Patients. A 71-year-old woman with sudden hearing loss and a contralateral vestibular schwannoma without clinical and genetic signs of neurofibromatosis type II. Intervention(s). Ipsilateral cochlear implantation and contralateral vestibular schwannoma extirpation with regular tumor follow-up. Main Outcome Measure(s). Comparison of ipsilateral pre and postcochlear implantation 3T MRI T1 GAD.  The vestibular schwannoma incidence rate is approximately 4.2 per 100,000/year. Thus far, about 700,000 cochlear implantations have been performed worldwide; therefore, the occurrence of vestibular schwannoma postcochlear implantations can be assumed to be infrequent. Recent developments allow safe observation and surveillance of the implanted-side internal auditory canal (IAC) and cochlea by magnetic resonance imaging (MRI), even after cochlear implantation.  We observed a tumor growing at the fundus of the internal auditory canal 1 year after cochlear implantation on the ipsilateral side. Although first detected after cochlear implantation beside a known vestibular schwannoma on the contralateral side, a scan slice thickness of 2 mm cannot fully exclude the preoperative persistence of a small tumor. Based on the clinical findings and after genetic exclusion of NFII, the patient was classified as a NFII mosaic type.  Even after cochlear implantation, tumors in the IAC causing vertigo, facial palsy, and affecting the audiologic outcome can be detected by MRI. The MRI slice thickness used before cochlear implantation should be under 2 mm. The occurrence of acoustic neuroma is described to be up to 4.2 per 100,000/y. A rising incidence has been detected due to the existence of better diagnostic tools and better access to healthcare , 4.The MRI scan slice thickness was previously set at 2 mm. Therefore, besides the occurrence of new acoustic neuroma after cochlear implantation, a limited probability exists of undetected small schwannomas being present before cochlear implantation. The development of cochlear implant magnets and increasing knowledge of implant and head position make it possible to perform MRI after cochlear implantation for postoperative visual assessment of the cochlea and internal auditory canal. For example, an evaluation of vestibular schwannoma and intralabyrinthine schwannoma after cochlear implantation was shown to be successful .To the best of our knowledge, we are presenting the first case of a cochlear implantee with an ipsilateral vestibular schwannoma, detected 2 years after initial cochlear implantation.In 2014, the patient (a 72-year-old woman) visited our clinic for the first time and had suffered for 15 years from known intracanalicular vestibular schwannoma with deafness on the left side and moderate hearing loss of 60–70 dB on the right side . The patSudden complete hearing loss on the right side occurred in 2018 , and a cThe patient showed an audiological performance after cochlear implantation with a monosyllabic understanding in quite of 65% at 65 dB after 6 months. After reaching a stable audiological result on the right side, promontory testing on the left side was performed and a positive response was observed. Consequently, translabyrinthine resection of the left vestibular schwannoma was performed.During her regular check-up with MRI control 1 year after surgery, the T1 GAD-based sequence raised suspicion of vestibular schwannoma on the right side Figures  and 5.  Based on the clinical pattern of a bilateral schwannoma, the patient was classified as a case of neurofibromatosis type II (NFII).NFII is a hereditary disease (Merlin coding gene) characterized by benign symmetrical tumors of the IAC in 90% of the cases.Sanger sequencing and multiplex ligation-dependent probe amplification (MLPA) did not reveal NFII genetic alterations in blood or tumor specimen. There was no suspicion of NFII beforehand, and there had been no other symptoms nor signs of NFII until that time point. The lack of clinical signs and symptoms in this case, therefore, raised suspicion of a case of mosaic NFII. Mosaic cases of NFII have mild clinical progression and are caused by missense mutations. A postoperative promontory testing of the left side is planned.The present case shows the importance of conducting MRI in cases of sudden hearing loss and contralateral known vestibular schwannoma. This finding underlines the importance of performing MRI scans even in cases of asymmetric hearing loss.The new developments in cochlear implant magnets, implant position, and head position inside the scanner make the follow-up possible, even for cochlear implantees .In the present case, although the radiological finding in the IAC was observed 2 years after the initial cochlear implantation, it remains unclear if the finding was present preoperatively but was undetected due to the slice thickness of 2 mm or if we observed a newly occurring tumor.A 2 or 3 mm slice thickness was the preoperative standard in our clinic. This standard might be insufficient, as this case possibly shows. A thinner slice thickness of under 2 mm might solve the problem of small, so far undetected VS. We changed our standard to 0.6 mm. The second explanation for this case is the new occurrence of a vestibular schwannoma after cochlear implantation. Given the rate of 4.2 per 100,000/y, the new occurrence of such a case is rare but possible.Additionally, other tumors such as lipoma or hemangioma can occur and radiologically mimic schwannoma . Cases oApart from this specific case, a new occurrence of sporadic vestibular schwannoma must be considered in cases of reduction of postoperative speech perception after cochlear implantation. Even the new occurrence of vertigo and facial palsy after cochlear implantation could be caused by postimplantation changes inside the IAC or labyrinthine. In cases of deafness with a contralateral schwannoma, an NFII case must be considered.MRI observation after cochlear implantation allows for monitoring changes in the IAC. The preimplantation MRI slice thickness should be under 2 mm to decrease the risk of small undetected VS. Vestibular schwannoma occurrence after cochlear implantation should be considered in cases of performance loss, vertigo, facial palsy, and contralateral schwannoma.


Marchiafava–Bignami disease (MBD) is a rare demyelinating disorder, usually associated with heavy chronic alcohol consumption. It may occasionally occur in patients who are not alcoholics but are chronically malnourished and patients with severe nutritional deficiencies . White-mA severely malnourished 49-year-old woman  with a long history of alcohol dependency was admitted to the Emergency Department with speech impairment and gait abnormality that had developed gradually over the preceding 2 weeks. Neurological examination revealed cognitive impairment, dysarthria, and tetraparesis (more pronounced in the lower limbs), which indicated cortical, bilateral corticobulbar and pyramidal tracts impairment. Physical examination showed a distended abdomen with rebound tenderness. Blood tests revealed moderately elevated serum aspartate transaminase (90 U/L), alanine transaminase (72 U/L), gamma-glutamyltransferase (96.00 U/L), significantly elevated pancreatic lipase (324 U/L), and high C-reactive protein (143 mg/L). Additional laboratory tests detected a decreased level of total albumin (44 g/L), albumin (23.8 g/L), iron (0.31 mg/L), and calcium (0.078 g/L), but not vitamins B1, B6, B12, or other electrolytes. The lipid profile was within normal limits. Abdominal computed tomography (CT) showed a lack of pancreatic parenchymal enhancement with multiple pancreatic cysts suggestive of acute pancreatitis and significant liver fatty change. Diffuse hypodensity of corpus callosum was seen on cranial CT imaging, confirmed by hyperintensity of the corpus callosum on FLAIR and T2 images in MRI . SimilarAfter 4 weeks of treatment, the acute pancreatitis subsided, with pancreatitis-function biochemical markers normalizing . Follow-up MRI revealed a significant regression of abnormalities originally seen in the primary area of involvement with residual hyperintensity of the splenium of the corpus callosum on FLAIR and T2 images . No signMBD occurs in patients with chronic alcoholism and, occasionally, in < 10% of all MBD patients , in malnTwo subtypes of MBD are distinguished in clinical and neuroradiological classifications. Type A is characterized by an acute to subacute onset of altered level of consciousness and cognitive deterioration. The brain lesions depicted on MRI are localized in the entire corpus callosum. Extracallosal lesions are frequently found and are associated with a poor prognosis. Type B with insidious clinical onset develops progressively. Patients demonstrate a normal or slightly impaired level of consciousness. MRI shows lesions partially involving the corpus callosum and less frequently extracallosal. Type B is associated with a favorable prognosis.Differential diagnosis includes other chronic, alcohol-related diseases of similar clinical presentation. Neuroimaging is crucial in achieving an accurate diagnosis and excluding other causes of neurological deficits. MRI, being of greater sensitivity, is the gold-standard diagnostic test, although bigger lesions are visible on CT. Typical callosal injuries are hypointense on T1 and hyperintense on T2 sequences (FLAIR and DWI), cause no mass effect, and may be visualized with contrast enhancement. Hyperintensities can also be found in other brain regions—cerebral lobes, hemispheric white matter, or basal ganglia . Central pontine myelinolysis shows lesions located in the central pons . Conditiet al. [Effective treatment is not available due to the uncertainty of the etiology of MBD. Thiamine and other forms of vitamin B supplementation are routinely used. Haas et al.  reportedet al. . RegardlOur case report documents the diagnostic process of rapidly developing MBD in an alcohol-dependent and severely malnourished patient with concurrent acute pancreatitis. Despite treatment, only partial symptom resolution was observed, probably due to deep and irreversible cellular changes in the brain tissue and the gastrointestinal tract. However, prompt diagnosis and supportive treatment possibly prevented a dramatic or even fatal outcome. This case should raise awareness of the coexistence of different multiorgan complications and the need for a multidisciplinary approach. Alcohol-dependent and malnourished patients presenting with acute neurological deficits should be thoroughly investigated to exclude potentially fatal conditions such as MBD. The mutual interplay between the gastrointestinal tract and nervous systems has been a matter of great interest in recent years. M.S., J.B., K.P., and A.S.S. conceived and designed the project. M.S., A.S.S., and J.B. collected the data. M.S., J.B., A.S.S., K.P., and K.R. analysed and interpreted the data. M.S. and J.B. drafted the manuscript. All authors read and approved the final manuscript.None declared.


