Rhabdomyosarcoma (RMS), a malignant tumor derived from the neoplastic proliferation of striated skeletal muscle cells, is the most common pediatric soft tissue sarcoma. Its treatment is mainly based on neoadjuvant chemotherapy (QT+), surgical resection, and adjuvant radiotherapy (RT+). RT+ has shown satisfactory results for locoregional control of the disease, in spite of promoting local side effects. The present case report was aimed at describing the clinical and therapeutic characteristics and the management of complications resulting from multimodal therapy in a patient with an atypical presentation of RMS in the sinonasal tract. A 20-year-old Afro-descendant man complained of an expansive tumor lesion, with left eye proptosis that reduced visual acuity and caused severe regional pain. Imaging analysis showed an extensive and infiltrative lesion in the periorbital region, sinonasal tract, left maxilla, and orbital roof. According to the histopathological analysis, the diagnosis was established corresponding to parameningeal alveolar RMS that was unresectable. Treatment was initiated with three cycles of QT+ which showed partial response and later RT+. After completing half of the RT+ sessions, the patient showed a complete response with reduction in tumor volume and improvement in pain and local conditions. Side effects such as alopecia and dermatological changes induced by radiation were observed. Moreover, painful erythematous areas were observed in the region of the hard and soft palate, uvula, and oropharynx, compatible with Grade 2 mucositis lesions. After the cytological swab test, some of them were diagnosed as herpes simplex lesions; thickening and decrease in salivary flow were also found. A local drug therapy approach was instituted, and photobiomodulation was performed to manage oral complications. RT+ was shown to be effective in locoregional control of the disease; however, the early management of its undesirable effects on the surrounding tissues was required. Sarcomas of the Head and Neck (SHN) are defined as malignant neoplasms derived from mesenchymal cells, whose origin is from bone, cartilage, muscle, vascular, adipose, and neurogenic tissues, with rapid growth, aggressive and infiltrative behavior, and the capacity for high locoregional recurrence , 2.SHN are rare, representing fewer than 1% of all malignancies in this region. When they occur, establishment of their initial diagnosis and their proper management are challenging tasks, due to their location and the anatomical structures involved. Among the most common sarcomas, especially in the maxillofacial region, the most representative are rhabdomyosarcoma (RMS) and osteosarcoma (OS) of the gnathic bones .RMS is considered the most common soft tissue sarcoma in the childhood and in young patients, with an incidence of 3.5% in children under the age of 14 and approximately 2% in teenagers from 15-19 years of age, with 40% of the cases affecting the maxillofacial region, whereas the maxilla and mandible are the gnathic bones with the highest incidence among younger children [RMS is classified, according to the patient's age and the site affected, into 4 well-differentiated histological subtypes: (a) embryonic subtype, which has a better clinical prognosis and has a subdivision into botryoid and spine cells; (b) alveolar subtype, with an unfavorable prognosis; (c) undifferentiated subtype, also with an unfavorable prognosis; and (d) pleomorphic or anaplastic subtype, rarely found in children .According to the primary location, RMS lesions are classified as parameningeal, nonparameningeal, and orbital. RMS of gnathic bones belong to the group of nonparameningeal entities and are mostly of the embryonic subtype  . The diaThe treatment of RMS is individualized, being mediated by the histological subtype of the tumor, its primary location and clinical staging, size, presence of free and/or microscopic and/or macroscopically compromised surgical margins , distant metastases, and regional lymph node involvement, based on neoadjuvant chemotherapy (QT+), resective surgery, and/or adjuvant radiotherapy (RT+).The role of RT+ in the treatment of RMS is still uncertain, but studies have demonstrated possible benefits in local control of the lesion, especially in the IRS II and III of any histological site and in the prevention of recurrence , 3. HoweAdjuvant therapies have been used to manage the side effects of multimodality therapy in order to decrease pain and general discomfort. Conventional medical management associated with photobiomodulation (laser therapy) and topical applications of corticosteroids have shown satisfactory clinical results in improving local conditions in affected patients .The present case report is aimed at describing the clinical and therapeutic features of an atypical RMS of the sinonasal tract in a young patient who underwent multimodal therapy and management of local side effects.A 20-year-old Afro-descendant man, complained of a painful, exophytic, and expansive lesion, with rapid growth in the left hemimaxilla region, affecting the orbital region, with ipsilateral ocular proptosis and partial loss of visual acuity . The MagHistopathological analysis was performed by incisional biopsy of the lesion in the supraorbital region, in the submental lymph node, and in the nasal region , the resInitial management was based on neoadjuvant chemotherapy in order to avoid distant metastasis and achieve reduction in the tumor volume. Three initial cycles of QT+ were performed, based on ifosfamide (1800 mg) and etoposide (100 mg) that showed a partial response observed clinically  and in t2-04 more cycles) was established after no initial response. Computed Tomography (CT) was performed for initial RT planning  of the disease, especially in those where the surgical approach is restricted due to the extension and impairment of anatomic structures , 3. In tManagement of these complications caused by multimodality treatment is essential in order to improve the quality of life and to maintain basic functions such as deglutition, chewing, and phonation, and there are numerous approaches with satisfactory results reported in the literature , 7. AlthFor the management of skin lesions, some adjuvant therapies such as phototherapy, photobiomodulation (FBM), and topical drug applications help in the treatment of these complications . In addiRMS of the sinonasal tract is rare, but LCR by multimodal therapy could be achieved. Side effects associated with treatment must be managed and reduced with the use of combinations of adjuvant therapies with palliative intent and pain control. Prospective studies should be conducted in order to gain better understanding of the role of each therapy in the multimodal management.


Combined hepatocellular carcinoma‐cholangiocarcinoma (cHCC‐CC) is a rare subtype in primary liver cancer, which is difficult to diagnose in clinics. In this report, we present a case of a 62‐year‐old male with abdominal pain and slightly elevated alpha‐fetoprotein. The contrast‐enhanced computed tomography scans showed a left liver mass, which showed adherence to the imaging characteristics of hepatocellular carcinoma. However, with the treatment of laparoscopic liver resection, the following histological examination displayed two distinct components, which were consistent with the diagnosis of cHCC‐CC. A 62‐year‐old man with a 6‐year history of hepatitis B virus infection presented with a 2‐month history of persistent upper abdominal discomfort but worsening for a week, and he was admitted to our department. Laboratory findings revealed his serum alpha‐fetoprotein was mildly elevated at 21, 312 ng/mL, and his hepatitis B serology was positive. Serum liver function tests were within the normal limits except for the slightly elevated alanine aminotransferase (250 U/L) and aspartate aminotransferase (210 U/L). Abdominal contrast‐enhanced computed tomography (CT) scans revealed a destructive lesion that showed enhancement during the hepatic arterial phase Fig.  and rapiHowever, the patient has subsequently performed a laparoscopic left hepatectomy and his pathology examination indicated the specimen was poorly differentiated and displayed two distinct components: one with HCC‐like feature and the other with cholangiocarcinoma (CC) pattern Fig. . FurthercHCC‐CC is a relatively rare entity of primary liver malignancy, with incidence widely varying among regions.


