Testicular lesions (TLs) are challenging clinical or ultrasound findings. When large, hard palpable lumps, TL management is mainly clinical, requiring conventional color-Doppler ultrasound (CDUS) to confirm that they are solid, vascularized lesions suggesting malignancy. However, when their CDUS characteristics are uncertain or when nonpalpable, multiparametric US (mp-US)  plays a key role in their characterization, aimed at differentiating benign from malignant TL. This is relevant, since TLs are frequent, testicular tumors are the most common malignancies in young men, and the accurate assessment of a TL is critical to define its correct management including testicular salvage and US follow-up or orchiectomy. In this scenario, this narrative and pictorial review reports a practical mp-US “identity card” and iconographic characterization of several benign and malignant TLs, useful to the physician in daily clinical practice.Background: Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs. Methods: An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs. Results: A practical mp-US “identity card” and iconographic characterization of several benign and malignant TLs is provided herein. Conclusions: The mp-US characterization of TL reported herein can be useful in daily clinical practice. Ultrasonography (US) represents the gold standard imaging method for scrotal investigation and is widely used to assess a variety of scrotal diseases ,2,3. It Currently, conventional gray-scale US (GSUS), supplemented by color-Doppler US (CDUS), is considered as being highly sensitive in detecting testicular lesions, however, it has limits in delineating their nature . If perfRecently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) have led to improvements in the differential diagnosis of testicular lesions . This leThe role of mp-US for characterizing testicular lesions has been investigated in some retrospective and prospective studies ,18,19,20Clinical history and physical examination are very important to suggest a correct diagnosis when facing a testicular lesion and should be performed before running US.Anamnesis should investigate testicular malignancy-related risk factors including age , family history of testicular tumors, history of contralateral testicular tumor, history of cryptorchidism/orchiopexy, and history of infertility, which represent the main risk factors associated with testicular tumors . In addiMp-US is increasingly recognized as a valuable problem-solving technique in scrotal pathologies, particularly in differential diagnosis of testicular lesions ,22. Mp-Uhttps://www.andrologyacademy.net/eaa-studies (accessed on 20 October 2023)). In particular, testicular US should be performed with a high frequency linear transducer, with the patient in the supine position. A US scan of both testicles should be performed including longitudinal, oblique, and transverse scans, with slow, continuous side-to-side movements that allow for the assessment of the entire parenchyma. The operator should evaluate at GSUS the volume of the testes  is relatively new. A detailed description of the standard operating procedures (SOPs) for performing scrotal CDUS have been reported by the European Academy of Andrology for the entire male genital tract ,24,25,26t testes  and the The methodological standards for the clinical practice of contrast-enhanced US (CEUS) in non-hepatic applications including scrotum investigation have been reported by the EFSUMB Guidelines . As a reFor CEUS, a dedicated machine-setting with a low mechanical index (0.05–0.08) is needed to avoid early microbubble destruction. US contrast medium  should be injected as intravenous bolus and followed immediately by 10 mL of 0.9% saline solution. The entire examination needs to be recorded to perform qualitative and quantitative analyses .The methodological standards for the clinical practice of sonoelastography (SE) in non-hepatic applications including testicular investigation have been reported by the EFSUMB Guidelines and Recommendations . So far,Several non-neoplastic diseases can occur within the testes, and may mimic testicular tumors. Differential diagnosis may be difficult but is imperative to avoid unnecessary surgical interventions. A summary of the clinical characteristics and mp-US features of non-neoplastic testicular lesions is provided in Prevalence: Intratesticular cysts are rare in pediatric patients [patients ,32 and iClinical history and physical examination: Simple intratesticular cysts are usually asymptomatic. They are often incidentally detected during US as they are usually not palpable [palpable . Howeverpalpable . On palpGSUS + CDUS: Upon GSUS examination, intratesticular cysts appear as solitary, or less commonly multiple, anechoic lesions, with a thin, clear, hyperechoic wall, and posterior acoustic enhancement [ancement . They ofancement . In CDUSSE: Intratesticular cysts generally appear as soft lesions showing a tricolor pattern, blue-green-red [reen-red .CEUS: CDUS is usually sufficient for the diagnosis of a testicular cyst, and CEUS is not necessary. However, if CEUS is performed, intratesticular cysts show absent contrast enhancement [ancement .Differential diagnosis: Complex testicular cysts must be differentiated from cystic teratomas. Complex teratomas tend to have solid, outlying, vascularized masses, rather than fibrous strands [ strands . As a coPrevalence: Epidermoid cysts represent 1.5–2.1% of all testicular benign tumors of germ cell origin among men aged 20 to 40 years [40 years .Clinical history and physical examination: At physical examination, they are palpable painless non-tender nodules (single or multiple) with sizes ranging from 1 to 3 cm [ to 3 cm ,37. SomeGSUS + CDUS: In GSUS, testicular epidermoid cysts show a variable appearance depending on their maturation, compactness, and amount of keratin component. They can be classified into four categories: type 1, well-circumscribed rounded lesions with an “onion-ring” pattern consisting of concentric rings of hypoechogenicity and hyperechogenicity  [ia (CAH) .Clinical history and physical examination: TARTs are supposed to originate from an adrenal-like pluripotent stem cell type rising from the urogenital ridge, already present in the gonads during embryogenesis, which undergo adrenal differentiation and increased proliferation under the stimulation of high levels of adrenocorticotropic hormone (ACTH) [e (ACTH) . Generale (ACTH) .GSUS + CDUS: In GSUS examination, TARTs usually appear as hypoechoic lesions with irregular, lobulated margins, or less frequently as hypoechoic lesions with hyperechogenic foci, and rarely as hyperechogenic lesions [ lesions  . In this case, the etiology is mainly bacterial [acterial ,2. Conveacterial ,2,35.Clinical history and physical examination: Primary orchitis is less common than epididymo-orchitis and is mostly caused by mumps during or after puberty [Escherichia coli) in young boys and sexually transmitted organisms  in older patients, although urine cultures are positive in only 10–25% of cases [ puberty . Epididyof cases ,35. ClinGSUS + CDUS: The testis appears enlarged, diffusely hypoechoic and inhomogeneous in GSUS and diffusely hyperemic in CDUS [ in CDUS ,2,3,4,20SE: In SE, orchitis appears with a heterogeneous pattern of firmness [firmness ,20.CEUS: In CEUS, diffuse vascular hyperenhancement throughout the testis can be observed [observed ,20.Differential diagnosis: When an enlarged, hard, hypoechoic, and diffusely hyperemic testis is detected in US, differential diagnosis should be considered with large seminomas or lymphomas. The occurrence of bilateral orchitis in postpubertal boys or of concurrent epididymitis in adult men can help to suggest primary or secondary orchitis, respectively, instead of large malignancies.Prevalence: Idiopathic granulomatous orchitis, an inflammatory condition of the testis of unknown etiology, is rarely encountered [ountered ,66. The ountered .Clinical history and physical examination: Idiopathic granulomatous orchitis is characterized by the presence of non-specific granulomatous inflammation and admixed multinucleated giant cells [nt cells . Histolont cells .GSUS + CDUS: In GSUS, idiopathic granulomatous orchitis appears as diffusely hypoechoic testis or focal hypoechoic areas with ill-defined margins  histological classification , testicuTesticular tumors usually present as painless or paucisymptomatic  testicular masses. In some cases, they are incidentally found during US performed for other reasons.Serum tumor markers must be included in the diagnostic work-up, namely alpha fetoprotein (α-FP), beta subunit of human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH) ,78. OverA summary of the clinical characteristics and mp-US features of neoplastic testicular lesions is provided in Prevalence: s-TGCTs represent 55–60% of TGCTs. The median age at diagnosis is 20–40 years [40 years . They arClinical history and physical examination: Patients with s-TGCTs can refer to clinicians for the detection of a testicular firm mass, testicular swelling, testicular pain, or lumbar pain when lymph node metastases are present. However, the diagnosis can be incidental during US performed for other reasons. Infertility [ertility ,84,85 anertility ,87 are certility . PhysicaGSUS + CDUS: The US appearance reflects the histological characteristics that consist of a nest of large, round cells with abundant cytoplasm and distinct borders, with fibrous septa containing lymphocyte infiltration. Occasionally, they can include syncytiotrophoblasts. Necrosis, intercellular edema, and hemorrhage can be present, especially in larger tumors [r tumors ,88. Therr tumors ,90,91  and hypervascularization of the ipsilateral epididymis, reactive hydrocele, associated scrotal edema, and pain [and pain . Among tand pain . FinallyPrevalence: Ns-TGCTs represent 40–45% of TGCTs. They usually occur in younger patients than s-TGCTs (median age at diagnosis 25 years) [5 years) .Clinical history and physical examination: Similar to patients with seminomas, those with ns-TGCTs can refer to clinicians for the detection of a testicular mass, testicular swelling, testicular pain, or lumbar pain when lymph node metastases are present. Due to a faster growth of ns-TGCTs, incidental diagnoses are rare, but possible [possible ,98.Gynecomastia is a frequent finding . Serum tNs-TGCTs are a heterogeneous group of tumors including