Adrenal schwannomas are extremely rare tumors often misdiagnosed. The patients are usually asymptomatic while some present with non-specific abdominal pain. Only a few cases are reported to date.We here present a case of a 55-year-old Nepalese man presented with nonspecific abdominal pain at our Outpatient Department (OPD) found to have mass on ultrasonography of abdomen. On further investigation with Contrast Enhanced Computerized Tomography (CECT) of the abdomen and pelvis, a well-defined heterogeneous adrenal mass of size (7.8 ∗ 8.3 ∗ 6) cm with foci of calcification was seen in the left retroperitoneum. The intraoperative finding of adrenal mass and histopathology of resected mass was suggestive of schwannoma arising from the adrenal gland which was further confirmed by immunohistochemistry.Adrenal schwannoma can mimic tumors like pheochromocytoma, adrenal adenoma, cortical carcinoma, neuroblastoma, and other masses. Only 1–3% of schwannomas are retroperitoneal. Radiological findings of this tumor are non-suggestive. The histological section shows spindle cells with Antoni A and Antoni B regions while positive staining of S-100 protein in Immunohistochemistry.The diagnosis of adrenal schwannoma in the retroperitoneum is often challenging. The treatment of choice is surgical resection with a good prognosis. •Adrenal schwannomas are extremely rare tumors.•These tumors are mostly found incidentally and often asymptomatic.•Complete surgical resection of the tumor is a must for good prognosis. They are slow-growing and uncommon ,2. MostlHere we report the case of left adrenal schwannoma incidentally discovered in a 55-year-old man presented in OPD with non-specific abdominal pain.This work has been reported in line with the SCARE criteria .2A 55-year Nepalese man, presented in our Out Patient Department with a chief complaint of non-specific central abdominal pain for six months. The abdominal pain was vague, generalized, mild intensity, non-radiating, and relieved by analgesics. He was a farmer by occupation and didn't have any prior surgical history and family history of malignancy. He didn't have a history of trauma, weight loss, fever, and abdominal distension.On physical examination, he was afebrile and all vitals were stable. On per-abdomen examination, there was no tenderness and no palpable mass. The examination of all other systems was grossly intact. He had the habit of chewing tobacco regularly for the last 30 years and was a social drinker.On blood investigations, hemoglobin level was found to be 11.6 g/dl, total leukocyte count (TLC) was 11,000/μl, urea level was 6.9 mmol/l, creatinine level was 125 μmol/l , sodium level was 132 mEq/l , potassium level was 3.7 mEq/l . On 24-h urine examination, vanillylmandelic acid (VMA) level was 5.4 mg/24 h  and metanephrine level was 82.64 μg/24 h .The patient underwent ultrasonography (USG) of the abdomen and pelvis for evaluation of abdominal pain; which showed a heterogeneous mass near the left adrenal gland. For further characterization of mass, contrast-enhanced CT of the abdomen and pelvis was done which showed a well-defined heterogeneous adrenal mass of size (7.8 ∗ 8.3 ∗ 6) cm with foci of calcification in the left retroperitoneum as shown in The resected mass was well-encapsulated which on the cut section showed heterogeneous grey white gelatinous to solid firm areas a and b. The post-operative period was uneventful and the patient recovered well. The patient was discharged on the sixth postoperative day. During discharge, all the vitals of the patient were stable and urine output was normal. The patient is on follow-up, doing well and satisfied with the treatment.3Schwannoma arises from Schwann cells encapsulating peripheral nerves of mainly head and neck or peripheral extremities. Retroperitoneal schwannoma is found incidentally using imaging techniques as spacious space allows growing tumors of large size. These are generally asymptomatic . SchwannA case series of 33 patients showed a median age of diagnosis to be 49 years ranging from 14 to 89 years predominantly in females . In this case series, Adrenal schwannoma was found incidentally in 20 (60.6%) patients while 13 (39.4%) patients were symptomatic with symptoms like abdominal pain or discomfort or pain in the flank region. Only one case showed high levels of urinary catecholamines [CT scan of abdomen and pelvis shows adrenal schwannoma usually as heterogeneous, round or oval, well-circumcised mass along with the cystic lesion and occasional calcification and septation . A studySchwannomas have non-specific or uncommon findings on different imaging techniques. This makes preoperative diagnosis and ruling out other adrenal masses especially related to retroperitoneum challenging . In our Surgery either open or laparoscopic is the mainstay for the treatment of adrenal tumors. A study by Hobart et al. showed no differences in outcomes of the above two surgical techniques. Laparoscopic surgery is the preferred treatment however it remains controversial for the resection of large tumors (>5 cm) ,16. Our The surgical resection of the tumor has a good prognosis. Zhou et al. concluded that the patient had favorable survival with no evidence of recurrences after follow-up from 7 to 115 months. In contrast, 33–50% of cases have reported having local recurrences in other studies . Our pat4Adrenal schwannomas are rare tumors that are mostly found incidentally and its suspicion could be considered in any adrenal mass. Pre-operative investigations are likely to be inconclusive which can change the outcome of the patient. Thus, prompt surgical excision along with the appropriate histological evaluation and immunohistochemical studies of the mass is crucial for accurate diagnosis and to predict the outcome.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.No patient and author details are included in the figure.Not commissioned, externally peer-reviewed.Not required.None.Sujan Timilsina accepts full responsibility for the work and/or the conduct of the study, had access to the data, and control the decision to publish.Not applicable.Purushottam Parajuli (PP), Durga Pandit (DP), Shovana Karki (SK), Sansar Babu Tiwari (SBT) = Study concept, Data collection, and surgical therapy for the patientSujan Timilsina (ST), Sujan Sharma (SS), and Surya Prakash Joshi (SPJ) = Writing - original draft preparationSujan Timilsina (ST), Sanjeev Kharel (SK) and Sansar Babu Tiwari (SBT) = Editing and writingDurga Pandit (DP), Purushottam Parajuli (PP) = Senior author and manuscript reviewerAll the authors read and approved the final manuscript.None.


Chondrosarcomas are the most common primary bone malignancy in adults within the United States. Low-grade chondrosarcomas of the long bones, now referred to as atypical cartilaginous tumors (ACTs), have undergone considerable changes in recommended management over the past 20 years, although controversy remains. Diagnostic needle biopsy is recommended only in ambiguous lesions that cannot be clinically diagnosed with a multidisciplinary team. Local excision is preferred due to better functional and equivalent oncologic outcomes. We sought to determine whether these changes are reflected in reported management of ACTs.The National Cancer Database (NCDB) 2004 to 2016 was queried for ACTs of the long bones. Reported patient demographics and tumor clinicopathologic findings were extracted and compared between patients who underwent local excision versus wide resection.We identified 1174 ACT patients in the NCDB. Of these, 586 underwent local excision and 588 underwent wide resection. No significant differences were found in patient demographics. No significant change was found in the reported percentage of diagnostic biopsies or wide resections performed over time. After multivariate regression, the single greatest predictor of performing wide resection on an ACTs was presenting tumor size.Evaluation of the NCDB demonstrated that despite changes in the recommended management of ACTs, there has not been a significant change in surgical treatment over time. Surgeons have been performing diagnostic biopsies and wide resections at similar to historical rates. Persistency of these practices may be due to presenting tumor size, complex anatomic location, uncertainty of underlying tumor grade, or patient choice as part of clinical shared decision making. The authors anticipate that the rate of biopsies and wide resections performed will decrease over time as a result of improvements in advanced imaging and the implementation of recently updated clinical practice guidelines. Historically, this conundrum required a tissue biopsy to make a distinction. However, utilization of dynamic gadolinium chelate-enhanced MRI and/or positron emission tomography CT (PET-CT) can aid differentiating between enchondroma and an ACT,10111213 negating the need for biopsy. If radiographic or advanced imaging demonstrates gross cortical erosion or soft-tissue infiltration, the lesion is approached as an intermediate- or high-grade chondrosarcoma until proven otherwise.9 Therefore, differentiating between an ACT and a high-grade chondrosarcoma is often less controversial. However, if there is still ambiguity, differentiation between these low-grade and high-grade lesions may also be conferred with advanced imaging,10111213 again negating the need for biopsy.ACTs are often seen as ambiguous lesions with cartilaginous appearance on standard imaging similar to that of an enchondroma. However, ACTs often display more aggressive and destructive features than their definitive benign counterparts. An enchondroma is a well-defined lytic lesion with stippled calcifications in the pattern of rings and arcs within the metaphysis or metadiaphyseal region of long bones.14-16 The utilization of advanced imaging and collaboration between multidisciplinary teams allows for high diagnostic accuracy.15-17 In addition, although treatment of an ACT with wide resection was often favored in the past due to concern for malignant potential,3 contemporary literature recommends extended intralesional excision with curettage, adjunctive high-speed burring, and bone void augmentation.1819202122232425 The more aggressive intermediate- and high-grade chondrosarcomas, especially within the pelvis, have high malignant potential and are treated with wide resection and reconstruction.25Therefore, because of high concordance of biopsy sample and presumed diagnosis on imaging studies alone, a diagnostic biopsy is often not necessary.With recommendations shifting away from biopsy and wide resection toward advanced imaging and less aggressive surgical management, this article investigates the trends in ACT management from 2004 to 2016 using the National Cancer Database (NCDB). In addition, we sought to identify factors that were associated with diagnostic biopsy and type of definitive surgery performed.26 Although participating cancer centers represent approximately 30% of hospitals within the United States, the NCDB encompasses approximately 70% of all patients newly diagnosed with cancer.28 Our institutional review board determined that this was nonhuman subject research and did not require formal review. ACT cases were extracted from the bone and joint participant use file from the NCDB (2004 to 2016) using International Classification of Diseases for Oncology (ICD-O) code of 9220 (cartilage-based tumors), behavior code 3 (chondrosarcoma), grade code 1, and long bone location. A biopsy performed was defined as either incisional, needle, or aspiration methodology.The NCDB includes 34 million patient records with a 90% follow-up during a 5-year period.29 history of previous cancers, American Joint Committee on Cancer tumor size (T), reported diagnostic biopsy procedure, and time from diagnosis to definitive surgery. These variables were categorized as local excision versus wide resection. The NCDB prohibits the reporting of parameter counts fewer than 10. Lymph node extension and metastatic staging were unable to be reported due to these parameter restrictions. A Kendall tau-b correlation was performed to determine trends in the percent of patients with a long bone ACT who underwent an initial diagnostic biopsy before definitive surgical management and the percentage of patients who underwent wide resection over time. Independent samples t-tests were used to compare means of continuous variables, and P values less than 0.05 were considered to represent a significant difference. For variables with Levene test for equality of variances greater than 0.05, equal variance was assumed. The Pearson χ2 test P values less than 0.008 were considered to represent a significant difference in categorical variables after Bonferroni correction. Binary logistic regressions were used to calculate odds ratios. Multivariate binary logistic regression was attempted for all significant variables and reported. All analysis was performed in SPSS version 25 .Demographic and outcome variables including age, sex, race, insurance status, and treatment facility type were reported. Patient and tumor-specific measures included Charlson-Deyo score,http://links.lww.com/JG9/A174). A significant association was found between the American Joint Committee on Cancer tumor size and the decision to perform a diagnostic biopsy . Patients who underwent diagnostic biopsy before definitive surgery were more likely to be treated with local excision than wide resection . Tumors staged as T1 preferentially underwent local excision procedures compared with tumors staged T2 . Subgroup analysis comparing the percentage of patients with T1 or T2 tumors undergoing diagnostic biopsies or wide resection from 2004 to 2016 also remained unchanged over time . No significant difference was found in the time from diagnosis to definitive surgery.We identified 1174 ACT patients in the NCDB. Of these, 586 underwent local excision, and 588 underwent wide resection. No significant difference was found between age, sex, race, insurance status, facility treatment type, Charleson-Deyo score, and history of previous cancers between the two groups . There was no significant change year to year in percent of patients who had a diagnostic biopsy  or wide resection .After multivariable regression, only ACT tumor size was statistically significant for predicting wide resection after correction for reported biopsy procedures  tumors were marginally more likely to be treated with extended intralesional excision, reflecting some appreciable acceptance in less invasive treatment options. However, larger (T2) tumors continued to undergo wide resection considerably more often than extended intralesional excision. It can be assumed that this was likely due to concern of diagnostic error or variability in the performed biopsy as large chondrosarcomas may be heterogeneous and can have variable low- and high-grade components. However, recent literature supports a high diagnostic concordance rate among biopsy and ultimately excised tumor for long bone chondrosarcomas.181920212223 There is a lower rate of complications in patients treated with intralesional excision treated patients than the wide resection, consistent with other studies.31 Specific comparative studies have also found improved Musculoskeletal Tumor Society score and better self-rated function with intralesional excision compared with wide resection.20 Collectively, these findings support the treatment of ACT with intralesional excision over wide resection. Regardless, it is crucial to consider the entire clinical picture as the location, size, and diagnosis have implications regarding prognosis and management.25 Again, the importance of establishing a multidisciplinary team cannot be overstated as together these teams determine the most appropriate courses of action for the management of musculoskeletal malignancies, particularly in the setting of ACTs. Although some physicians remain concerned about the development of metastatic spread from an ACT, the probability of developing metastases due to ACT is relatively low and reported as 5% at 5 years and 8% at 10 years.31 Chen et al23 recently performed a meta-analysis and found no difference in ACT local recurrence or metastasis between intralesional excision and wide resection even when accounting for specific anatomic locations . Therefore, patients with larger (T2) ACTs may still be receiving more aggressive surgical treatment than necessary.The surgical management of ACTs has not significantly changed over time. This may have resulted in patients being treated with more aggressive surgical modalities than necessary. Multiple previous systematic reviews, meta-analyses, and comparative studies have been performed comparing intralesional excision and wide resection for ACT.26 Analysis is limited to variables provided by the database and may not include demographic or treatment considerations such as patient employment status, hospital size, types of imaging used for staging purposes, or the reported cause of death. Specific to this study, we were not able to determine whether there was utilization of dynamic gadolinium chelate-enhanced MRI and/or PET-CT10111213 to obtain and underlying diagnosis. Ultimately, the NCDB is a database, and although there are highly standardized reporting protocols with a number of integrity checks and quality assurance measures to ensure accuracy of reporting, human error and ambiguous diagnoses must be considered in interpretation of results. In addition, there has been growing evidence over the past 20 years for the use of advanced imaging and local excision over the more traditional biopsy and wide resection treatment. However, the World Health Organization classification for ACTs and updated clinical practice guidelines only recently changed, and long-term changes in the NCDB may not be appreciated at this time.There are a number of limitations with the use of large databases including the NCDB. A larger proportion of individuals younger than 65 years are captured in the database.Notable controversy has surrounded the diagnosis and surgical management of long bone ACTs in years past. Contemporary recommendations for the surgical management of ACTs of the extremities do not necessitate biopsy and include extended intralesional excision with curettage, adjunctive high-speed burring, and bone void augmentation. The NCDB was queried and showed that surgeons have been choosing to obtain a biopsy and/or perform wide resection over extended intralesional curettage in patients diagnosed with ACT of the extremities. This may have resulted in potential for more aggressive treatment than was necessary in some cases. Wide resection procedures were associated with larger initial presenting tumor sizes, however may also be attributed to ambiguity of biopsy samples, periarticular tumor locations necessitating reconstruction, or other patient-specific considerations. Ultimately, each patient should be considered on a case-to-case basis. The authors anticipate that the rate of biopsies and wide resections performed for ACTs will decrease over time as a result of improvements in advanced imaging and the implementation of recently updated clinical practice guidelines. It behooves orthopaedic surgeons to establish a multidisciplinary team early on in the diagnosis and evaluation steps, as this may lead to less aggressive surgical treatments with overall better functional outcomes.