Neurofibromatosis type 1 (NF1) is an disorder characterised by various phenotypic features like hyperpigmented spots, neurofibromas, Lisch nodules, skeletal abnormalities and tendency to develop neoplasms.We present the case of a 12-year-old patient referred by his pediatrician for intermittent dysphagia and a sensation of food attachment, in whom several café-au-lait spots on the body had been found, and a case of type 1 neurofibromatosis in the patient's siblings. The decision was to closely follow-up the patient, the progression of his symptoms and the size of the cervical neurofibroma. The patient's current follow-up has been two years, with a minimal increase in the frequency of episodes of dysphagia, and with Ct-scan performed every year. No major growth of the cervical mass was noted.Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder characterised by various phenotypic features like hyperpigmented spots, neurofibromas, Lisch nodules, skeletal abnormalities and tendency to develop neoplasms.The treatment is not codified and abstention therapeutic may be a wise decision. •NF1 shows an autosomal dominant pattern of inheritance and wide phenotypical variability.•Neurofibromatosis type 1 is a neurogenetic disorder.•The cervical soft tissues may also be the primary site for tumors.•The treatment is not codified.•Abstention therapeutic may be a wise decision. NeurofiNeurofibromatosis type 1 is a neurogenetic disorder with a birth prevalence estimated around 1:2500 . While iNeurofibromatosis type 1 (NF1) is an disorder characterised by various phenotypic features like hyperpigmented spots, neurofibromas, Lisch nodules, skeletal abnormalities and tendency to develop neoplasms .The condition is characterised by multiple skin lesions such as café-au-lait macules and neurofibromas growing along the parent nerves.Plexiform neurofibromas represent a special variant of NF-1 in which neurofibromas can arise from multiple nerves as bulging and deforming masses . The tre1.1We present the case of a 12-year-old patient admitted to our department for Intermittent dysphagia and a sensation of food attachment, in whom several café-au-lait spots on the body had been found, and a case of type 1 neurofibromatosis in the patient's siblings. Our general examination had to be complete, and was oriented towards this neurofibromatosis given the clinical information. The examination found a right cervical swelling in the middle part of the sternocleidomastoid muscle, slowly evolving according to the parents  A, and aAt this point, several criteria were in favor of type 1 neurofibromatosis, namely: a history of this disease in the siblings, Eight café-au-lait spots greater than 5 mm on the body , a nodulNeither biopsy nor surgical procedure for this probable cervical neurofibroma were retained in a multidisciplinary meeting, in view of his cervical location, hard to reach by external or endolaryngeal approach, the surgical risks on the jugulo-carotid vessels, comorbidities or sequelae that would result from surgery. The decision was to closely follow-up the patient, the progression of his symptoms and the size of the cervical neurofibroma. The endolaryngeal biopsy was planned if the mass grew and arrived closely to the endolaryngeal or endopharyngeal mucosa. The patient's current follow-up has been two years, with a minimal increase in the frequency of episodes of dysphagia, and with Ct-scan performed every year. No major growth of the cervical mass was noted.2Neurofibromatosis (von Recklinghausen disease) was first described as a distinct entity by von Recklinghausen in 1882 [Especially in paediatric and adolescence population not more than 2% develop clinical symptoms. The majority of these tumors is found in the parapharyngeal, carotid, or retropharyngeal spaces. All described cervical soft tissue tumors are plexiform neurofibromas, but the appearances of these tumors vary. NF1 gene maps on chromosome 17q11.2. Microdeletions of this region are responsible for NF1 microdeletion syndrome, observed in 4.2% of all NF1 patients. Large deletions of NF1 and its flanking regions have been associated with more severe phenotype than NF1 general population. Four types  of such large NF1 deletions have been reported so far, with differences in size, breakpoint location, number of genes deleted and somatic mosaicism [Type-1 is the most frequent 70–80%), while 8–10% are atypical [0%, whileThe tumor is most often supraglottic, rarely infraglottic. Sarcomatous degeneration of the cervical neurofibromas or primary malignant tumors of the cervical soft tissues are rare, especially in children, although reported ,10.1.Six or more cafe au lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals2.Two or more neurofibromas of any type or one plexiform neurofibroma3.Freckling in the axillary or inguinal regions4.Optic glioma5.Two or more Lisch nodules (iris hamartomas)6.A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex, with or without pseudarthrosis7.A first-degree relative  with NF1 by the above criteria.The diagnosis of NF1 requires two or more of the following :1.Six orThe clinical presentation of these entities  is usually not related to the tumor size. Dysphagia, vocal cord paralysis, hoarseness of voice, and heart rate changes are the most common manifestations.Preoperative diagnosis of a neurofibroma arising from cervical vagus nerve is challenging. The differential diagnosis includes enlarged lymph node and other neurogenic tumors . The difMicroscopically, neurofi bromas display well-diff erentiated, fusiform, spindle cells, without frequent mitoses. Neurofibromas exhibit a typical homogeneous appearance, with a loose arrangement of spindle-shaped cells in a clear mucinous matrix (Antoni B-type tissue) . The cur3It is up to the surgeon to have a global vision and to evaluate the risk-benefit balance before proposing to propose a surgery. The evolution of the lesions during puberty and into adulthood should be taken into account when discussing the best time to perform surgery. In our case, therapeutic abstention and surveillance was the decision with a stable disease for 2 years.The authors declare having no conflicts of interest for this article.None.I declare on my honor that the ethical approval has been exempted by my establishment.Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient's parents.Wydadi Omar: Corresponding author writing the paper, Ahmed Brahim Ahmedou: writing the paper, Youssef Oukessou: study concept, Sami Rouadi: study concept, Redallah Abada: study concept, Mohamed Roubal: correction of the paper, Mohamed Mahtar: correction of the paper, Registration of Research Studies.Researchregistry5198.The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.


Anal canal adenocarcinoma is a kind of rare malignant tumor of the intestinal tract with a low incidence rate.A 42-year-old man came to our department with anal tenderness accompanied by intermittent drainage of mucus discharge for 2 weeks.The computer tomography showed a strip-shaped high-density shadow in the rectal wall. The magnetic resonance imaging showed a cyst-like mass of about 33 × 57 × 30 mm in the anal area. The lesion penetrated the anal canal, and plaque-shaped high signal shadow can be seen in the left side of the anus. The intraoperative pathology indicated the mass as anal canal adenocarcinoma.The abdominal perineal resection was performed for this patient. The postsurgical pathology showed that the tumor was anal canal adenocarcinoma with large amounts of mucus.The patient recovered well and was discharged from our department at 12th day post-surgery. This patient received further pelvic radiotherapy.Anal canal adenocarcinoma is a kind of malignant tumor that is extremely rare clinically. Computer tomography, magnetic resonance imaging, coloscopy, and histopathology are vital for the diagnosis of anal canal adenocarcinoma. Comprehensive treatment, including abdominal perineal resection, radiotherapy, and chemotherapy, is important for the treatment of anal canal adenocarcinoma. Anal canal adenocarcinoma mainly originates from the anal canal epithelium and includes the primary adenocarcinomas which derive from the mucosa surface, anal glands, and fistula.,3 Anal canal adenocarcinoma is very rare in clinic, and the correct diagnosis mainly depends on the histopathology analysis. In this study, we reported a rare case of anal canal adenocarcinoma that was diagnosed with anal fistula first. But the rapid intraoperative pathology confirmed the diagnosis of anal canal cancer, and radical surgical resection was further performed for this patient.Anal canal cancer is a kind of rare malignant tumor of the intestinal tract. Squamous cell carcinoma accounts for 75% to 80% of anal canal cancers, and others are mainly adenocarcinoma and adenosquamous carcinoma.2This study was approved by the Ethics Committee and Institutional Review Board of the Second Hospital of Jilin University, Changchun, China. The patient provided informed consent for publication of the case.A 42-year-old man came to our department with anal tenderness accompanied by intermittent drainage of mucus discharge for 2 weeks. The patient had anal pain with no obvious inducement 2 weeks ago. The patient also complained about increased defecation frequency (7–8 times a day) with a sense of urgency. The fecal volume was small, and a small amount of dark red bloody and a large number of mucus secretions on the surface of the defecation can be found. This patient didn’t receive systematic treatment.Medical history: The patient underwent radical resection of anal fistula 3 years ago. He denied any history of hypertension, diabetes, coronary heart disease, blood transfusions, or drugs and food allergies. Physical examination: The abdomen shape was normal and there was no abdominal tenderness or rebound pain. At about 2 cm from the anus, an abscess of 2 cm in diameter at two to three points position was observed (chest-knee position). The abscess surface was ulcerated with a small amount of white pus discharged. The digital anal examination (chest-knee position) indicated an irregular mass which was 2 × 2 × 2 cm in size, and 1 cm away from the anal margin at 2 to 5 points position. The mass was tough with uneven surface and the tenderness was positive. Compression of the mass could induce purulent and mucus discharge from the anal canal mass and perianal abscess. Based on the symptoms and physical examination results, our medical team suspected the diagnosis of anal fistula, but the anal canal cancer or rectal cancer should be excluded.9/L, normal: 3.5–9.5 × 109/L) and carcinoembryonic antigen . There were no other abnormal biochemical results. The patient didn’t perform the electronic colonoscopy because of the anal stenosis that was caused by the anal fistula surgery. In addition, he also denied the preoperative pathology. The computer tomography (CT) showed that the wall of the lower rectum was thickened and uneven in density. In addition, a strip-shaped high-density shadow can be seen in the rectal wall  was performed for this patient. Partial sigmoid colon, total rectum, rectal mesentery, part of the levator ani muscle, anal canal, and perianal canal fat and skin were resected Fig. A. The po3 Most of the tumors are located behind the anal canal and about one-third of the tumors are located outside the anal canal or in the sciatic rectum fossa. The prognostic factors of anal canal adenocarcinoma mainly include the tumor size, tumor staging, surgical methods, whether receiving radiotherapy or chemotherapy, etc.–3 About one-half of the tumors are accompanied by anal fistula.,6 In this study, the anal canal tumor tissues invaded the whole anal canal and did not locate in the sciatic rectum fossa. This patient mainly complained about the symptoms of anal fistula, which was anal tenderness accompanied by intermittent drainage of mucus discharge. This may because that the tumor tissues invade the anal canal and induce perianal inflammatory responses, thus leading to the formation of anal fistula.Anal canal adenocarcinoma is a kind of malignant tumor that is extremely rare clinically.,8 CT and MRI are important for the diagnosis of anal canal cancer. The electronic colonoscopy and histopathology should be performed for correct diagnosis of anal canal adenocarcinoma. However, because of the anal stenosis that was caused by the anal fistula surgery, the colonoscopy was not performed. In addition, the patient denied the presurgical histopathology examination. The intraoperative histopathology examination was performed which decided further APR surgery for this patient.Anal canal adenocarcinoma mainly originates from the anal canal epithelium. The histology and immunophenotype of anal canal adenocarcinoma are the same as those of common colorectal adenocarcinoma, but its location is lower and the prognosis is worse than that of squamous cell carcinoma. For early invasive anal canal adenocarcinoma, local resection should be considered. Local resection is less invasive and has a lower incidence of complications. In the opinions of some researchers, local resection is suitable for the treatment of anal canal tumors, which are small in diameter (<2 cm), well-differentiated, and below the dentate line.,7,8 In addition, the sphincter should not be invaded. However, if the margin is positive after local resection, radiotherapy or chemotherapy is recommended postsurgery. For patients who are not suitable for local resection , APR is suggested. For APR, partial sigmoid colon, total rectum, rectal mesentery, part of the levator ani muscle, anal canal, and perianal canal fat and skin should be dissected. Because the rectal vaginal septum is often invaded by tumor tissues, the posterior vaginal wall should also be resected for female patients. The survival time of anal canal cancer is negatively correlated with tumor size. After radical resection, the 5-year survival rate of anal canal cancer is 55% to 71%. The recurrence rate of anal canal cancer after APR is about 40% and the average recurrence time is 12 to 15 months. Local recurrences are the most common and distant metastasis is rare. In our study, the tumor diameter was >2 cm, the tumor penetrated the anal canal, and the sphincter was invaded. As a result, APR was performed.Radical resection is important for the treatment of anal canal adenocarcinoma.,12 In the United States, the comprehensive treatment scheme for anal canal cancer is continuous pelvic radiotherapy, with the total dose of 45 GY  and 2 cycles (the 1st and 5th week) of 5-Fu infusion (1000 mg/m2), and 1 time of mitomycin (10 mg/m2) treatment.–15 If the complete remission was not achieved after 6 weeks of treatment, the patient received a 1-week supplementary treatment with 9 GY radiation of primary tumor. If residual lesions are still present, APR is recommended. The 5-year survival rate of patients with anal canal cancer receiving concomitant radiotherapy and chemotherapy is about 73%. Whether radiotherapy and chemotherapy should be performed simultaneously or in sequence is still inconclusive. In addition, whether the combination of radiotherapy and chemotherapy can substitute radical resection is still controversial. In the present study, APR was performed first, followed by radiotherapy.In recent years, the combination of radiotherapy and chemotherapy attracts more and more attention for the treatment of anal canal cancer.In this study, we reported a rare case of anal canal adenocarcinoma that was mainly manifested as anal fistula. Comprehensive treatment, including APR and radiotherapy, were performed for this patient. In addition, the characteristics, diagnosis, and treatment methods of anal canal adenocarcinoma were summarized.Conceptualization: Xiaowei Song, Huimin Zhao, Linxian Zhao.Data curation: Yongping Yang, Linxian Zhao.Formal analysis: Huimin Zhao.Funding acquisition: Jiannan Li.Investigation: Yongqing Zhao.Methodology: Xiaowei Song, Yongping Yang, Yongqing Zhao.Software: Yongping Yang, Linxian Zhao.Supervision: Yongping Yang, Linxian Zhao, Yongqing Zhao.Validation: Linxian Zhao.Visualization: Yongping Yang.Writing – original draft: Xiaowei Song, Jiannan Li.Writing – review & editing: Huimin Zhao, Jiannan Li.