different malignancies such as embryonal carcinomas, teratomas, choriocarcinomas, yolk sac tumors, and mixed germ cell tumors, whose mp-US characteristics are reported below.Prevalence: Embryonal carcinoma accounts for about 3% of TGCTs. It represents the most frequent (80%) component in mixed TGCTs.Clinical history and physical examination: See above  [e above) . Serum tPrevalence: Teratomas account for about 5–10% of TGCTs.Clinical history and physical examination: See above . They are usually divided into mature and immature tumors according to histology and in prepubertal and postpubertal according to the age of incidence. Prepubertal tumors are usually benign and have a conservative treatment [reatment , while pThe US appearance varies according to the different histological features of the tumor . They usSE: As other TGCTs, teratomas usually appear as hard lesions showing low/absent elastic strain [c strain , but depc strain ,102.CEUS: Teratomas show hyperenhancement within the solid part of the lesions with rapid wash-in and rapid wash-out. Anechoic areas are usually non-enhanced.Differential diagnosis: The differential diagnosis of teratoma is usually with other ns-TGCTs, especially mixed ones due to large size and is not always possible. Internal cysts, if present, different content, and internal septa are usually hallmarks.Prevalence: Choriocarcinoma accounts for about 0.5–1% of TGCTs. They represent about 5–10% of mixed TGCTs.Clinical history and physical examination: See above  in its pure form while it is the most common TGCT in children (60%). It represents 40% of mixed TGCTs.Clinical history and physical examination: See above . After CEUS administration, LCT shows a homogeneous and intense hyperenhancement of the whole lesion [e lesion . A rapide lesion ,40,103  account for <1% of all testicular tumors, and can be found in men with a wide age range (18 to 80 years), although they are more frequent in young adults [g adults . Rarely,g adults .Clinical history and physical examination: See above . The US hallmark of lymphomas are infiltrating margins and the vascular pattern, which besides the detection in men aged >50 years old can help in suggesting the diagnosis.Prevalence: Primary testicular leukemia is a rare presentation of leukemia, more frequent in children and young patients. Testicular involvement is found in 1% to 2.4% of boys with acute lymphoblastic leukemia, but is very rare in adult patients [patients ,132.Clinical history and physical examination: Testicular localization may be simultaneous to the diagnosis of the primary disease or can occur after treatment/remission of the primary disease. Patients are usually asymptomatic. Physical examination can reveal testicular involvement by increased size, irregular swelling, and firm consistency of the testes [e testes .GSUS + CDUS: GSUS appearance can include two patterns. On the one hand, an infiltrating pattern with irregular hypoechoic longitudinal striae radiating peripherally from the mediastinum to the entire testicle with CDUS showing increased vascularity of non-branching linear patterns has been described. On the other hand, a focal pattern with irregular hypoechoic nodules with smooth irregular margins with increased vascularity in CDUS can be found [be found ,135,136 be found ,102,134 SE: In SE, an increased testicular stiffness is reported [reported ,134  with a rear shadow cone [dow cone ,154. Hisdow cone ,157,158.dow cone ,157,158.dow cone ,156,157.SE: In the parenchyma surrounding the scar/calcification, a focal area of increased stiffness can be observed in SE.CEUS: The fibrotic scar and surrounding areas are usually not enhanced with CEUS [ith CEUS .Differential diagnosis: A burned-out tumor can be confused with a simple fibrotic scar or a linear macro-calcification. When the imaging is uncertain, serum tumor markers, which show high levels in burned-out tumors, must be performed to exclude distant spread of the disease.According to the aforementioned information, mp-US shows relevant advantages in relation to the investigation of testicular lesions. In fact, combining different US techniques, mp-US can provide a more detailed characterization of testicular lesions than a single US technique alone, helping in the differential diagnosis of benign or malignant lesions and in the effort to identify the type of lesion assessed ,2,3. HowMp-US is a valuable diagnostic paradigm combining information derived from different US techniques , which, along with clinical history and physical examination, can help in the differential diagnosis of testicular lesions. Mp-US can provide a more detailed characterization of testicular lesions than a single US technique alone. Although GS and CDUS are often sufficient to suggest the benign or malignant nature of testicular lesions, CEUS can be decisive in the differential diagnosis of unclear findings, and SE can help to strengthen the diagnosis. The knowledge of mp-US patterns of testicular lesions, summarized in this review, is useful to the physician in daily clinical practice to discriminate benign and malignant lesions, thus improving the management of critical patients by suggesting testicular salvage and US follow-up or orchiectomy.