The brachial plexus injury is a rare complication after vaccination like that of the Influenza virus. Though a well-known and reported complication, there is still a dearth of literature mentioning its pathophysiology, the trend of involvement, symptoms, and treatment. This has also been reported after the coronavirus disease 2019 (COVID-19) vaccination. To the best of our knowledge, to date, only four cases have been reported so far. Every case needs to be reported to better understand the complication and formulate a line of management for better outcomes. We report a case of brachial plexus involvement after Covishield vaccination with complete recovery after treatment. The brachial plexus is a network of nerves arising from the cervical spine and supply motor and sensory conduction to the upper limb. Though rare in adults, the most common cause of brachial plexus injury is trauma . The incA 34-year-old male with no known co-morbidities presented to the hospital with complaints of weakness in the left arm and pain in the left upper limb for one month. There was a history of COVID-19 vaccination (Covishield) immediately prior to the onset of symptoms. On examination, there was a loss of shoulder contour. There was the weakness of rotator cuff muscles especially supraspinatus muscle confirmed with positive empty can test and drop arm test. The patient was unable to abduct his arm even against gravity. The neurological examination of distal muscles to the elbow of the left upper limb was normal. The patient was further evaluated with x-rays of the cervical spine, magnetic resonance imaging (MRI) of the cervical spine, and electromyography (EMG) and nerve conduction velocity (NCV) study. The x-ray and MRI were clear with no obvious pathology , antinuclear antibody, rheumatoid factor, Lyme antibodies, angiotensin-converting enzyme, herpes simplex antigen, and varicella-zoster virus antigen, etc. to rule out any inflammatory or other viral cause ,7. In ouThe treatment of this condition is intravenous or oral steroids. Most of the authors have used oral steroids in involvement after the COVID-19 vaccination. Most of these patients have good results with recovery to near normal. The regimen can be different depending on the experience of the author. We used deflazacort on tapering dose for a month and there was complete recovery on follow-up. In our daily practice, we prefer deflazacort among steroids as it has shown higher efficacy and good tolerability compared to other steroids [Brachial plexus neuropraxia is a rare but known complication after influenza vaccination. With widespread vaccination of COVID-19, this complication is reported from different parts of the world, and knowledge of this may help healthcare workers in managing it. We recommend the use of EMG, NCV, and MRI of the cervical spine in a patient with clinical suspicion of brachial plexus involvement and a history of COVID-19 vaccination. Early use of steroids has better outcomes.


Extranodal mucosa-associated lymphoid tissue (MALT) is a type of non-Hodgkin’s lymphoma (NHL). It commonly involves the GI tract, but the involvement of the urinary bladder is very rare. It comprises less than 1% of bladder tumors and 0.2% of extranodal lymphomas. Fewer than a hundred cases are reported so far and limited literature is available on the management. Here we are presenting a gentleman with MALT lymphoma of the urinary bladder who presented with urinary frequency, an urgency which was initially managed as benign prosthetic hyperplasia. Initially, the treatment helped him with improvement in his symptoms. After a recurrence of his symptoms 11 years later, he underwent cystoscopy with biopsy that revealed MALT lymphoma of the bladder and underwent radiotherapy. The malignancy of the urinary bladder is mainly epithelial in origin. In nearly 10-20% of cases, advanced lymphoma of another site metastasizes to the bladder . The preA 78-year-old gentleman with a past medical history of benign prostatic hypertrophy, type 2 diabetes mellitus, and nicotine dependence started having urinary frequency 10 years back. He was treated with tamsulosin and finasteride but had minimal improvement in his symptoms. Later he was treated with solifenacin that improved his symptoms. He was continued on solifenacin and remained symptoms-free until two years ago when he came to see urology with a complaint of reappearance of urinary frequency and urgency. He was continued on medical treatment but was not helpful. He came to see urology one month later with urinary retention which was initially thought to be due to solifenacin and it was stopped. He underwent an ultrasound of the pelvis which showed a normal bladder wall without thickening or trabeculation. Post-void residual volume was 15 ml. He underwent cystoscopy which showed thickening of the lateral wall of prostate and posterior bladder wall erythema. Bladder mass was removed and biopsy was taken from the erythema area which showed findings suggestive of extranodal marginal zone lymphoma of MALT lymphoma with extensive plasmacytic differentiation  showed no gross evidence of locoregional or distant metastasis. Bone marrow aspirate and biopsy of left iliac bone showed no morphological or immunophenotypic evidence of lymphoma in the bone marrow. A diagnosis of primary MALT lymphoma of the bladder was made based on these findings. A wide array of treatment options, ranging from conservative management, surgery, radiation therapy, and chemotherapy with immunomodulators such as rituximab were presented to the patient. The patient opted for radiation therapy and received one cycle of radiation therapy (2400 cGy in 12 fractions). Patient symptoms gradually improved and a follow-up cystoscopy six months later showed prior resection site with no gross evidence of tumor. The patient was monitored for symptoms.Malignant lymphoma can either be nodal or extranodal. Extranodal malignant lymphoma most commonly involves the GI tract. Other common sites of involvement are the thyroid and salivary glands. Primary malignant lymphoma involving the bladder is a rare entity that constitutes less than 0.2% of non-Hodgkin’s lymphoma (NHL) and less than 1% of bladder tumors ,5. The tGiven the rarity of this tumor, a limited literature review is present and there is no standard protocol for the management of the tumor. Treatment approaches are variable, and patients were treated with approaches including surgical excision of the tumor, chemotherapy, radiation, antibiotics, or combined modality in different cases with complete remission . A clearPrimary lymphoma involving the bladder is a very rare presentation. MALT lymphoma involving the bladder has a favorable prognosis if treated with chemotherapy, radiation, or surgery timely. Limited literature is available on the presentation and management hence more research is needed to know more about this rare malignancy.