Isolated tubal torsion is an unusual cause of acute abdominal pain in young sexually inactive patients. However, it should be still taken into account regarding the differential diagnosis of such conditions. Isolated tubal torsion is an unusual cause of acute abdominal pain in young sexually inactive patients. However, it should be still taken into account regarding the differential diagnosis of such conditions. We present the interesting case report of a tubal torsion accompanied with hydrosalpinx, diagnosed in a 17‐year‐old patient that was sexually inactive adolescent.Hydrosalpinx is the condition in which the fallopian tube is filled with fluid as a result of total distal occlusion and abnormal distension of the ampullary portion.Although the pathophysiology of isolated torsion is not determined with certainty in many cases, several pathologic conditions have been described as risk factors. Pelvic inflammatory disease, hydrosalpinx, endometriosis, paratubal, para‐ovarian masses, hydatid cyst of Morgani, autonomic dysfunction of the fallopian tube, previous abdominal operations, history of peritonitis are some of the main causes of a tubal torsion.We present the interesting case report of a tubal torsion accompanied with hydrosalpinx, diagnosed in a 17‐year‐old patient that was sexually inactive adolescent with no previous abdominal surgeries.2Α 17‐year‐old girl was admitted as an emergency to our gynae department reporting nausea, over ten episodes of vomiting, and convulsive pain to the left lower abdomen. Symptoms initiated 2 h before admission to hospital. Menstruation was rather abnormal, while the last regular gynecologic examination was totally normal 2 years ago. She had no history of sexual intercourses and also no history of any gynecological or any other abdominal surgery. On admission, blood pressure was 135/75 mmHg, pulse 90/min, body temperature was 36°C and oxygenated hemoglobin was normal. She had a BMI of 23.Clinical examination revealed normal bowel movements on auscultation, but also tense and sensitivity on abdominal palpation mainly to the left lower quadrant. No vaginal examination was performed, as the patient was virgo and there was no sign of vaginal bleeding. Peripheral blood test showed mild leukocytosis 11.100/μl and normal C‐reactive protein of 1.3 mg/L. The hemoglobin level was of 11.7 g/dl. Transabdominal ultrasound demonstrated a large unilocular cyst of about 8 cm in diameter in the left ovary with reduced vascularity. Based on clinical and ultrasound findings, there was a high suspicion of ovarian torsion and a computed tomography (CT) was asked in order to confirm or exclude the potential diagnosis of ovarian torsion. Decision for surgical treatment with laparoscopy was thereafter decided. [Figure Laparoscopy was performed under general anesthesia. Four trocars were used: one of 12 mm diameter at the umbilicus and three peripheral of 5 mm to the lower abdomen. Intraoperative findings included a massively enlarged fimbrial funnel and a paraovarian cystic tumor with torsion of the distal part of the fallopian tube [Figure In order to preserve ovary, the necrotic mass was resected at the level of corresponding mesosalpinx from the proximal to the distal end of the fallopian tube therefore performing a left salpingectomy. The cystic mass was afterward sent for pathological examination. Diagnosis was acute hemorrhagic necrosis, while hydrosalpinx was also histologically reported.The patient recovered from the surgery without any complications and was discharged uneventfully onthe first postoperative day.3This case report describes the extremely rare diagnosis of an isolated tubal torsion with coexisting hydrosalpinx in a 17‐year‐old patient without history of sexual intercourses.A possible explanation for ITTH in adolescents could be the presence of a congenital malformation of the tube in the peripubertal period. As the reproductive axis is stimulated between 9 and 14 years, menses may activate ovarian and tubal function, revealing a previously asymptomatic distal occlusion of the tube. An episode of asymptomatic pelvic inflammation near tubes may cause a distal occlusion, hydrosalpinx, and then torsion. Besides, torsion of the hydatid cyst of Morgani, located near the fimbriated end of the tubes, could also cause the pathologic process.Diagnosis of ITT is usually difficult because symptoms are non‐specific and common with many other conditions.Regarding most common location, Boukaidi et al conducted a review of the literature and targeted reports published from 1999 to 2009 where 13 cases of ITTH in adolescents were reported.Ultrasound is the imaging modality of choice as it is non‐invasive and avoids radiation exposure but diagnosis is not always definitive. Abdominal ultrasound showing the fallopian tubes as fluid‐filled tubular structures folded onto themselves to form a C or S shape and separated from ovaries is consistent with a diagnosis of hydrosalpinx. Color Doppler may be useful, but the presence of normal flow does not necessarily rule out torsion.Finally, gravity of clinical condition is associated with the duration and degree of torsion. Boukkaidi et al. proposed a classification of the tubal status by conducting salpingoscopy. Grades I and II would correspond to potentially salvageable fallopian tube, whereas grades III or more would require salpingectomy. According to this proposal, Grade I and II are treated by puncturing the hydrosalpinx and completing a detorsion. The correction of the distal occlusion is established by salpingoplasty few weeks later. In the contrary, grade III represents a compromised tube that indicates the necessity of salpingectomy.In conclusion, isolated tubal torsion associated with hydrosalpinx in children and sexually inactive adolescents is an extremely rare entity. Its presentation raises difficulties in the differential diagnosis. Ultrasonography with Doppler should be the primary imaging option; however, laparoscopy remains the gold standard I in both diagnosis and treatment.The authors declare no conflict of interest.All authors of the present manuscript have contributed significantly and their contribution justifies authorship. AD, SC, and SP write the initial draft. C M‐S provided significant language editing and revision to manuscript. AL and KD also revised critically the draft.The authors report compliance with all ethical standards required.Informed consent was obtained from the patient.


