptical approach, whereas the adult patient was treated with lateral rhinotomy extended by an elliptical approach to remove the hemangioma and ligate the feeding arteries. After surgery, the adult patient was followed up for 5 months, whereas the pediatric patient was followed up for 3 months. The results for both patients were good, with minimal scar formation.Despite the limitations of technology and human resources in a remote area of Indonesia, the surgical approach used in these cases produced good outcomes for both patients. Vascular anomalies are congenital lesions of abnormal vascular development. There are two major groups of vascular abnormalities, including vascular malformation, which is a local defect in vascular morphogenesis, and vascular tumor (hemangioma), which is cellular hyperplasia . Hemangiet al. [Approximately 15.8% of facial hemangioma cases occur in the nose. A case of nasal dorsum hemangioma was reported by Waner Deep or subcutaneous hemangioma is considered rare, with only 15% of cases being subcutaneous hemangioma. The majority of hemangioma cases were superficial hemangioma and mixed hemangioma, with the proportions of cases being 50–60% and 25–35%, respectively [et al. advocated a midline elliptical incision, which can give good functional results and preserve the nasal contours but leaves a rather obvious midline scar on the nasal dorsum [et al. performed three different surgical techniques for nasal dorsum hemangioma: open rhinotomy, lenticular excision, and circular excision. They reported that open rhinotomy provided a better outcome than circular excision and lenticular excision [Pitanguy l dorsum . An ellil dorsum . Simic eexcision .The authors found two cases of hemangioma on the nasal dorsum in patients of very different ages in West Nusa Tenggara Regional Hospital. The first patient was a 2-year-old Sasak girl, and the other was a 40-year-old Sasak man.Patient 1 was a 2-year-old Sasak girl who had a bulky soft tissue mass on the nasal dorsum of 3 months’ duration Fig. a. AccordPatient 2 was a 40-year-old Sasak man known to have a mass for more than 2 years. He complained of a bulky soft mass on the nasal dorsum Fig. b. The maLombok island is part of West Nusa Tenggara Province, Indonesia. Geographically, this province is separated from the mainland of Indonesia, and the distance from Jakarta  is a 2-h flight. On the other hand, the total population in West Nusa Tenggara is almost 5 million, 65% stay in Lombok island . According to the relatively large number of population, many kinds of medical cases are found in this island, including subcutaneous nasal haemangioma. Several patients from this island who have needed advanced or high-technology treatment have refused to be referred to other hospitals outside of Lombok. Repeated consultation is also one of the obstacles on this island. Economic and educational factors influence the decision whether to follow the physician’s recommendation. These factors are reflected by the human development index in West Nusa Tenggara Province, which showed that the island was ranked 29th among 34 provinces in Indonesia [A hemangioma can occur in every part of the body, but the most common area is the head and neck region . Hemangiet al. preferred to use magnetic resonance imaging and magnetic resonance angiography to differentiate the type of hemangioma due to its capacity to confirm the diagnosis, determine the extent of the anomaly, classify the lesion appropriately, and document the associated abnormalities [The diagnosis of hemangioma may frequently be based on a patient’s history and clinical examination . Howevermalities .In West Nusa Tenggara Regional Hospital in Lombok, the authors found two cases of nasal dorsum hemangioma in patients of very different ages. The diagnosis of hemangioma was based on physical examination and supported by CT scan to explore the involvement of deeper structures and intracranial connections. The CT scan did not show any connection between the mass and intracranial structures. Biopsy was not performed in both cases, owing to the risk of bleeding; however, postoperative histopathologic examination was done. Histopathologic examination showed a tissue covered by squamous epithelial cells, and there was a proliferation of large arteries inside, which contained erythrocytes Fig. . This hiThe treatment options for nasal hemangioma are pharmacological, surgical, or laser interventions . A laserSeveral techniques and approaches are used to treat subcutaneous hemangioma. The elliptical or midline elliptical approach is one of the simple methods for managing these cases. There are several advantages and disadvantages of this method. The advantages are a simple and direct approach to the tumor and arteries with a relatively small incision; however, scarring may occur after surgery and could have cosmetic consequences. In a pediatric patient, the authors used an elliptical incision due to the medium size of the tumor. On the other hand, in an adult patient, the authors performed rhinotomy with a lateral incision extended by elliptical incision due to larger mass size and blood vessels. This led to more profuse bleeding in the adult patient. The authors used this approach because of its simplicity and versatility in regard to minimizing tissue removal, skin movement, and incision length. The results of the surgery after 5 months and 3 months in the adult and pediatric patients, respectively, are shown in Fig. Because of the limitation of technology and human resources in a remote area such as Lombok, performing surgery for subcutaneous hemangioma in the nasal dorsum is challenging. Nevertheless, in the patients described in this report, the authors provided a good outcome for an adult patient and a pediatric patient through use of an elliptical incision. Furthermore, elliptical incision could be an alternative approach to manage subcutaneous hemangioma in remote areas.Additional file 1. Surgical Case Report (SCARE) 2018 checklist.