Primary omental tumors are extremely rare. Herein, we report the first case of a primary omental neuroendocrine tumor (NET).A 59-year-old woman was referred to our hospital for the treatment of an 18-mm tumor located at the ventral side of the duodenum. No other tumor was detected. The preoperative imaging diagnosis was omental tumor. A laparoscopic tumor resection was performed. Histopathological examination revealed that the tumor consisted of cuboidal cells with eosinophilic, granular cytoplasm showing trabecular or ribbon architecture. No other component was seen. The mitotic count was of 5 per 10 high-power fields. Immunohistochemical staining was positive for chromogranin A, synaptophysin, and CD56. Her Ki-67 index was 5%. These results led to the diagnosis of grade 2 omental NET. The patient was discharged on the 3rd postoperative day without any complications and did not develop any recurrence for 3 years.We encountered a very rare case of omental NET. Complete resection is recommended with minimally invasive surgery for the diagnosis of NET.The online version contains supplementary material available at 10.1186/s40792-021-01217-4. Neuroendocrine neoplasms (NENs) are most commonly located in the gastrointestinal tract (approximately 68% of patients), followed by the respiratory tract 25%), whereas other locations are extremely rare . The neu5%, whereA 59-year-old woman was referred to our hospital for the treatment of a growing tumor detected by computed tomography (CT) with calcification on the ventral side of the duodenum. Six years before the presentation, a nodule with calcification that had grown from 6 mm to 7.5, 15, and 18 mm at 14-, 56-, and 68-month follow-up, respectively, in the CT  Fig. . Sharp dMacroscopically, tumor showed well-circumscribed brown to black ovoid mass measuring 20 mm Fig. a, b. HisThe postoperative course was uneventful, and the patient was discharged on postoperative day 3. She developed no signs of recurrence by CT/MRI follow-up at 42 months. No other primary suspected lesion was detected on endoscopic examination. Therefore, we diagnosed the omental NET as the primary lesion.NENs are relatively rare; they mainly develop in the gastrointestinal tract, accounting for < 2% of all primary gastrointestinal tumors . PrimaryThe omentum could be a metastatic site from the stomach, gallbladder, pancreas, large bowel, and ovaries. Therefore, it is important to examine the whole body to find any possibility of another lesion. In some reports, In-111 octreotide scintigraphy is considered useful for whole-body screening with sensitivity of 80–90% , 6. In oPrimary solid tumors of the greater omentum are rare and sporadic. Their etiological factors are still unknown. In a review of the literature, Fagkrezos et al. reported 54 cases of extra-gastrointestinal stromal tumors , Barel eWe encountered a very rare case of omental NET. Complete resection by minimally invasive surgery is recommended for diagnosis because of the difficulty of preoperative diagnosis.Additional file 1. The tumor was easily identified at the omentum near the RGV.


There are two techniques for a spleen-preserving distal pancreatectomy (SPDP): SPDP with splenic vessel preservation, and SPDP with splenic vessel resection. In some cases, although the splenic artery (SpA) can be preserved, the splenic vein (SpV) must be resected. We report the short- and long-term outcomes of three patients who underwent a new technique of laparoscopic SPDP with SpA preservation and SpV resection (SPDP-VRes). A grade B pancreatic fistula, which occurred in two patients, was successfully treated with drainage tube management. In all cases, the omental branches of the left gastroepiploic vein functioned as a drainage vein, and there was no splenomegaly, thrombocytopenia, or varix formation during the follow-up period (19 months to 5 years). Patients undergoing laparoscopic SPDP-VRes had no severe complications during the follow-up period; preserving the left omental branch is a key to this procedure. Laparoscopic SPDP-VRes might be a useful treatment option for patients undergoing SPDP. There are two variations of the SPDP: SPDP with splenic vessel preservation (SPDP-Pre) , and SPDThe main elements of laparoscopic SPDP-VRes surgical procedures are as follows. The patient is placed in the supine position with the arms extended laterally with the legs apart. One transumbilical access port was used for videolaparoscopy and working trocars were inserted into four additional ports . A Natha4/μL, respectively. The pre- and post-operative (8 postoperative months [POMs]) spleen volumes measured by CT scan were 195 and 144 cm3, respectively. The patient remains healthy without a recurrence 5 years postoperatively.A 31-year-old woman was diagnosed with a solid pseudopapillary neoplasm (SPN) based on endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology. Contrast-enhanced computed tomography (CT) showed a 25-mm tumor with calcifications in the pancreatic body that widely contacted the SpV, but was not close to the SpA . It was 4/μL, respectively. Pre- and post-operative (5 POMs) spleen volumes were 126 and 145 cm3, respectively. The hypoglycemic symptoms improved and she has been alive without a recurrence 4 years postoperatively.A 46-year-old woman was shown to have hypoglycemia during a medical examination. She presented to our hospital for evaluation of worsening hypoglycemic symptoms. A CT scan of the abdomen did not reveal any abnormalities. Contrast-enhanced magnetic resonance imaging (MRI) showed a 5-mm tumor in the pancreatic tail which had a low-signal intensity on T1-weighted images and a high-signal intensity on T2-weighted images . EUS-FNA4/μL, respectively. The pre- and post-operative (7 POMs) spleen volumes were 133 and 185 cm3, respectively. The patient remains healthy without a recurrence 19 months postoperatively.A 38-year-old woman was diagnosed with a mucinous cystic neoplasm (MCN) based on imaging studies. A CT scan showed a 35-mm cystic tumor in the pancreatic tail which was in contact with the SpV and close to the SpA . AlthougReports on laparoscopic SPDP have been increasing  because Splenic vessel preservation may be the optimal way to preserve blood flow to the spleen, but the SpV must be resected during this process in some cases. The SpA usually passes through the cranial portion of the pancreas and there are a few branches from the SpA. Therefore, it is relatively easy to divide the pancreas and the SpA. Because the SpV usually passes through the groove behind the pancreatic body and tail and there are many small branches into the SpV, the SpV is relatively difficult to divide from the pancreas. Moreover, if there is pancreatitis and adhesions to the SpV, it is more difficult to divide the vein and pancreas without injury or bleeding. In addition, there are other reasons for surgical difficulty; specifically, tumors close to the SpV are a risk for residual lesions, perforation of the cystic wall and tumors that are too large to secure the field of view. In such cases, SPDP-Res or conventional distal pancreatectomy with splenectomy is generally indicated.Because SPDP-Res is a relatively simple procedure compared with the SPDP-Pre, the SPDP-Res has a shorter operative time and less blood loss . SplenicCongestion of the spleen and the development of gastric varices is a concern when performing a SPDP-VRes. Blocking SpV flow and preserving the SpA is similar to a pancreaticoduodenectomy with combined PV resection for pancreatic cancer invading the PV/SMV confluence, which results in left-sided portal hypertension , 12. To In the previous reports of SPDP-Res and SPDP-Pre, the left omental vessels and the splenocolic ligament are divided , 2. ThisSPDP-VRes may be a useful treatment option for patients who have tried to undergo SPDP-Pre. There were no serious complications during short- and long-term follow-up. It is important to preserve the omental branches of the LGEV to avoid spleen congestion.


Electrochemotherapy (ECT) is a novel non-thermal ablative technique that combines chemotherapy and the application of electric pulses for reversible cell membrane electroporation. This method was recently performed in the treatment of deep-seated liver tumors during open surgery but experience about percutaneous ECT is rare and further developments like combination of percutaneous ECT with stereotactic navigated devices may be very promising. We report on a case of a 4.7 × 4.5 × 3.5 cm unresectable HCC at the hepatic hilum adjacent to the major vessels and the bile duct that was successfully treated using percutaneous ECT in combination with stereotactic navigation. Follow-up imaging 6 weeks and 6 months after ECT showed complete response. In recent years, local ablative procedures have become a curative treatment option even for patients with increasingly large hepatocellular carcinoma (HCC). This is due to technical advances in 1) thermal ablative procedures such as multiantenna microwave ablation (MWA)  thermal , (2) comResulting from the abovementioned limitations percutaneous ablation can be very challenging, especially in case of a large central tumors.Electrochemotherapy (ECT) is a non-thermal ablative technique that combines chemotherapy and the application of electric pulses for reversible cell membrane electroporation. Consequently, mitotic tumor cell death results through high intracellular concentrations of the chemotherapeutic agent. In contrast to ECT, IRE uses irreversible cell membrane electroporation  that results in damage to the cell membrane and apoptosis. ECT has proven to be a safe and effective treatment for cutaneous tumors/metastases and first case series state, that ECT is also an effective treatment method for liver lesions in intraoperative settings –10.We report a case of ECT for treatment of a large central HCC using a stereotactically navigated percutaneous approach.A 75-years old male patient with Child A liver cirrhosis presented with a 4.7 × 4.5 × 3.5 cm large central HCC involving liver segments IV/VIII and a satellite HCC . The portal vein showed thrombosis resulting in cavernous transformation while the hepatic artery and the central bile ducts were located in close proximity to the HCC resulting in local cholestasis  was injected intravenously (as bolus); 8 min after Bleomycin injection, 8 electric pulses with a frequency of 1000 Hz, impulse length of 100 µs, and voltages ranging from 1.4 to 3 kV were delivered between each electrode pairing over a timespan of 16 min. Stereotactic MWA of the satellite tumor was performed during the same session. A control-scan in arterial and portal-venous contrast phase showed complete devascularization of both, tumor and satellite. No periinterventional adverse events occurred. Total procedural time  took 3 h and 24 min.The procedure was performed under general anesthesia and deep muscle relaxation in the supine position with the right side slightly lifted. A Somatom Definition Edge CT-scanner  was used in combination with a stereotactic navigation system  for optimized percutaneous placement of ECT electrodes . Induction of general anesthesia, patient preparation and setup of the stereotactic navigation system took 37 min. Six electrodes with 4.0 cm active tip were placed within and around the tumor with the distance between the electrode-tips ranging from 2.1 to 3.0 cm  performed 24 h after the procedure confirmed complete devascularization of tumor and satellite. The patient was discharged two days after the procedure in good condition and without complications. Alpha-fetoprotein decreased to 7.55 ng/ml.Contrast-enhanced MRI 6 weeks and 6 months after ECT showed complete response with no residual or recurrent HCC and without any signs of damage of the central bile ducts or affection of the liver artery Fig. .Fig. 3FoDuring open surgery, ECT has proven to be a potential method for treatment of HCC in 10 patients . As of tIn our case ECT was performed using a primary stereotactic percutaneous approach for treatment of a large (4.7 × 4.5 × 3.5 cm) central unresectable HCC involving the major vessels and the main bile ducts. Multiantenna MWA was not suitable due to the central localization of the tumor with the associated risk of incomplete ablation due to heat sink effect from the hepatic hilar vessels and the risk of thermal damage to the central bile ducts [So far, ECT has never been combined with stereotactic navigation. A stereotactic percutaneous approach for ablation of liver lesions results in more precise positioning of the probes and the possibility to predict the exact ablation zones without extension of the procedure time . By usinThe short hospitalization in this case reflects the advantages of minimal-invasive percutaneous ablation therapy: median length of hospital stay after ECT during open surgery for liver metastases was 14 days .Stereotactic percutaneous ECT has the potential to be used as a curative treatment method for HCC with diameters of more than 4 cm, even in close proximity to critical structures like major blood vessels and central bile ducts.