Vertebral hemangiomas (VHs) are benign vascular tumors that develop from the endoderm of blood vessels, although their exact pathogenesis is poorly understood. Most hemangiomas are small, about a third are multiple in number, and a very small number of these hemangiomas cause symptoms. Even more rare are aggressive VHs, which comprise a small number of all VHs, and are associated with expansion and extraosseous extension into the paraspinal and epidural spaces. Management of aggressive VHs involve pre-op embolization, spinal surgery, and reconstruction. Pain management, physical rehabilitation, and close neurological follow-up are imperative to near-total recovery. Aggressive VHs are most commonly seen in the thoracic region but may rarely involve a large number of vertebrae. Cutaneous hemangiomas, when seen along with VHs, are often metameric. We present a rare and challenging case of compressive myelopathy and a large cutaneous hemangioma or a "purple shoulder", found during an exam in a young male. He was found to have an extensive VH extending through 13 vertebral levels (C7 to D12), non-metameric to the cutaneous lesion. A thorough physical examination and evaluation along with prompt surgical treatment were the cornerstone of treatment and prevention of permanent neurological deficits. Hemangiomas are benign, malformed vascular lesions that develop from the endoderm of blood vessels. Vertebral hemangioma (VH) is the most common benign tumor of the spine with an incidence of 10-12%. [A 30-year-old male presented with complaints of walking difficulty and getting up from a squatting position. These symptoms began three months ago and were progressive. Along with progressive weakness, he complained of numbness that started in his feet and gradually ascended to his mid-thighs. On further questioning, he also reported urinary urgency but denied active or historical back pain. A thorough neurological examination was then undertaken, revealing normal mental status, intact cognition, and an unremarkable cranial nerve exam. Upper limb examination revealed distal forearm wasting on the right compared to the left. However, the motor exam was unremarkable, and power was symmetric and 5/5 on the Medical Research Council (MRC) muscle power scale bilaterally. The motor exam of the lower extremities was noted to be 4/5 on the MRC muscle power scale bilaterally. This decrease in power was associated with spasticity, brisk deep tendon reflexes, and bilateral extensor plantar responses. A sensory exam was then performed, revealing impaired sensations below the L1 spinal level. Other pertinent findings included a large erythematous dusky red plaque with a bluish hue on the right upper trunk and arm that the patient reported was present since childhood (Figure To further evaluate the etiology of this chronic dorsal myelopathy, a decision to obtain imaging was made. CT imaging showed coarse trabeculations, corduroy cloth appearance of the involved vertebra, consistent with the classic "jail-bar" sign highly suggestive of an intra-osseous hemangioma Figure . To defiThe patient reported worsening of symptoms in the subsequent days. In view of worsening spastic paraparesis with bladder and bowel involvement, the decision was made for him to undergo urgent decompression surgery. Cervical cord laminectomy from C7 to T4 with decompression of extradural hemangioma was done. The excised tissue was sent for the microscopic examination, which revealed large dilated and thin-walled vascular channels filled with blood and lined by flattened endothelial cells, along with intervening stroma of loose fibrotic tissue. This was consistent with our final diagnosis of cavernous hemangioma. The postoperative course of our patient was uneventful,and his spasticity improved, and his power gradually returned to a near-complete recovery. He was discharged after four weeks of extensive physiotherapy. He was consistently followed up in our specialized neurology clinic. On his most recent follow-up, three months after surgery, he was able to ambulate independently without any difficulty and reported a significant improvement in quality of life.Hemangiomas are benign tumors of vascular origin, the pathogenesis of which is still poorly understood. Several postulated theories include growth factors and hormonal and mechanical influences primarily affecting the abnormal proliferation of endothelial cells. No genetic factors have been identified thus far . DespiteOur patient had an extensive VH involving about 13 vertebral bodies from C7 to T12. This is virtually unheard of in the existing literature. In addition to the extradural compression, a detailed interpretation of neuroimaging revealed cord ischemia, which might further explain intramedullary symptoms. Also, the presence of an extensive cutaneous hemangioma with associated wasting of the distal forearm corroborates the aggressive nature of this vascular lesion in our patient (Figure Vertebral hemangiomas are benign vascular tumors of the spine, with a prevalence of 10% in the general population. They are rarely, if ever, symptomatic. A thorough neurological exam is imperative in suspecting and diagnosing myelopathy and possibly aggressive VH. Occasionally, they are seen in a metameric fashion with cutaneous hemangiomas, and again, the importance of a comprehensive physical exam cannot be stressed enough. CT imaging is a preferable initial test to evaluate for VH and shows a plethora of characteristic findings. MRI can be considered to assess for extent and compression definitively. Treatment options are many and range from conservative management for asymptomatic VHs, to a multi-step surgical approach for aggressive lesions. Close follow-ups with a neurologist, a detailed neurological exam on each visit, and a focus on multi-modal therapies, including physiotherapy for strengthening, are imperative to make a full recovery.


A primiparous female developed acute large bowel obstruction Day 1 post lower segment Caesarean section. Initially presumed to be post-operative ileus, increasing abdominal pain and distension over the next 24 h prompted a surgical consult. Computed tomography imaging demonstrated an abrupt transition point of the large bowel behind a polymyomatous uterus. Although this case resolved with vigorous patient mobilization, literature review reveals previous cases resolving only after intraoperative mobilization of the uterus. It is distinct from ileus as bowel sounds are present, onset is abrupt, progression is rapid and mobilization of the uterus causes immediate resolution. This condition is likely to be more common than the literature would suggest, its scarcity partially due to the reluctance to image young females especially during pregnancy. Large bowel obstructions, while not as common as small bowel obstructions, still account for up to 4% of surgical admissions . Of the A 35-year-old female was referred to the surgical team with 24 hours of increasing abdominal pain.She had undergone emergency lower segment Caesarean section (LSCS) the day prior for preterm premature rupture of membranes. Eight hours post-operatively, the patient developed cramping abdominal pain with increasing abdominal distension, nausea and vomiting. At time of review, she had not passed flatus for 24 h and had not defecated for 4 days. She was primiparous, had no other known medical conditions and no previous surgeries.On examination, she was in marked discomfort with a grossly distended abdomen. Despite generalized voluntary guarding, her abdomen was soft, with no focal peritonism. Bowel sounds were frequent and high-pitched, and percussion was tympanic throughout the upper abdomen. Abdominal X-ray by the treating Obstetrics team noted dilatation of the entire bowel above the pelvic brim, as shown in CT images suggested complete obstruction of the sigmoid colon secondary to impingement by polymyomatous uterus see . The traComplete bowel obstruction caused by the uterus alone is an elusive condition that has not been proven on imaging until this day. The concept was introduced to English readers through reviews of German and French literature by Blair in 1932, and Eliason and Erb in 1937 . They suIn order to cause a mechanical obstruction, the uteri in these cases were either physiologically or pathologically enlarged. A bicornuate uterus with an 8 week fetus in one of its horns caused a large bowel obstruction until the fetus was surgically aborted . Ghosal Many authors have emphasized the importance of imaging to define the pathology and direct appropriate management , 10, 11.There is no consensus on the management of this condition, however specific successful methods include rectal tubes, enemas in knee–chest position, or putting the patient in right lateral or prone positions , 6, 10.


Abdominal liposarcoma is most often located in the retroperitoneum. Small bowel mesentery is a rare site of liposarcoma. Dedifferentiated liposarcoma (DDLS) is a rare variant of mesenteric liposarcoma with only 12 cases reported in the literature. DDLS has a worse prognosis compared to a well-differentiated liposarcoma. Here, we present a case of giant liposarcoma located in the jejunal mesentery diagnosed on the contrast-enhanced computed tomography of the abdomen. The patient underwent complete surgical excision with uneventful postoperative recovery. DDLS was confirmed on histopathological examination of the resected specimen. The patient is currently receiving adjuvant therapy with doxorubicin and ifosfamide in view of close resection margin, mitotic rate and high rate of recurrence. Liposarcoma is one of the commonest soft tissue sarcomas in adults. It is most often seen in the soft tissues of the extremities and retroperitoneum. It usually occurs in the fifth to seventh decades of life with a higher incidence in males. There are five main subgroups of liposarcoma: well-differentiated, myxoid, dedifferentiated, pleomorphic and myxoid pleomorphic . DDLS isA 55-year-old man presented with complaints of a lump in the left upper quadrant of the abdomen for two months. There was no associated fever, vomiting, abdominal pain, altered bowel habits, hematemesis or Malena. There was no significant past surgical or medical history. On clinical examination, a hard mobile lump of 9 x 9 cm was palpable in the left side of the abdomen. Routine blood investigations and tumor markers were within normal limits.On contrast-enhanced computed tomography (CECT) of the abdomen, a large lobulated well defined complex lesion of 11 x 19 x 13 cm with heterogenous density was present in the left side of the abdomen involving the mesentery. The lesion had predominantly fat component with an enhancing soft tissue component of 5.9 x 6 x 6 cm in its inferior aspect  was grade 3. The stage of the disease was pT2bNxM0. All the resection margins were free of tumor. The dedifferentiated areas in both the large and small nodules were positive for CDK4 and MDM2 while negative for CD117, DOG1, CD34, SMA, desmin and S100 on the immunohistochemical analysis Figures -3F. The DDLS is a rare pathological variant of liposarcoma. It was first described by Evans in 1979 . It consDDLS typically occurs in the extremities and retroperitoneum similar to the other variants of liposarcoma. Mesenteric liposarcomas are rare. In most of the cases, it presents as a unicentric disease. However, there have been few reported cases of multiple or multifocal mesenteric DDLS as seen in the index case ,8. FemalComplete surgical excision is the mainstay of treatment for mesenteric DDLS similar to that of other types of liposarcoma. Adjuvant chemotherapy for soft tissue sarcoma in adults has been shown to cause a significant improvement in the overall recurrence-free survival . HoweverThe mesentery is a rare site of DDLS. DDLS should be included in the differential diagnosis of patients with mesenteric lipomatous tumor. Mesenteric DDLS can be multifocal. Complete surgical excision is the only effective treatment of DDLS. Appropriate preoperative surgical planning should be performed to achieve R0 resection. The histopathological examination of the resected specimen is essential to make the definitive diagnosis. Adjuvant chemotherapy may be considered for mesenteric DDLS with a high risk of recurrence.