Inflammatory cap polyp is a very rare benign entity of the distal left colon, characterized by inflammatory polyp with a “cap” of fibrinopurulent exudates. They are usually multiple and commonly present with bleeding per rectum or mucoid discharge. Solitary polyp presenting with intermittent intussusceptions is rare.We report the case of a 45-year-old Nepalese male with a solitary inflammatory sigmoid colon polyp. The patient presented with a 1-month history of rectal bleeding, mucoid discharge, and severe colicky abdominal pain due to intussusceptions. On colonoscopy, there was an exophytic mass with surface exudates. Colonic resection and anastomosis were performed, due to recurring partial intestinal obstruction. At a 6-month follow-up, the patient was asymptomatic.Inflammatory cap polyp is a benign entity, and it should be kept in mind as an important differential diagnosis of exophytic colonic mass with surface exudates. The diset al.  in 1985.et al. , 4. HereA 45-year-old Nepalese male presented with abdominal pain and blood-mixed stool for 1 month. The pain was located in the left iliac fossa, intermittent, colicky, and at times requiring injectable analgesics for relief. He also complained of the passage of large amounts of mucopurulent discharge, per rectum. He denied any past medical illness and loss of weight or appetite. Moreover, there was no history of smoking or alcohol consumption or family history of inflammatory bowel disease or any gastrointestinal illness. General physical examination was normal. Abdominal and digital rectal examination was also normal, with no palpable lump or tenderness. Blood investigations revealed normal hemoglobin (11.8 gm/dl) and biochemistry. Colonoscopy showed an exophytic mass (size 5 × 5 cm) at descending/sigmoid colon junction that occupied half of the lumen with surface exudates and erosions Fig. .Fig. 1CoSince the time of colonoscopy, the patient had already been placed on a liquid diet, as part of bowel preparation. The decision to opt for an operative procedure, without obtaining a histopathological diagnosis, was made in view of the fact that the patient had recurring pain, suggesting intussusceptions with a lead point of the tumor. At surgery, there were no features of metastases. There was an intraluminal tumor at the sigmoid colon, which was resected with a wide margin and was anastomosed in two layers. Cut-section of the resected colon revealed a reddish, soft polypoidal lesion Fig. . The posCap polyp is a rare, nonneoplastic condition that primarily involves the distal colon and the rectum, characterized by the presence of inflammatory polyps with a cap of granulation tissue . They arHelicobacter pylori infection, mucosal prolapse secondary to colonic dysmotility, and previous pelvic surgery [The pathogenesis of cap polyp is controversial, but it has been hypothesized to be caused by dysbiosis of gut microbiota, chronic mucosal irritation caused by straining at defecation,  surgery , 7. The  surgery , 5. Some surgery . Biopsy  surgery , 6.H. pylori antigen status should also be evaluated to exclude inflammatory bowel disease and infectious origin polyps [The main differential diagnosis is pseudopolyp of pseudomembranous colitis (PMC), inflammatory bowel disease , and the adenomatous/malignant polyps covered by the exudates , 9. In Pn polyps , 7, 9.H. pylori eradication therapy, and infliximab [The optimal treatment of cap polyp/polyposis is not known; however, a trial of medical therapy should be given to all patients initially . This infliximab , 10.Recurrence of the disease is possible and has been described. Hence, postoperative close clinical follow-up or surveillance after colonoscopic polypectomy is necessary to exclude recurrence.Inflammatory cap polyp is a rare, benign polyp of the left side of the colon and the rectum. It can present with intussusceptions and, hence, should be kept in mind by the treating physicians when they encounter a “cap” of fibrinopurulent exudates on the polyp on colonoscopy.


Rhabdomyosarcoma (RMS) is a soft-tissue sarcoma of mesenchymal origin that exhibits skeletal muscle differentiation. It is classified into various histologic subtypes, including alveolar rhabdomyosarcoma (ARMS), embryonal rhabdomyosarcoma, pleomorphic rhabdomyosarcoma, and sclerosing rhabdomyosarcoma.A 67-year-old woman admitted for inpatient chemotherapy for ARMS presented with a scalp nodule. The patient noticed the enlarging, asymptomatic nodule 3 months ago on the parietal aspect of the right side of the scalp . She denPhysical examination revealed a 15-mm mobile, erythematous nodule on the parietal aspect of the right side of the scalp. A 4-mm punch biopsy revealed malignant tumor composed of micronodular aggregates of small blue cells with strongly positive for muscle-specific actin and desmin , consiston theright side of the buccal mucosa was also identified; an incisional biopsy demonstrated histologic findings consistent with metastatic ARMS. Further treatment and next steps are to be determined by oncology.Three months later, otolaryngology performed a wide local excision of the mass which had enlarged to 4.7 × 2.0 cm. A 2.5-cm mass ,,,In the United States, soft-tissue sarcomas account for 1% of adult malignancies, of which 2% to 5% can be attributed to adult RMS.,,It is well documented that adults with RMS have poorer outcomes compared with children.,Generally, RMS presents as a fleshy-lesion, erythematous mass with overlying telangiectasia, or soft-tissue swelling.In summary, we report a case of metastatic ethmoidal ARMS presenting as a scalp nodule in an adult woman. Our case adds to the existing literature regarding the clinical and histopathologic findings of cutaneous metastasis from RMS. Although rare, scalp nodules or other cutaneous lesions in individuals with soft-tissue malignancy may represent metastasis and necessitate biopsy to avoid misdiagnosis. Confirmation of metastasis may warrant referral to oncology for further work-up of tumor spread.None disclosed.


Keratocysts, which are benign cystic lesions that usually arise in the jawbones, particularly the mandible, can rarely occur in the skin and soft tissues. Odontogenic keratocysts, which are keratocysts in the jaw, are considered hallmarks of nevoid basal cell carcinoma syndrome (NBCCS). In contrast, cutaneous keratocysts (CKCs), which can occur in association with NBCCS, are rare. To date, only a few studies have reported CKCs arising independently of NBCCS. Herein, we report a rare case of CKC in the scalp of a 49-year-old female patient without the clinical features of NBCCS, intending to increase awareness of this rare presentation among pathologists who encounter cutaneous cystic lesions in daily practice. Cutaneous keratocysts (CKCs) are benign cystic lesions lined with epithelial cells that share histological features with odontogenic keratocysts (OKCs). Both types of keratocysts are features of nevoid basal cell carcinoma syndrome (NBCCS), which is also known as Gorlin-Goltz syndrome , a rare A 49-year-old woman presented to the general surgery clinic with the chief complaint of painless swelling in the scalp for three years, which increased in size a month before presentation. She denied any constitutional symptoms. The medical, surgical, and family histories of the patient were unremarkable. On examination, a mobile, non-tender, single nodule, 3×3 cm in size, was identified in the left parietal area of the scalp. The clinical diagnosis was a sebaceous cyst, and the nodule was surgically excised under local anesthesia.The gross examination of the specimen fixed in 10% neutral buffered formalin revealed a collapsed gray cystic lesion, measuring 1.5×0.9×0.2 cm. Sectioning of the excised specimen revealed a cystic lesion with a thin, firm, tan-white wall. No skin was identified. Histologically, the cystic lesion showed prominent infoldings of the epithelium into the connective tissue wall Figure . The epiCKCs, exceedingly rare tumors that were first described in association with NBCCS by Barr et al. , are conThe differential diagnosis of CKCs includes epidermal cysts, trichilemmal cysts, and steatocystomas. Epidermal (infundibular) cysts, also known as epidermoid cysts or epidermal inclusion cysts, are usually located in the mid- and lower dermis and are lined by stratified squamous epithelium exhibiting epidermal-type keratinization with a prominent granular cell layer and flattened surface epithelium. The lumen often contains abundant keratin flakes . ConversThe pathogenesis of CKCs is not clear; however, a role for genetic alterations in PTCH1 on chromosome 9q22.3, which is also altered in NBCCS, has been proposed . CKCs haThe diagnosis of CKCs is based purely on characteristic histological features. However, the presence of CKCs should prompt further investigation to rule out the possibility of NBCCS, particularly in young patients. Albeit rare, sporadic cases can occur without NBCCS features. Combining sporadic CKCs and steatocystomas under the unifying name “sebaceous duct cysts” might be considered, whereas the term CKC might be retained for cysts that occur in association with NBCCS.