Primary epiploic appendagitis (PEA) is a rather uncommon and self-limiting cause of acute abdomen managed conservatively. Overlapping clinical features with other common causes of acute abdomen usually requiring surgical intervention, and rare occurrences have led to misdiagnosis of the condition and unnecessary surgical intervention. However, with identification of definite characteristic features on imaging (computed tomography [CT] scan) has led to easier diagnosis and avoidance of exploratory laparotomy. Here we present a case of PEA in a 34-year-old otherwise healthy Caucasian male with a chief complaint of acute left-sided abdominal, flank and inguinal pain with diarrhea. Laboratory investigation reports were more or less within normal limits; CT scan confirmed the diagnosis of PEA. The patient was managed successfully with an oral antibiotic and a non-steroidal anti-inflammatory drug. CT scan should be done in cases of acute abdomen (if not absolutely contraindicated) for confirmation of diagnosis, as in our case CT scan helped in confirmation of diagnosis of PEA and thus avoided unnecessary surgical intervention. However, with the current advances in radiological tools, correct diagnosis of acute abdomen has become a lot easier, leading to timely surgical intervention and also at the same time avoidance of unnecessary exploratory laparotomy. Again, with documentation of specific characteristic radiological features of PEA, diagnosis of PEA has become much easier. After careful correlation among clinical, radiological, and laboratory findings, diagnosis of PEA was confirmed. The patient was managed conservatively at home with the advice of plenty of fluid intake and bed rest. Furthermore, he was prescribed an oral antibiotic (ciprofloxacin) and a non-steroidal anti-inflammatory drug (ibuprofen) empirically for seven days to prevent further complications like adhesions, bowel obstruction, intussusception, peritonitis, and local abscess formation. The patient recovered completely  after one week. To conclude, it can be said, although rare in occurrence and lacking in specific presenting features, diagnosis of PEA has become easier with imaging techniques like CT scan and magnetic resonance imaging (MRI); thus, with prior awareness regarding this disease among physicians, unnecessary surgical interventions can be avoided. Epiploic appendages are tiny, mobile fatty pouch-like structures (approximately 50-100 in number in adults) arising from the peritoneum and typically located on the outer part of the tenia coli (from sigmoid colon to cecum) . TorsionPEA is one of the rare causes of acute abdomen. The common sites of PEA are at the sigmoid colon and at the ileocecal regions with localized pain often leading to misdiagnosis of the case as diverticulitis and acute appendicitis, respectively .Although it is a self-limiting condition where most of the patients recover with conservative management, because of its rare occurrence, and non-specific clinical features , there is a high possibility of misdiagnosing the condition and performing unnecessary laparotomy ,5.However, with the current advances in radiological tools, correct diagnosis of acute abdomen has become a lot easier, leading to timely surgical intervention and also at the same time avoidance of unnecessary exploratory laparotomy. Again, with documentation of specific characteristic radiological features of PEA, diagnosis of PEA has become much easier. Here, we present a case of PEA in an otherwise healthy male patient who was managed successfully with conservative approach.2), presented to the general surgery department in our hospital with lower abdominal pain with bloating. His VAS  pain score was 3 out of 10. Abdominal examinations were normal and per rectal clinical examination findings were hemorrhoid. The patient was diagnosed with hemorrhoids and gastritis and was prescribed proton pump inhibitor (pantoprazole) and otilonium bromide with simethicone for gastritis, and capillary stabilizing agent (essin) for hemorrhoids.A 34-year-old Caucasian man, manual worker by profession . There was no personal or family history of irritable bowel syndrome or inflammatory bowel disease; however, his mother underwent surgery for colon cancer.On physical examination, the patient had tenderness and pain in the left iliac fossa associated with abdominal guarding, suggestive for diverticulitis. There was no pulsatile or palpable mass. All of his vital signs were within normal limits. Physical examination was otherwise unremarkable.3/µL, hemoglobin: 15.1 g/dL, hematocrit: 43.6%, red blood cell level: 5.4×106/mm3, and platelet: 2.33×105/µL.Laboratory investigations revealed total leukocyte count (TLC) 6.4×10Urine analysis report was within normal limits.Fecal occult blood was positive for transferrin and hemoglobin.After consulting with radiologist, computed tomography (CT) scan of the abdomen and pelvis without contrasts was performed.The abdominal CT scan (without contrast)  revealed presence of an ovoid lesion 14x7 mm in diameter, extending anteriorly from the mesocolon to the lower tip of the descending colon in the left lower quadrant; also, there were inflammatory changes in the adjacent fat tissue (suggestive of primary epiploic appendagitis)  and non-steroidal anti-inflammatory drug (ibuprofen) empirically for seven days to prevent further complications like adhesions, bowel obstruction, intussusception, peritonitis, and local abscess formation.The patient recovered completely  after one week.Epiploic appendagitis was first described in the year 1956 by Dockerty et al. . It is o2). The diagnosis of PEA is not straightforward as it presents with nonspecific and overlapping clinical features like other common causes of acute abdomen  like acute appendicitis and diverticulitis. Also, because of its rare occurrence, it is highly possible that the surgeon might not consider it as a differential diagnosis.Although PEA can affect people of any age group, people in the fourth and fifth decades of life are the most commonly affected . Males aRegarding presenting symptoms of PEA, Chen and his colleagues reviewed the presenting symptoms and CT scan findings of 21 patients of EA 5). Abdominal pain without any accompanying fever was the most common presenting feature in all those patients [. AbdominOn clinical examination, abdominal tenderness and guarding are common findings; in our patient, we had similar findings . However3)There are no specific laboratory findings for PEA other than nonspecific rise in inflammatory markers like C reactive proteins and occasional leucocytosis; usually other blood parameters remain within normal limits ,5. In ouThus, the lack of specific clinical signs and symptoms, and laboratory findings and rarity of the disease makes the diagnosis of PEA very much challenging. Often patients of PEA are misdiagnosed as acute appendicitis or diverticulitis depending upon the site of pain in the abdomen. In our case because of left-sided pain in the abdomen, initial diagnosis after clinical examination was that of diverticulitis.In earlier days without radiological support (CT scan or color Doppler ultrasound scan), PEA was most commonly diagnosed during exploratory laparotomy. However, fortunately, nowadays with the help of CT scan and color Doppler ultrasound, diagnosis of PEA has become easier.PEA has typical characteristic features on CT scan with regard to the location, size, and density of the lesion. Singh and his colleagues described the spectrum of contrast-enhanced CT scan findings in 50 patients diagnosed with acute epiploic appendagitis 10). As per their study the most commonly affected site is sigmoid colon (62%) followed by descending colon (18%), and ascending colon being the least commonly affected site (8%) [. As per Again, Singh and his colleagues also described in their study that usually (in 86% of the cases) the fatty portion of the lesion measures between 1.5 and 3.5 cm with inflammation in the surrounding region . In our Magnetic resonance imaging (MRI) is not routinely done in PEA; however, because of the lack of risk of radiation exposure it is preferred in children and pregnant women .Despite the specific radiological features of PEA on CT scan, radiologists might miss the diagnosis because of lack of prior knowledge and exposure to these characteristic findings.PEA being a self-limiting disease is managed conservatively with a better understanding of the disease, and conservative management is established as the treatment of choice ,5,12.Also, unlike earlier days, because of better imaging techniques (CT scan and MRI), accurate diagnosis has led to avoidance of unnecessary surgery in PEA patients.Usually the symptoms of PEA relieve within one to four weeks with conservative management (9). Ozdemir and colleagues published a case series on PEA; they reported that symptoms of PEA resolved within three weeks with conservative treatment and they remained symptom free during the seven-week follow-up period .Our patient was managed conservatively with antibiotic (to avoid complications) and oral non-steroidal anti-inflammatory drugs. Although oral anti-inflammatory drugs are recommended for four to seven days for pain, antibiotic is usually not recommended unless there is fear of complications.Surgical intervention is rarely required in patients who do not respond to conservative management or develop complications like intussusception, abscesses, and intestinal obstruction.To conclude, it can be said, although rare in occurrence and lacking in specific presenting features, diagnosis of PEA has become easier with imaging techniques like CT scan and MRI; thus, with prior awareness regarding this disease among physicians, the unnecessary surgical interventions can be avoided.


Human acts as an intermediate host and gets infected by eating parasitic eggs. As it is well known, lungs and liver are the most commonly involved organs in this disease. When the pleura is involved, it is almost always secondary to a ruptured primary lung cyst.The purpose of this paper is to present a case of 16-year-old male with complaints of dyspnoea and dry cough for 6 months. His vital signs, CBC, and laboratory tests were all within normal. Chest X-ray showed a complete opacification of hemithorax.CT revealed multiple cysts filling up the whole pleural cavity with collapsed lung and to-left mediastinal shift. The patient was diagnosed with primary pleural hydatidosis. The treatment was surgical, followed by parasitic medications. During the surgery, surgeons were able to simply extract many cysts by hand and eventually the collapsed lung returns to its normal volume and normal functional state. The patient was indicated to continue with Albendazole for 1 year after surgery. Three days after the surgery, chest X-ray was within normal.Primary pleural hydatidosis is such a rare case to present as full filled up pleural cavity and a complete opacification of hemithorax on CXR. Using the developed technical methods helped to confirm such case and in choosing the best surgical intervention. The result was satisfactory with fully expanded and functional lung. •Primary pleural hydatidosis is an extremely rare clinical entity.•Liver and lungs are the most common locations for primary cysts.•Hydatid disease could be asymptomatic or present with nonspecific symptoms.•Surgery is the main treatment for hydatid disease, followed by oral medications.•Prognosis is excellent in hydatid disease after surgery. The defAs it is well known, hydatid cysts could exist in multiple locations in the body, but Liver represents the most commonly involved location, while Lungs are the most common site for the extrahepatic disease . To the Here in our case, we had numerous of small cysts showing up on chest X-ray as a complete opacification of hemithorax, and the surgeon was able to simply extract many of them by hand. This work has been reported in line with the SCARE criteria .2A 16-year-old non-smoker and non-drinker male presented to our clinic complaining of dyspnoea, and dry cough that started 6 months before and exacerbated during the last 2 months, he had a history of falling from 2 m height occurred 3 years ago. On physical examination, the patient was hemodynamically stable, his blood pressure, heart rate, temperature, and respiratory rate at rest were all within the normal ranges, breathing sounds were absent in the right side, also vocal fremitus were found to be absent, along with dullness on percussion over the right side of the chest, clinical examination of the left side was normal, his laboratory tests were within the normal ranges. Chest X-ray revealed a complete opacification of hemithorax on the right side .Fig. 1PaComputed tomography revealed multiple round-shaped cystic formations filling up the entire right pleural cavity along with collapsed right lung and to-left mediastinal shifting .Fig. 2Pa(video. 1), the pleural cavity was completely evacuated then repeatedly washed, the lung was trapped. After surgical decortication, the collapsed right lung was fully re-expanded, there was no parenchymal damage.The patient then underwent surgery by our well experienced surgical team in Al-moassat hospital. We did a right posterolateral thoracotomy through the fifth intercostal space, the parietal pleura was irregularly thickened. Hypertonic saline was introduced into the pleural cavity to kill the scolices, then the pleural cavity was opened. The pleural cavity was discovered after draining 2 l litres of yellow coloured fluid, it was filled up with too many small secondary hydatid cysts, we also found some ruptured cysts, as well as large laminated layer which may be belonged to the ruptured primary cyst. The laminated layer was removed, as well as hundreds of secondary hydatid cysts , which wThe patient was extubated immediately after the surgery and he had uneventful recovery. As a postoperative follow up, daily chest X-ray was performed and the lung was fully re-expanded 3 days after the surgery . The pathttps://doi.org/10.1016/j.amsu.2021.102290Supplementary video related to this article can be found at VideoThe following is the supplementary data related to this article:3Hydatid cysts can develop in multiple locations in the body, Intrathoracic but extrapulmonary disease; involving the presence of hydatid cyst in the pleura, heart, pericardium, mediastinum, chest wall, and diaphragm, is an extremely rare clinical entity which represents a diagnostic challenge, especially in cases without a primary cyst in a common location . Most prPrimary pleural hydatidosis is defined by the presence of a primary hydatid cyst in the pleural cavity, or a parasitic pleural effusion. According to Erkoc, M. et al., less than 1% of all hydatidosis cases are primary pleural hydatidosis .Hydatid cyst can develop in the pleural layers, due to the permeability of the laminated layer to water, urea, calcium, chloride, and other nutrients that can pass through the membrane by diffusion .In our case, the cysts were found only in the pleura, we removed the laminated membrane of the primary cyst along with many small secondary cysts, the parasitic pleural effusion was also drained. We could not find any extrapleural lesions, and then we concluded that the diagnosis was primary pleural hydatidosis, and this represents an extremely rare clinical entity.Pleural hydatidosis can mimic the clinical presentation of pleural effusions such as dyspnoea, chest pain, dry cough, and to-shift mediastinal shift, as it can be asymptomatic in 15% of cases .The diagnosis of pleural hydatidosis is mainly based on the radiological imaging. In most cases, chest X-ray and CT scan are able to confirm the diagnosis and help in the planning for surgery, which is the main treatment for hydatid disease in addition to the postoperative antiparasitic therapy .4Primary pleural hydatidosis is a very rare disease with very few reported cases. In our case, it was confirmed depending on series of medical diagnostic methods, starting with the chief complaint and clinical story to CT scan. The prognosis was very good, the lung re-expanded to full size and functional ability. It is very important to do CXR on follow up to detect any recurrence, it is also essential to indicate anti-parasitic medications to keep recurrence rate low.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.Not commissioned, externally peer-reviewed.None.None.MA: reviewed the literature, wrote the abstract, and the introduction.AB: reviewed the literature, wrote the case presentation, and the discussion.IA; lead the surgical team, checked the spelling and grammar, revised the manuscript and helped in writing the discussion.None.N/A.Mr. MHD Othman AlKhatibWritten 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.All of the authors declared that they have no conflict of interest.


We report a case of neonatal small left colon syndrome (NSLCS) that underwent surgery. A female infant was born at 38 weeks of gestation. The mother had gestational diabetes requiring insulin therapy. The baby was admitted for respiratory distress. Abdominal distension was observed, and the gastric residue increased. Contrast enema revealed a small caliber of the left colon up to the splenic flexure. At 14 days, the full-thickness biopsy of the sigmoid and transverse colons was performed. Pathological diagnosis showed that the sigmoid colon had few ganglion cells, therefore the transverse colostomy was performed. At 6 months of age, a rectal biopsy was performed to confirm the diagnosis of Hirschsprung’s disease; the intestinal plexus and ganglion cells were normal. The surgery was changed from a pull-through to a stoma closure. The postoperative diagnosis was NSLCS, and the course up to 3 years was good without defecation or growth problems. NSLCS dA female infant was born at 38 weeks of gestation by cesarean section. Birth weight was 3002 g and height was 49 cm. During antenatal period, the mother had gestational diabetes requiring insulin therapy from 12 weeks of gestation. The postnatal course was good, insulin treatment was discontinued and she was discharged 6 days after delivery. The baby was admitted to the neonatal unit for respiratory distress, which required respiratory management with directional positive airway pressure. Abdominal distension was observed from 8 h after birth, and the amount of milk-like gastric residue increased. The passage of meconium was confirmed by glycerin enema, but abdominal distension persisted. An abdominal X-ray showed dilated bowel loops and absent rectal gas. Therefore, intermittent continuous gastric suction was started. Contrast enema revealed a small caliber of the left colon up to the splenic flexure at 3 days of age .. A tranAt 14 days of age, surgery was performed using the umbilicus approach, and first, a full-thickness biopsy of the sigmoid and transverse colons was performed. Pathological diagnosis showed that the sigmoid colon had few intestinal ganglion cells and the transverse colon was normal, so a transverse colon stoma was placed in the umbilicus . PatholoNSLCS is one of the functional intestinal obstructions that develop in newborns; it is characterized by a narrow left colon with an abrupt transition zone at the splenic flexure on contrast enema. Meconium plug syndrome, meconium ileus and HD are clinically similar but are distinguished by the absence of meconium retention and the lack of ganglion cells in the distal intestinal tract. The etiology is unknown, but there are various theories such as functional immaturity of the ganglion cells, abnormalities of the autonomic nervous system and drug use by the mother. In particular, there is a significant association between gestational diabetes and NSLCS , 3. It wIn this case, there was abdominal distension from the neonatal period, and HD was suspected by contrast enema. Although the symptoms were improved by transanal tube drainage, a stoma was constructed due to tube trouble. It was possible that colostomy could have been avoided if reassessed during the 1-week waiting period before surgery. A rectal biopsy just prior to the pull-through confirmed normoganglia, and further intervention was avoided. Therefore, rectal biopsy should be performed first when performing surgical treatment, including colostomy.In neonatal intestinal obstruction, it is important to recognize NSLCS as a disease to be differentiated, especially in the case of maternal diabetes. However, it is difficult to differentiate between HD and NSLCS in infants with a caliber change. Conservative treatment should be considered for at least 2 weeks if symptoms do not improve, and a rectal biopsy should be performed before surgical treatment,, including colostomy.None declared.None.