Myiasis is defined as the infestation of living tissues by Diptera larvae. Ophthalmic involvement occurs in less than 5% of cases. As the most uncommon type of involvement, orbital myiasis usually affects patients with poor personal hygiene, a low socioeconomic status, a history of surgery, and cancer.In January 2020, an 89-year-old man presented to the Oculoplastic Department of Farabi Eye Hospital (Iran) with a history of left-side progressive orbital mass for six months. A large infiltrative mass of the left orbit with extension to the globe, periorbita, and adnexa was remarkable at the presentation, and its appearance suggested malignancy. Our findings persuaded us to perform exenteration and histopathological evaluation which were reported as “undifferentiated carcinoma”. Regular follow-up visits were recommended. In June 2020, with a 3-month delay, the patient presented with the recurrence of the mass complicated with mobile alive larva. Examinations revealed numerous maggots crawling out of an ulcerative and foul-smelling lesion. He stated that fear of COVID-19 infection postponed his follow-up visit. The patient underwent immediate mechanical removal of larvae, followed by wide local excision of the mass.Patients with carcinoma of the adnexal tissues seem to be more prone to myiasis infestation even though it is an uncommon disease. Since COVID-19 is an ongoing pandemic with no end in sight appropriate protocols should be implemented to prevent loss of follow-up in these high risk patients.The online version contains supplementary material available at 10.1186/s12348-021-00271-1. This coLimited reports are available in the literature on orbital myiasis. Herein, we report a rare case of orbital myiasis in an old man with a history of orbital tumor that missed his follow-up visits due to the COVID-19 pandemic. Eventually, he presented with the recurrence of the tumor complicated with orbital myiasis.In January 2020, an 89-year-old man presented to the Oculoplastic Department of Farabi Eye Hospital with a history of left-side progressive orbital mass for six months. At the presentation, the best-corrected visual acuity (BCVA) of the right and the left eyes was 20/100 and no light perception (NLP), respectively. Examinations of the right eye revealed dermatochalasis and 3+ nuclear sclerosis cataract. Other slit and fundus examinations of the right eye were normal. The examination of the left globe was not possible due to a large infiltrative mass with extension to the globe, periorbita, and adnexa. The patient’s history was negative for systemic disease or malignancy. The appearance of the mass was suggestive of malignancy more than other diagnoses. Our findings persuaded us to perform exenteration and histopathological evaluations which were reported as “undifferentiated carcinoma in some foci admixed with sarcomatous stroma (carcinosarcoma), most probably metastatic in origin”. An immunohistochemistry (IHC) study showed weakly positive EMA, positive Pan CK, CK-HM, and CK-LM, diffusely positive vimentin, positive CK7, and negative CK20 and S100 in tumoral cells. An oncology consultation was requested to investigate the possible origin of the tumor. To date, all of the investigations were negative.The patient was asked to visit in March 2020, a date that coincided with the beginning of the COVID-19 epidemic in Iran, leading to quarantine policies and measures. This condition coupled with his poor compliance delayed his follow-up visit. In June 2020, the patient presented after a 3-month delay with recurrence of his mass complicated by numerous maggots crawling out of an ulcerative and foul-smelling lesion. He stated that fear of the COVID-19 pandemic had caused him to postpone his follow-up visits. The size of the lesion was approximately 10 × 8 cm. We used a single dose of oral ivermectin prior to surgery to reduce the difficulty of the mechanical removal of the maggots. After oncology consultation, a wide local excision was planned. The specimen for the histopathological study showed interesting findings: undifferentiated carcinoma in some foci in the stroma, with diffuse foreign body-type granulomatous inflammation containing many multinucleated giant cells , Cochliomyia hominivorax (screw worm), Hypoderma bovis (ox warble fly), and Oestrus ovis (sheep botfly) are accounted as the most common species [Up to 80 species of Diptera can infest human tissues.  species . The lar species . The Dip species . An inte species . Among t species . Table 1The diagnosis is based on clinical findings, and the treatment aims to remove all of the larvae and prevent bacterial superinfection . Brain, Patients with carcinoma of the adnexal tissues seem to be more prone to myiasis infestation even though it is an uncommon disease. Since COVID-19 is an ongoing pandemic with no end in sight appropriate protocols should be implemented to prevent loss of follow-up in these high risk patients.Additional file 1: Video 1. Showing numerous maggots crawling out of an ulcerative lesion with necrotic surface.


Diverticulosis is an out-pocketing of the bowel wall that can affect the small bowel through the large bowel. Small bowel diverticulosis is rare and not as common as colonic diverticulosis, which is an important diagnosis for hospitalizations. Moreover, jejunal diverticulosis is rare among cases of small bowel diverticulosis. Jejunal diverticulitis is one of the complications of jejunal diverticulosis that can be conservatively managed with antibiotics instead of surgery.We report a case of a 41-year-old African American man who presented with vague epigastric pain and was diagnosed with adhesive jejunal diverticulitis upon contrast-enhanced computed tomography of the abdomen. The patient did not develop any life-threatening complications such as perforation or peritonitis, and recovered after conservative management with antibiotics. Adhesive jejunal diverticulitis with fat stranding was the distinctive finding in our patient, as he might have had multiple asymptomatic episodes.Initial diagnostic modalities include radiography and contrast-enhanced computed tomography. Enteroclysis is the most reliable and accurate diagnostic modality, but is not available in all urgent settings. Recently, endoscopy has replaced radiological studies. Conservative management is adequate for uncomplicated cases of jejunal diverticulitis. However, surgical intervention is required in most cases of complicated jejunal diverticulosis, or mortality rates will be high. Diverticulosis is a sac-like out-pocketing of the bowel wall that can affect the small bowel through the large bowel. Small bowel diverticulosis is rare and not as common as colonic diverticulosis, which is an important diagnosis for hospitalizations. Moreover, jejunal diverticulosis (JD) is rare among cases of small bowel diverticulosis and can occur anywhere in the small bowels. However, occurrence in the small bowel is rare and usually discovered through endoscopy and radiological imaging methods. The incidence of small bowel diverticulosis ranges from 0.3% to 1.3% in the general population and is 2.3% in autopsies [We report a 41-year-old man with no significant medical history except essential hypertension. He presented with a sudden onset of epigastric and periumbilical abdominal pain with no associated symptoms such as nausea, vomiting, fever, chills, diarrhea, melena, or hematochezia. He had a history of intermittent, vague abdominal pain for which he did not seek medical help, as it has resolved on its own. The rest of his pertinent history included chronic tobacco use and occasional alcohol abuse. His vital signs were stable. Physical examination revealed tenderness in the upper abdomen but no rigidity or rebound tenderness. Bowel sounds were heard in all four quadrants. His labs including complete blood count and comprehensive metabolic panel, which included blood glucose levels, serum electrolytes and calcium, liver function tests, blood urea nitrogen and creatinine, were essentially within normal range. Plain abdominal radiography showed a non-obstructive bowel gas pattern, but was otherwise normal. Contrast-enhanced computed tomography (CT) of the abdomen and pelvis showed multiple diverticula involving the jejunum Figure . A smallThe first case of small bowel jejuno-ileal diverticulosis was published in 1794 . JD is rJD often presents with no symptoms, and the diagnosis is coincidental in 70% of patients. Thirty percent of patients present with nonspecific symptoms such as abdominal pain, malabsorption syndrome-related signs and symptoms that arise from complications such as diverticulitis, perforations with local or generalized peritonitis, obstruction, adhesions, abscess formation, gastrointestinal hemorrhage, and rarely, volvulus . Thus faAs the diagnosis of JD in most of the patients is incidental, they might suffer from diverticulitis long before they clinically present. Our patient might have had subclinical or asymptomatic episodes of diverticulitis before he was admitted to the hospital. Upon further interview, our patient also admitted that he had episodes of vague abdominal discomfort that resolved without any medical intervention, so he did not seek further medical help. Plain abdominal radiography is the initial diagnostic modality. However, the most accurate and reliable study is enteroclysis, which may not be possible to do in all urgent settings because of unavailability. Contrast-enhanced CT of the abdomen is the gold standard for providing useful diagnostic information . In someUncomplicated small bowel diverticulosis should be left untreated. Conservative management with intravenous antibiotics is adequate for diverticulitis, unless perforation or obstruction develops. Our patient responded to intravenous antibiotics and was discharged after two days of hospitalization. Complications usually occur in jejunal and ileal diverticular diseases and often require surgical interventions. Complications are rare in DD and usually improve with conservative management and surgical intervention may not be required .Unlike the more common colonic diverticulosis, JD is a rare form of bowel diverticulosis. Diagnosis of JD is usually incidental as the majority of patients are asymptomatic. Initial diagnostic modalities include radiography and contrast-enhanced computed tomography. Enteroclysis is the most reliable and accurate diagnostic modality, but is not available in all urgent settings. Recently, endoscopy has replaced radiological studies. Conservative management is usually adequate in uncomplicated patients. However, in complicated cases such as perforation, obstruction, abscess formation, and volvulus, emergent surgery is mandatory or the mortality rate will be high.


Herein we present a previously unreported rare case of mucinous adenocarcinoma arising from a congenital ejaculatory duct cyst. Radiographic and endoscopic examinations revealed the tumor occurred in a cyst running through the prostate. Initially, the immunohistochemical pathology results showed that it was a metastatic mucinous adenocarcinoma, but no other primary lesions were clinically evidenced. Based on the embryonic development process of the male urogenital tract, the malformation of the patient's ejaculatory duct, and the pathological examination of the resected specimen, we considered the tumor to be a primary mucinous adenocarcinoma which originating from the hypoplastic ejaculatory duct. The tumor may have developed from the foci of intestinal metaplasia from cloacal remnants during embryonic development. The ejaculatory tube is composed of the excretory tube of the seminal vesicle and the vas deferens. Bilateral tubes enter into the base of the prostate and opening on both sides of the membrane of verumontanum. Ejaculatory duct cyst is rare congenital or acquired lesion, with fewer than 30 previous reports in the literature . Only twMucinous adenocarcinomas are malignant tumor which usually occur in the gastrointestinal tract and are rare in the genitourinary tract. We report a case of primary mucinous adenocarcinoma arising from a congenital ejaculatory duct cyst, which may have been related to the cloacal remnants during embryonic development.A 74-year-old man who was married with a son and daughter was admitted because of intermittent mucoid discharge from his urethra and difficulty voiding for 3 years. Indwelling catheterization was performed because of urinary retention. Digital rectal exanmination revealed a suspicious soft cystic mass with an unclear boundary in the upper left area of the moderately enlarged prostate. Serum prostate-specific antigen (PSA) was 4.12 ng/ml. Imaging studies  and an eMucinous adenocarcinomas are a special pathological type of adenocarcinoma, in which >50% of the lesion is composed of pools of extracellular mucin . Of all +, PAX2− and PAX8−, indicating that it was not derived from the mesonephric or paramesonephric duct. Thus, the tumor likely did not arise from the seminal vesicle or vas deferens. Strong CDX-2+ expression indicated that it was either metastatic colorectal mucinous adenocarcinoma or intestinal metaplasia, but no clinical evidence was found to support colorectal tumor metastasis, other than a rectal tubulo-villous adenoma.This case was pathologically confirmed as a mucinous adenocarcinoma, occurring in a cystic structure with invasion of the left seminal vesicle and vas deferens. Three-dimensional radiological reconstruction and histological examination revealed no normal ejaculatory duct was found in the left prostate lobe. The cyst, which was located at the left lower posterior of the bladder, passed through the prostate and connected to the right seminal vesicle through the prostatic urethra . We therThe cloaca is the common compartment in the urogenital and anorectal channels in the 5-week-old human embryos. During weeks six to seven of embryonic development, the urorectal septum subdivides the cloaca into two separate parts . In thisInterestingly, the initial pathological diagnosis suggested that the neoplasm in the cyst was a tubulo-villous adenoma, which also occurred in the patient's rectum. Of colorectal adenocarcinomas, 95% develop from adenomas, which are classified as villous, tubular or tubulo-villous. The latter two are highly correlated with malignancy (including mucinous adenocarcinoma) because they contain villous tissue . SeveralThe patient underwent radical prostatectomy and seminal vesiculectomy. MRI performed 6 months postoperation showed normal signaling of the vesicourethral anastomosis area and no enlarged lymph node was detected in the pelvis. However, 15 months postoperation, the patient experienced difficulty urinating. Cystoscopic examination revealed neoplasms at the vesicourethral anastomosis. The sample obtained via transurethral resection was pathologically confirmed to be mucinous adenocarcinoma. Tumor-cell seeding through the mucus secreted by the tumor might have been the main cause of recurrence. Chemotherapy was recommended.