Due to the early diagnosis of primary hyperparathyroidism the musculoskeletal manifestations of this disease are becoming less frequent. When this disease manifests secondary to a giant adenoma, it presents with more aggressive symptoms and can have important repercussions such as the hungry bone syndrome after parathyroidectomy. There are few reported cases of hyperparathyroidism secondary to a giant adenoma in the literature, as the presence of a brown tumor is often misinterpreted as a metastatic lesion from an unknown primary tumor.  We describe a case and performed a literature review to identify all case reports. A literature search was carried out on PubMed/MEDLINE and EMBASE bibliographic databases. All available studies from May 2009 to May 2021 were included. Data were tabulated, and outcomes were cumulatively analyzed.  Twenty-four cases of primary hyperparathyroidism due to giant adenoma have been described; the majority were women, with a mean age of 52 years. They presented with heterogeneous symptoms such as palpable nodules (45%), bone pain (33%), brown tumor (12.5%), asymptomatic (12.5%), metabolic profile with a mean calcemia of 13.8 mg/dL, PTH 1109 ng/L, and mean tumor weight of 47.24 g.  Primary hyperparathyroidism due to giant adenoma increases the risk of developing potentially serious postoperative complications such as hungry bone syndrome. This implies the need of implementing preventive measures comprising administration of intravenous zoledronic acid and early supplementation of oral calcium to prevent complications after resection. Primary hyperparathyroidism (PHPT) arises from the excessive function of parathyroid glands, secondary to an adenoma, gland hyperplasia, or parathyroid carcinoma . This clParathyroid adenomas (PTA) have been described to be the cause for up to 85% of PHPT . A PTA wNowadays, PHPT is less associated with severe skeletal features due to prompt diagnosis. Nonetheless, most studies published in developing countries previously report these kinds of lesions in half of the patients 52.9%) [2.9% [5].We present the case of a patient with GPTA associated with classical hyperparathyroidism features, diagnostic tests, complications, and treatment. Furthermore, we performed a case-based literature review about PHPT cases secondary to GPTA.A literature review was performed in PubMed and EMBASE databases using the keywords, “primary hyperparathyroidism”, “giant parathyroid adenoma”, “hungry bone syndrome”, “pseudogout”, “brown tumor”. Articles published in English, Portuguese, or Spanish from May 2009 to May 2021 were included as the first reported case regarding the giant parathyroid adenomas was published in 2009. A total of 92 articles matched the search criteria of which, full texts were included, regardless of the methods used . The cliA 55-year-old female patient was referred from the outpatient clinic due to a four-year history of mechanical pain in the right shoulder, which progressed to the knees, clavicle region, hips, and lumbar spine. The patient also mentioned an exacerbation in pain and loss of strength in the right upper limb during the month before consultation. The patient had also undergone a cholecystectomy six months before admission as well as had a past medical history of arterial hypertension and osteoarthritis in medical management.The orthopedics department ordered an X-ray to evaluate her. The X-ray , showed After consultation with the oncologic orthopedics department, the proximal humerus lesion was considered suggestive of metastatic cancer of unknown primary - thorax and abdomen. Computed tomography (CT) was performed, with evidence of expansive lytic lesion on the proximal humerus, sternum, acromion, sixth anterior left costal arch, iliac bones, left femoral head, and fracture of the superior vertebral disc . Anticoagulant therapy with dalteparin was initiated.Simultaneously, a CT coronary angiogram was performed which confirmed acute and chronic pulmonary embolisms with lobar and segmentary branches involvement in both inferior pulmonary lobules. The clinical evolution was satisfactory. A month after discharge, the patient remains asymptomatic, with normal calcium, phosphorus, magnesium, and vitamin levels, serum PTH under 60 pg/mL, and urinary calcium of 25 mg (<4 mg/kg/24 h).a > 250 mg adenoma [Parathyroid adenomas are a well-known cause of PHPT. When the diameter exceeds 2 cm, a differential diagnosis between GTPA and parathyroid carcinoma (PC) must be performed . One of  adenoma .Our patient presented a pathological fracture associated with osteitis fibrosa cystica (OFC). In a cohort of 74 patients with hyperparathyroidism, 40% presented with musculoskeletal complaints such as pseudogout, back pain, vertebral fracture, and arthralgias. Furthermore, in 20.2% of the patients, OFC was the most common radiological finding . Until 2Similar to this case, neoplastic suspicion is the first differential diagnosis often reported in patients who are diagnosed with OFC and brown tumors . This meThis patient developed one of the most fearsome complications of parathyroidectomy - HBS, observed in up to a fourth of patients who undergo parathyroidectomy due to secondary hyperparathyroidism in the USA. They are re-admitted in the first 30 days because of hypocalcemia (incidence of 28%), however, less precise data has been reported in primary hyperparathyroidism (between 4 and 87%) .a >1000 pg/mL for PTH and >3 times the upper normal limit for AF [Al-Hassan et al. have previously described a relationship between the size of GTPA and the incidence of HBS in a case series . In our t for AF . Other ft for AF .HBS treatment must be initiated as soon as the diagnosis is done, as these patients can develop severe complications that increase morbidity and mortality . It is rIn our patient, normocytic-normochromic anemia was notable, which improved after disease treatment and hyperparathyroidism resolution; anemia in a patient with primary hyperparathyroidism is multifactorial, however, three mechanisms have been described to explain the pathophysiology. First, a direct inhibition of erythroid line growth by PTH which, in cell cultures, improves when erythropoietin (EPO) is administered . Second Another complication our patient developed was pulmonary embolism. The association between hypercalcemia and thrombosis has been described in literature. However, the evidence is scarce and the direct association with PHPT is still controversial . In a leIn conclusion, PHPT due to GTPA is a disease that can develop bony lesions that may be confused as metastatic lesions of unknown primary. Also, the incidence of postoperative complications such as HBS seems to be greater compared to PA. A correct clinical and laboratory evaluation may clear the diagnosis of a curable disease and could prevent morbidity and mortality in these patients.


Complete suprapatellar plica is a rare congenital anomaly that separates the suprapatellar bursa from the knee joint cavity. Although the pathological incidence of this condition is not known, it can cause patellofemoral symptoms, anterior knee pain, and rarely hemarthrosis. We report a patient with a hematoma in an unusual location just three weeks after an arthroscopic procedure, associated with a complete suprapatellar plica undetected during primary surgery. The hematoma was not in the synovial cavity, rather between the quadriceps tendon and the synovial membrane and presenting with pain and catching. This unusual location has not been reported before. Repeat arthroscopic surgery with drainage of hematoma and plica resection relieved the symptoms. Knee plicae are embryological synovial membrane remnants . The incIn the previously reported cases of symptomatic plica, a traumatic or spontaneous process was mentioned ,8. SymptA 34-year-old woman was presented with chronic infrapatellar knee pain after a fall on her left knee five months ago. Routine radiographs were unremarkable. The patient had persistent pain at the inferior border of the patella, increasing with palpation and activities. Patellar tendonitis was diagnosed upon patient’s symptoms, physical examination, and MRI findings Figure .Conservative treatment modalities were performed for four months with rest, activity modification, exercises, and later on with platelet-rich plasma injection and dry needling. Since the patient could not get satisfactory pain relief, a minimally invasive surgical intervention was required. Diagnostic arthroscopy showed no meniscal, ligamentous, or chondral pathology. Since no pathology was expected in the suprapatellar region, that area was not evaluated in detail Figure . RemovalThree weeks after surgery, she experienced sudden-onset suprapatellar knee pain that started while she was getting up from sitting. Within a few days, a mobile, firm, palpable fullness was formed in the suprapatellar pouch, extending laterally. The mass was prominent in flexion and was causing pseudolocking combined with snapping. The patellar tap test was negative. The patient had no history of disease that would predispose to bleeding tendency. There were no signs of knee infection such as warmth or redness of the skin over the knee and complete blood cell count, C-reactive protein, and erythrocyte sedimentation rates were within normal limits. On MRI, a well-circumscribed, fluid-intensity collection was observed in the suprapatellar pouch, separated from the joint cavity by a band-like structure Figure .This structure was not noticed in the previous MRI and during arthroscopy performed for patellar tendonitis. Despite the conservative management with general anti-inflammatory medication, compressive bandaging, and cold therapy, the collection did not regress, and arthroscopy was planned to alleviate the symptoms. Pre-arthroscopy aspiration of the collection revealed a hemorrhagic nature. Complete aspiration was not performed in order to be able to determine the location of the collection during the arthroscopic intervention. This arthroscopic examination revealed that meniscal structures, cartilage, and ligaments were intact. The complete suprapatellar plica was viewed and perforated with a shaver blade Figure .At this point, the hemorrhagic fluid was expected to drain, but it was not Video . The pliThis membrane that encircled the hematoma was completely resected. The fullness disappeared. No tumoral tissue was detected in the pathology samples. No complaints and no recurrence were noted postoperatively.The complete suprapatellar plica is usually thought to be asymptomatic . HoweverComplete suprapatellar plicae can also present as a mass lesion, less frequently mentioned in several case reports ,8,12-18.The incidence of complete suprapatellar plica has been reported to be 4-20% during routine arthroscopic surgery ,19. WhilWe report this unique post-arthroscopic complication presenting with a hematoma at an unexpected location in the presence of a complete suprapatellar plica and fullness. Surgery by re-arthroscopy relieved the symptoms. Therefore, it should be kept in mind that under similar circumstances, a hematoma in an unexpected location may be overlooked. In order to prevent this complication, more care may be taken to aspirate the residual fluid after arthroscopy.