De novo small bowel adenocarcinoma (SBA) in the terminal ileum is the least common of the SBA types. However, its highest prevalence is found in the presence of Crohn’s disease (CD). As patients with SBA and CD present with similar symptoms, there is a high chance of misdiagnosing SBA as CD. This can lead to delay in proper diagnosis and can affect prognosis. In this article, we discuss two cases of de novo SBA mimicking CD, in the absence of CD, on conventional CT, CT enteroclysis and magnetic resonance imaging (MRI) enteroclysis. Moreover, it underlines the importance of suspecting SBA in cases where there is a lack of response to long-term medical treatment. CD is a well-known risk factor for SBA. A 2006 meta-analysis reported a relative risk of 31.2  for small-bowel neoplasm in CD.5 In contrast, we herein introduce two cases of de novo SBA in the terminal ileum mimicking CD on conventional CT, CT enteroclysis and MRI enteroclysis in the absence of a final diagnosis of CD.The prevalence of small-bowel adenocarcinoma (SBA) is very low, present in just 5% of all cases of gastrointestinal malignancy.A 64-year-old female presented with a 2-month history of central intermittent non-radiating abdominal pain with vomiting. There was no haematemesis or haematochezia. There was no significant recent weight loss. She had a background history of polymyalgia rheumatica (on long-term steroid), chronic obstructive pulmonary disorder and use of a cardiac pacemaker. She had a smoking history of 45 pack a year but a low degree of alcohol consumption. There was a notable family history of both bowel and breast cancer.−1) and elevated faecal calprotectin (402 μg/g).On clinical examination, left iliac fossa tenderness with guarding was noted. Test results of blood drawn at admission showed elevated C-reactive protein (CRP)  imaging showed mild thickening of the distal and terminal ileum throughout a section measuring approximately 10 cm long but no signs of colonic mass or malignancy . As MRI Based on the image findings and clinical pictures, the patient received 40 mg of methylprednisolone intravenously bd for 2 days and, as her symptoms improved, she was transferred to 40 mg of oral prednisolone 40 mg once daily as a tapering dose. She was discharged with a follow-up plan to be seen by a gastroenterologist in 8–10 weeks’ time as an outpatient.9/L) and CRP level (75 mg l−1) were elevated. On clinical examination, her abdomen was soft but mildly tender. An urgent colonoscopy was performed which revealed a terminal ileum tumour. A cold biopsy was taken, which confirmed a moderately differentiated adenocarcinoma. Contrast enhanced CT CAP was performed for staging which showed more prominent mural thickening and mild hyperenhancement of the terminal ileum. However, there was no locoregional lymphadenopathy or proximal small bowel dilatation  but otherwise normal full blood counts and urea and electrolytes. CT CAP imaging was repeated, showing a segment of possible CD within the terminal ileum and ascending colon, with dilatation of the ileum proximal to the inflammatory stricture. Probable further skip lesions were seen within the jejunum but no intra-abdominal abscess was apparent , nausea and vomiting (16%), fatigue and anaemia (15%), gastrointestinal haemorrhage (7%), jaundice (6%) and weight loss (3%).15 Bowel obstruction, diarrhoea and fistula are also well-known findings; however, all of these symptoms are also commonly seen in CD. Moreover, symptoms related to malignancy tend to improve with short-term steroid use, which makes the diagnosis of SBA even more complex. The prognosis of cancer majorly depends on successful early detection; however, monitoring the response to steroids and awaiting outpatient colonoscopy delays the diagnosis. In a retrospective study, 67% of cases of CD-related SBA were found incidentally at surgery.16To understand the prevalence of the presentation of SBA as CD, a literature search was conducted in the PubMed database. Both broad and specific terms such as ‘adenocarcinoma’, ‘carcinoma/cancer’ or ‘tumour/tumor’; ‘small bowel’ or ‘ileum/ileal’; and ‘Crohn’s’ as well as ‘without’, ‘mimicking’, ‘simulating’ or ‘Therefore, clinicians should be more cautious when diagnosing CD in patients with a lack of long-term response to medical treatment such as corticosteroids. Furthermore, the possibility of SBA in the terminal ileum with inflammatory changes on CT or MRI scans should not be overlooked.De novo small bowel adenocarcinoma (SBA) in the terminal ileum is the least common of the SBA types.Changes in CT and MRI enteroclysis in patients with SBA can look very similar to those with CDIn the early stages of CD or SBA, thickening and hyperenhancement of the mucosa with bowel-wall stenosis can be very difficult to distinguishThis makes the diagnosis of terminal ileal adenocarcinoma in the absence of CD more difficult due to the high possibility of misdiagnosing it as CDInvestigations for CD can delay the diagnosis of SBA, so the possibility of SBA should not be overlooked with inflammatory changes in the terminal ileum on CT or MRI, especially with a lack of long-term response to medical treatments


Melanotic oncocytic metaplasia of the nasopharynx is an uncommon disease, usually asymptomatic, that could be misdiagnosed for melanoma, because of its macroscopic features. For this reason, is necessary to know it thoroughly and to take it into account in the differential diagnosis.A 69-year-old Italian woman presented to our Otorhinolaryngology Clinic with a 1-month history of sore throat. She has been a smoker for several years. During the nasopharyngoscopic examination, grey-brown, irregular and slightly elevated lesions, measuring few millimetres, were found near the right Eustachian tube opening. The preliminary diagnostic hypothesis was malignant disease. After biopsy and histopathological assessment, the lesion was diagnosed as melanotic oncocytic metaplasia of the nasopharynx that is a benign and rare disease. So, given the multiple lesions and their benign nature, they were controlled with regular nasoscopic examinations. Melanotic oncocytic metaplasia is a benign lesion of the nasopharynx and it is necessary to emphasize the importance of its clinical awareness for differential diagnosis with malignant lesions. Melanotic oncocytic metaplasia (MOM) of the nasopharynx is a rare lesion first described by Shek et al. in 1995 -6. Moreover, it is often an incidental finding during endoscopic evaluation because related symptoms are uncommon . AlthougIn this study, we present the first case of 69-year-old Caucasian  woman with incidental finding of MOM of the nasopharynx.In 2019, a 69-year-old Italian woman presented to our ENT Clinic with a 1-month history of sore throat. She was a smoker with the consumption of 15 cigarettes per day for several years. As for the rest, her past medical history was unremarkable. So, a nasopharyngoscopic examination was performed with the incidental finding of multiple, grey-brown, irregular and slightly elevated lesions, ranging from 2 to 4 mm in the maximal diameter, with clearly identified margins, near the right Eustachian tube opening . The overlying mucosa was intact, without signs of necrosis or bleeding when touched. Melanoma, melanosis or malignant tumour were suspected on macroscopic evaluation. Examination of neck, nasal cavity and larynx didn’t reveal abnormalities. Under local anaesthesia, one of the larger lesions was biopsied for histological assessment. The surgical specimen was a single, grey-brown, mucosal piece measuring 0.2x0.2x0.1 cm. Microscopic examination revealed a well demarcated lesion, covered by normal respiratory epithelium and composed by several seromucinous glands with diffuse oncocytic metaplasia. Moreover, scattered brown pigments was found in the cytoplasm of oncocytic cells. They were positive for Fontana-Masson staining and negative for Pears’s ones, confirming the melanin nature. There weren’t either cytological atypia nor mitotic figures in the epithelial cells of the glands. Immunohistochemically, dendritic cells were immunoreactive to S-100 protein and negative for HMB-45. Thus, based on these findings, the lesion was assessed as melanotic oncocytic metaplasia of the nasopharynx. Considering the benign nature of MOM, other similar lesions around the right Eustachian tube opening weren’t excised but only followed with periodic nasoscopic examinations. As previously stated, after diagnosis, the patient was controlled with nasopharynx endoscopy each three months. Thus, at nine-month follow-up, lesions in nasopharynx, near the right Eustachian tube opening, were unchanged, without progression to malignancy.Melanotic oncocytic metaplasia (MOM) of the nasopharynx is an uncommon and little-known disease. Indeed, oncocytic metaplasia is most frequently detected in other sites, as salivary glands, thyroid and parathyroid glands ,7. Histoelanosome in oncocytic cells and by immunohistochemistry that finds S-100 positive and HMB-45 negative dendritic cells ,10,11.This metaplasia is often an incidental finding during nasopharyngeal examination for other disease since it’s usually asymptomatic, as well as in our case. However, given its siting near the Eustachian tube opening, the most common related symptoms are otitis media, tinnitus, nasal obstruction and rhinorrhea. Moreover, analysing the literature , MOM usuEpidemiologically, most of the patients are men (8 men: 1 women) with a mean age of 70 years . Moreover, to date, the literature reports only cases of Asiatic people affected by MOM. Hence, our case report differs from these since the patient is a 69-year-old Italian woman, thus the first case of European patient affected by MOM, to the best of our knowledge. Furthermore, in 20 of 33 cases of MOM reported in literature patients were smokers ,8,15,16,Melanotic oncocytic metaplasia of nasopharynx is a rare disease and it is crucial to investigate it further because, although rare, it may be misdiagnosed as a malign and more serious lesion (i.e. melanoma) which would require a more invasive treatment and would be correlated to a worse prognosis. Melanotic oncocytic metaplasia of the nasopharynx is a rare and benign disease.This disease should be considered in differential diagnosis of small, grey-brown, lesions around the Eustachian tube opening (i.e. melanoma).Given the benign nature of this disease, excision if it’s a single lesion or follow-up if they are multiple represent the proper management.


Very little data exists on salvage surgery in previously unresectable or metastatic disease treated with initial immunotherapy. Only a handful of case reports/series regarding surgery for advanced lung cancer after immunotherapy mention the technical challenges involved. We report the case of a 67‐year‐old female with a left lung squamous cell lung cancer revealed by computed tomography‐guided biopsy. Treatment started with chemotherapy followed by immunotherapy in which a partial response was recorded. Subsequent salvage lingulectomy with the thoracoscopic approach was performed. The patient fully recovered and shows no sign of recurrence at follow‐up 16 months on. Our case discusses the surgical tactics involved in the procedure, highlights similar findings encountered in the literature, and contributes to the few reports therein. Thoracoscopic intrapericardial lingulectomy following immunotherapy can be safely performed even in the presence of pulmonary hilar fibrosis. The use of immune checkpoint inhibitors (ICI) has been gaining ground in the treatment of non‐small cell lung cancer (NSCLC) worldwide. Early studies of these drugs in patients with advanced NSCLC suggest that long‐lasting sound treatment responses in such cases can be expected.A 67‐year‐old woman presented to our hospital with cough and progressive dyspnea. A computed tomography (CT) of the chest revealed an ill‐defined left lung mass with obstructive atelectasis and massive pleural effusion Figure . Her resConsidering the residual tumor after treatment, the patient underwent salvage surgery 4 months after the last cycle of immunotherapy. A double‐lumen endotracheal intubation was performed with right decubitus positioning. The patient underwent left three‐port thoracoscopic approach. Diffuse intrapleural adhesions and dense hilar fibroses were encountered, which were considered remnants of the previous malignant pleural effusion and probably a postimmunotherapy phenomenon Figure  and enabThe use of immune checkpoint inhibitors (ICI) is gaining traction in the treatment of NSCLC. Hence, a full understanding is imperative due to its potential of becoming a part of mainstay treatment. Several prospective pilot studies revealed the viability of resection after ICI therapy.Under similar circumstances, we performed intrapericardial division of the lingular vein followed by stapling the remaining hilum due to severe adhesions between the lingular bronchus and artery. In this manner, the danger of pulmonary air leakage and vascular injury can be circumvented. In cases reported by Bott et al. and Fujishita et al., the possibility of a fusion between the pulmonary artery and bronchus following the administration of an ICI has been documented. The former authors cut both artery and bronchus together with a single stapler,Despite the way immunotherapy has reshaped the treatment approach to NSCLC, dense fibrosis and adhesions of pulmonary hilum may be anticipated during operations based on previous surgical experiences. However, more evidence is still required to validate the data through ongoing clinical trials. From our viewpoint, the merits of intrapericardial division of pulmonary vessels to avoid directly managing/dissecting hilar structure can be considered. Furthermore, thoracoscopic segmentectomy or even lobectomy can be performed safely with careful manipulation using proper surgical techniques.The authors report no conflict of interest.None declared.


Background and Objectives: Retroperitoneal schwannoma is a very rare case of schwannoma which commonly occurs in the other part of the body. However, it is difficult to distinguish schwannoma from other tumors before pathological examination because they do not show specific characteristics on imaging study such as ultrasound, computed tomography (CT), and magnetic resonance image (MRI). Case summary: A 60-year-old male showed a retroperitoneal cystic tumor which is found incidentally during evaluation of coexisted bladder tumor. Neurogenic tumor was suspicious for the retroperitoneal tumor through pre-operative imaging study. Finally, a schwannoma was diagnosed by immunohistochemical examination after complete surgical excision laparoscopically. Conclusion: As imaging technology is developed, there may be more chances to differentiate schwannoma from other neoplasm. However, still surgical resection and histopathological examination is feasible for diagnosis of schwannoma. Schwannoma (neurilemmomas) are benign tumors that originate from nerve sheath cells along peripheral nerves . They geA 60-year-old male presented with a two-week history of intermittent gross hematuria. There was a 2.5 cm-sized papillary tumor at the left anterolateral wall of the urinary bladder on cystoscopy. A contrast-enhanced abdominal computed tomography (CT) scan incidentally revealed a 4.8 cm cystic mass with septa at the left pelvic wall. Lymphangioma or cystic changes of the neurogenic tumor were suspicious for a cystic tumor. Magnetic resonance image (MRI) was recommended for differential diagnosis of a necrotic metastatic lymph node, which was the least-likely suspected diagnosis. MRI revealed that the bladder tumor was likely muscle-invasive with Vesical Imaging-Reporting And Data System (VI-RADS) category 4, and the pelvic mass exhibited cystic changes, suggestive of a neurogenic tumor  [5]. TheFirst, TURBT was performed under general anesthesia with the patient in a lithotomy position. The bladder tumor was histologically confirmed as a high-grade papillary urothelial carcinoma, Ta. One month later, laparoscopic pelvic mass excision was completed under general anesthesia using four trocars with the patient placed in the supine position. A 12-mm incision port for the laparoscope plus three other working ports were placed. The left retroperitoneal space was exposed after an incision of the left abdomen peritoneum. The plane was developed by a combination of sharp and blunt maneuvers. The left ureter and left common iliac vessels adherent to the pelvic mass were identified and dissected carefully. Finally, the mass was gently separated from the pelvic wall and extracted into a laparoscopic specimen bag. The specimen was sent to the pathologic department for routine staining and sectioning . SuctionSchwannoma most commonly occur in the head and neck . AlthougCystic changes happen when the tumor overgrows its blood supply . Over haStill, surgical excision and immunohistochemical examination are necessary to reach a definitive diagnosis. Intense staining of the S-100 protein is used to confirm the diagnosis of benign nerve sheath tumors, including schwannoma. The recurrence rate is very low in patients with benign schwannoma, while malignant tumors are associated with a very poor prognosis and high recurrence rate . In thisWe reported a case of an incidentally discovered retroperitoneal schwannoma, which is very rare and difficult to diagnose preoperatively. As the use of radiological examinations becomes more common, we expect that there will be increasing cases of incidental schwannoma. However, as imaging studies are limited in their ability to achieve definitive diagnosis, complete surgical resection and regular follow up are necessary.


Background: Abdominal wall hernias are frequent in patients with peritoneal dialysis. Guidelines recommend an open hernia repair with extraperitoneal mesh placement to avoid access to the abdominal cavity. Method: We performed a lateral docking robotically assisted enhanced-view totally extraperitoneal repair (eTEP) of a recurrent umbilical hernia with diastasis recti in a patient with peritoneal dialysis due to polycystic kidney disease. After suturing of the midline a 20 x 28 cm mesh was placed in the retrorectus space, covering the whole area of preparation while also overlapping all trocar sites. A drainage was left in the retrorectus space until the first session of PD did not sample any form of leakage.Result: Robotically assisted totally extraperitoneal hernia repair was feasible. The patient was able to continue peritoneal dialysis without intermittent hemodialysis. There was no leakage of the dialysate to the retrorectus space. Postoperative recovery was uneventful. 6 months after surgery the patient was free from pain and showed no signs of recurrence. Conclusion: Robotically assisted totally extraperitoneal hernia repair in patients with umbilical hernia and peritoneal dialysis could be a promising surgical technique to combine the advantages of minimally-invasive surgery with totally extraperitoneal mesh placement without access to the abdominal cavity. Peritoneal dialysis (PD) is frequently associated with abdominal wall hernias. Last year European Hernia Society (EHS) and American Hernia Society (AHS) published guidelines, focusing on primary ventral hernia repair in PD . Open reWe report a case of a robotically assisted enhanced-view totally extraperitoneal hernia repair (eTEP) of a recurrent umbilical hernia, performed on a 43-year-old male patient with polycystic renal disease and PD. The patient presented with a 2.5 x 2 cm recurrent umbilical hernia, associated with a 3.5 cm diastasis recti and an additional epigastric hernia. The year before suture repair of aforementioned umbilical hernia was performed during the implantation of the Tenckhoff catheter. An additional suture repair of another epigastric hernia between both hernia localisations prior to implantation of the catheter was reported. The patient had a BMI of 31 and no further comorbidities other than epilepsy. Ultrasound examinations showed that the catheter was implanted close to the umbilicus while passing the retrorectal space more caudally Figure 1 . Hence wRegarding the necessity of regular peritoneal dialysis, we established following problems:Due to peritoneal dialysis abdominal pressure is elevated, resulting in a higher risk of hernia recurrence.The anticipated area of mesh placement is compromised by the catheter crossing the abdominal wall while also increasing the risk of infection.Intraperitoneal mesh placement is not favoured in patients undergoing peritoneal dialysis.The peritoneal cavity is altered by PD in a way that makes it less accessible to surgery and is also accompanied by an increase in morbidity.An appropriate mesh covering the whole epigastrium including the diastasis recti, the concomitant epigastric hernia as well as the trocar sites is obligatory.In coherence with all the aforementioned, we decided that an eTEP hernia repair, with an uncoated mesh placed in the retrorectal space, would be a suitable procedure. The right retrorectus space was entered with an optic trocar. After blunt dissection with the camera the first DaVinci trocar was placed medially to the right semilunar line. During endoscopic dissection two more trocars were placed in the same line and the DaVinci X system was docked coming from the left side of the patient. Crossover to the left retrorectal space was started with an incision of the right posterior rectus sheath laterally to the linea alba. The preperitoneal fat of the ligamentum falciforme was separated from the linea alba and the left rectus sheath was opened by an incision of the left posterior rectus sheath. During crossover the hernias were repositioned and a small opening of the peritoneum was sutured. Dissection was proceeded in a lateral direction towards the left semilunar line until the catheter covered by a membrane of peritoneum could be visualised Figure 3 . After sPostoperatively PD was paused for 72 h. The drain remained in place until the first session of PD did not sample any form of dialysate in the drain. Over 6 weeks a reduced amount of dialysate was used. Clinically and sonographically there were no signs of recurrence 6 months after surgery whilst PD was able to be performed with its preoperative parameters.In 2020 the EHS and AHS focused on the treatment of umbilical hernias occurring before or during PD in their guidelines for treatment of primary ventral hernias in rare locations or special circumstances . VariousA few case series were published stating that simultaneous ventral hernia repair and peritoneal catheter placement seems to be a reliable and safe surgical procedure , 8]. Th. Th8]. TThomas et al.  examinedArticles about management of ventral hernias occurring during PD are rare. There are one review and a few case series recommending tension free mesh repair to continue PD , 5], , , 11]. U. U11]. UA novel approach using the eTEP technique for endoscopic retromuscular hernia repair  was evalRobotic total extraperitoneal hernia repair in patients with umbilical hernia under peritoneal dialysis could be a promising surgical technique to combine the advantages of minimal-invasive surgery with totally extraperitoneal mesh placement without access to the abdominal cavity.The authors declare that they have no competing interests.