Spindle cell hemangioma (SCH) is an uncommon tumor that usually presents as a subcutaneous or deep dermal nodule affecting the extremities of young people. It is primarily a benign vascular neoplasm with a tendency to recur locally. Reports describing SCH diagnosed in muscles, retroperitoneum, mediastinum, and even in the spinal cord occasionally surface in the literature. We report a very rare case of SCH diagnosed in the lung. Spindle cell hemangioma (SCH) is a rare benign tumor characterized by cavernous blood vessels and spindled areas that typically arise in the subcutis of the distal extremities, particularly the hand, or under the mucous membranes. These tumors are more common in a younger population, and, although they have low malignant potential, they tend to recur locally. Previously only one case of SCH in the lungs has been reported . Herein,This 62-year-old female had a history of left breast cancer for which she underwent a mastectomy in 2006, hypercholesterolemia, hypertension, and a smoking history of one pack per week from her teens to her mid-50s (approximately six pack-years). She was incidentally found to have a 7-mm pulmonary nodule in her right middle lobe and multiple smaller nodules bilaterally during surveillance computed tomography (CT) scan in 2009. She had a chronic dry cough and dyspnea on exertion but denied any other symptoms including chest tightness, fever, or weight loss. Pulmonary function tests showed preserved lung function. In 2013, she was diagnosed with and underwent surgery for granulosa theca cell tumor of the neck. During the workup, a positron emission tomography (PET) scan was done, which measured the largest pulmonary nodule in the right middle lobe at 9 mm and multiple small nodules. This nodule did not take up fluorodeoxyglucose and thus was considered metabolically inactive. The nodule had smooth borders with uniform density and did not have any features suggestive of malignancy on imaging. Based on patient preference, a decision was made to follow up the nodules with subsequent CT scans. Between 2013 and 2018, the nodule gradually increased to 13 mm in size Figures -1D. The Gross examination showed a red-tan soft oval tumor with cystic areas. Microscopically the tumor was composed of bland spindle cell proliferation, dilated blood vessels, hemosiderin-laden macrophages, and calcifications Figure . The spiIn 1986, Enzinger et al. described a new variant of vascular tumor which they proposed as “spindle cell hemangioendothelioma” with limited malignant potential . The tumPer previous reports, SCH most commonly arises in the sub-cutis in distal extremities or in mucous membranes, specifically the oral mucosa. Case reports describe SCH in muscles, retroperitoneum, mediastinum, and spinal cord . Per ourIn our case, SCH presented as a single enlarging pulmonary nodule on a background of multiple smaller stable nodules and ground-glass opacities. In contrast to the previously reported case of pulmonary SCH, which described findings at a single time point, we demonstrate the slow evolution of an SCH lesion over many years. The largest nodule in our patient slowly increased in size and changed its morphology from smooth to irregular density and speculated margins; these radiologic features suggest a typical malignant lesion. Histology of our patient’s lesion showed no evidence of malignancy; rather, features were characteristic of SCH. This is in accordance with the literature describing difficulty in preoperative diagnosis of SCH, with diagnosis relying primarily on postoperative pathological analysis and immunohistochemistry .The major differential diagnosis of pulmonary nodule includes - malignancy, infectious/non-infectious granuloma, tuberculosis, and hamartoma . The patAs noted previously, only one previous report of pulmonary SCH has been described in the literature. Consequently, there is no consensus on the management and prognosis of pulmonary SCHs. Thus, the management philosophy could be borrowed by extrapolating the management of SCH elsewhere. SCH is primarily treated by local resection, and although a high recurrence rate is noted, no long-term metastases or mortality has been attributed to SCH themselves. Thus, local resection of pulmonary nodule when considered suspicious should be done as deemed necessary, and upon diagnosis of SCH, no further radiation or chemotherapy should be needed.SCHs are benign vascular neoplasms that present as red-purple nodules under the skin or mucus membrane of young adults and have a similar incidence in both sexes. Only one reported instance of SCH in the lungs presenting as bilateral, round lesions with smooth margins were found in the literature. To the best of our knowledge, this is only the second case of pulmonary SCH, and the first to show the progressive growth and morphologic change over time. In both cases, a diagnosis of SCH was made only after undergoing surgical resection of the suspicious pulmonary nodule. As pulmonary SCH seems to present as pulmonary nodules, a decision for radiologic monitoring and surgical intervention should follow the widely agreed upon Fleischner society guidelines. Once diagnosed, surgical resection should suffice and there should be no need for additional surgery, chemotherapy, or radiation therapy. This case report broadens the differential diagnosis of enlarging and irregularly contoured pulmonary nodules.


Non-ossifying fibromas (NOFs) are common lesions most frequently found in the growing bones of children and adolescents. Although NOFs are benign, their presence as incidental findings often triggers further investigation as they are sometimes mistaken for more sinister bone lesions such as aneurysmal bone cysts. NOFs can also pose an increased risk of pathological fractures. However, there are currently no guidelines on the follow-up of NOFs. We present a case series of five patients from Addenbrooke’s Hospital with NOFs illustrating their morphological features on plain radiographs and highlighting specific characteristics to support clinicians in diagnosing and managing NOFs. Non-ossifying fibromas (NOFs) are common bone lesions, estimated to be present in 20-30% of all four to ten-year-olds . They arWe present five patients found through the Addenbrooke's Hospital's electronic patient record system (EPIC) who were identified with at least one NOF. We identified the common imaging modalities used to investigate these patients and staged these lesions by Ritschl stage, using the methodology implemented by Blaz et al. . The maiWe analyzed patients based on their demographics, clinical presentation, workup, presence of fracture, management, and clinical outcomes. The age at presentation ranged from 9 to 27 years old with three female and two male patients. None of the patients had a concurrent fracture at the site of the NOF or required surgery for the management of their NOF. Plain radiographs of these patients were used to stage their NOFs according to the Ritschl stage. One stage A, one stage B, one stage D, and two stage C lesions at the time of initial presentation were identified after Ritschl staging. These findings are summarised in Table Case 1:A nine-year-old boy presented to the ED with left-sided lower back pain radiating to the groin region. The pain was worse on walking but relieved by sitting and lying down. One café-au-lait spot was noted on the boy’s left arm. Bilateral anteroposterior (AP) and frog-leg lateral radiographs showed no evidence of a slipped upper femoral epiphysis (SUFE) or fracture. Following referral to the pediatric orthopedic clinic, a diagnosis of biomechanical pain was concluded. An incidental finding of a sclerotic lesion of non-aggressive appearance in the left femoral diaphysis was reported on a plain radiograph Figure . The corCase 2:A 15-year-old boy presented with a two-month history of left ankle pain possibly related to a sports injury. The ankle was tender to touch on the anterolateral aspect. The foot was externally rotated, and an antalgic gait was noted. A palpable lesion was found on the lateral aspect of the ankle. On imaging, a lesion of 6.7 cm in length was found in the distal diaphysis of the left tibia, a few centimeters above the physis. The lesion occupied the entire width of the diaphysis and was multilobulated with a sclerotic margin, lying against the cortex Figure . No fracCase 3:An 11-year-old girl came to the ED with acute onset right anterior knee pain after tripping over while on a walk. A few months later, she was seen in the clinic for recurrent falls and knocking knees. Radiographs showed mild genu valgum. A very small translucent lesion was seen in the lateral cortex of the proximal fibula Figure . A year Case 4: A 14-year-old girl presented with a red and swollen right distal radius and reduced range of movements after falling from a curb onto an outstretched hand. A plain radiograph of the wrist was ordered to check for any fractures. Incidentally, a well-circumscribed cortically based lucent lesion at the lateral aspect of the right distal radial metaphysis was noted in the absence of a fracture Figure . An MRI Case 5:A 27-year-old female dance teacher was referred by physiotherapists to orthopedics with bilateral knee pain which was worse on climbing stairs and dancing. MRI found edema-like signal changes in Hoffa’s fat pad consistent with impingement and suggestive of patellar maltracking. In addition, a 40 mm x 19 mm x 19 mm cortical lesion with sclerotic margins and normal marrow fat was noted in the posterior aspect of the lateral femoral metaphysis, highly suggestive of a healing NOF Figure . She wasOn X-ray imaging, NOFs most commonly appear as a well-defined lesion with an eccentric location in the metaphysis of long bones. Due to mild bone remodeling, the cortex over the lesion may appear expanded and thinned . These lAll patients in our case series presented with NOFs which were asymptomatic and unrelated to their initial presentation. Their radiographic images were all typical of NOFs showing cortically based, non-aggressive lesions with a narrow zone of transition and sharp well-circumscribed borders indicating poor biological activity. Our findings reaffirm the current literature that NOFs can be confidently identified based on clinical presentation and plain radiographs. However, our case series also highlights the high tendency for further MRI investigation to be requested, as seen in three out of four of our patients who had initial plain radiographs. MRIs should rarely be necessary and used only for cases with diagnostic challenges, when lesions are atypically large or at high-risk locations such as the growth plates. Herget et al. reported that stage B lesions are at a higher risk of fracture and recommended clinical surveillance at 6-12 month intervals until stage C is reached . SakamotAlthough NOFs are very common in the pediatric population, there is a lack of awareness for identifying these lesions as well as guidelines regarding their management. Our case series has shown an overuse of MRI involved in NOF diagnosis. There needs to be greater confidence in identifying NOFs by using X-ray imaging in combination with the patient’s clinical presentation. In this way, increasing awareness of NOFs as benign lesions and highlighting their characteristic findings on plain radiographs can reduce the burden on more expensive imaging modalities and result in fewer unnecessary investigations for the patient. Unlike X-ray imaging, MRIs and CT scans require the patient to lay immobile in a closed space for a fixed period of time, which can be difficult for some patients. Furthermore, CT scans result in an unnecessary greater radiation exposure than X-ray imaging and MRIs produce harsh sounds which may not be tolerated well by some patients, especially children. It is important to be aware that NOFs do not require invasive interventions such as biopsy. By correctly recognizing NOFs on radiographs, physicians can ease the anxiety of patients by reassuring them of the benign nature of these lesions and by avoiding less tolerable investigations. Conflicting evidence has been shown regarding variables affecting the pathological fracture risk of NOFs. More rigorous studies are required to evaluate these parameters and provide standardised follow-up guidelines to monitor NOF progression and prevent abnormal growth in the pediatric population.