Endometrial stromal sarcoma is a rare mesenchymal tumor with the potential for intravascular metastases. We present the case of a 52-year-old female patient with a history of previously resected endometrial sarcoma who was found to have an inferior vena cava thrombus with intracardiac extension. Pathological assessment following resection revealed intravascular extension of an underlying endometrial stromal sarcoma. This case demonstrates the aggressive nature and intracardiac metastatic potential of endometrial sarcomas. Although occasionally observed in other malignancies, such as renal cell carcinoma, malignant extension of ESS into the IVC is rare. In this report, we describe a complex case of a large-burden IVC tumor thrombus stemming from an underlying ESS with extension from the iliac veins through the entire IVC, right atrium, and right ventricle before ending in the proximal pulmonary artery. This case also brings to light educational imaging and interventional approaches for rare, high-risk cases.Endometrial stromal sarcoma (ESS) accounts for approximately 0.2% of all malignant uterine tumors. Considered a rare malignant mesenchymal tumor, ESS accounts for 10–15% of all uterine sarcomas, with an annual incidence of 1–2 per million women3/mL . She had a significant medical history of endometrial stromal sarcoma managed with partial hysterectomy, followed by adjuvant hormonal therapy with letrozole and progesterone. She also had a history of a massive pulmonary embolism after hysterectomy requiring thrombectomy with IVC filter placement followed by long-term anticoagulation, chronic right ureteral stent replacement every 6 months, surgically repaired aorta-to-right atrial fistula, and ITP. Before admission, the patient complained of worsening fatigue and shortness of breath for several months. Initial physical examination revealed +3 pitting edema of the lower extremities. Laboratory investigations showed acute kidney injury with subsequent ultrasound showing no hydronephrosis or ureteral obstruction. An MR venogram was performed to rule out an IVC thrombus obstructing the left renal vein, given her previous IVC thrombus. MRV demonstrated a bland IVC thrombus causing distension of the IVC that extended to the right atrium and ventricle  could not be administered because of a repeat platelet count of 15 × 10nd CD31. .Postoperatively, the patient developed acute shock requiring multiple vasopressors, as well as worsening renal function requiring hemodialysis. On postoperative day 1, the patient developed a significant hemothorax that required surgical chest tube placement. On postoperative day 2, the patient developed unstable SVT that deteriorated into ventricular tachycardia. Despite ACLS support with CPR and defibrillation, the patient’s ventricular arrhythmia could not be corrected, and the died.1. Late recurrences have been seen in 30–50% of cases3. ESS has been known to metastasize through both lymphatic and hematogenous spread (4. A potential symptom after vascular invasion is new-onset peripheral edema due to increased intravascular hydrostatic pressure secondary to blockage of the IVC, which was observed in our case (5–8. A literature review identified 19 patients with advanced low-grade ESS complicated by invasion of the great vessels and IVC tumor thrombus9. Among these 19 patients, four had extension to at least the right atrium, with two showing extension into the pulmonary artery9. The present case is another example of this rare presentation.In the early stages, the 5-year survival rate for ESS has been reported to range from 54% to nearly 100% but falls to 11% in those with advanced diseases spread 4. A poteour case 5–8. A li10. One case study examined the management of inoperable cases with long-term anticoagulation to prevent further thrombus formation in the context of cancer metastasis and hypercoagulability11. The use of the AngioVac System, a mechanical aspiration device that has FDA approval for removing unwanted intravascular material during extracorporeal bypass, has been studied as an alternative to surgical resection in the setting of advanced renal cell carcinoma involving the IVC. A case study reported the unsuccessful removal of an ESS-related IVC tumor thrombus using the AngioVac System, thought to be the result of significant lumen adhesion by the tumor12.In terms of management, surgical resection of the tumor thrombus is the preferred approach. However, the rarity of this condition has resulted in a paucity of published studiesEndometrial stromal sarcoma is a rare condition with the potential for significant vascular invasion. Patients with metastasis to the IVC commonly present with peripheral edema and can have extensive IVC tumor thrombosis, potentially extending into the heart chambers and pulmonary artery. Surgical thrombectomy, with or without extracorporeal bypass, is the mainstay of treatment, but carries a significant surgical risk. Inoperable cases are typically managed with long-term therapeutic anticoagulation to prevent further propagation of tumor thrombus. The use of the AngioVac System and other aspiration cannulas represents a novel option in high-risk surgical cases and warrants further evaluation.


Meckel's diverticulum is a common congenital abnormality. In this study, we reported a case of small bowel occlusion due to Meckel's diverticulum causing a small bowel obstruction and a life-threatening condition.28-year-old man complaining of abdominal pain for 3 days. The physical examination found the patient appeared profusely unwell with a blood pressure of 80/40 mmHg. The abdominal examination found abdominal rigidity suggesting peritonitis. The patient's C-reactive protein was 210 mg/l with normal white blood cell count. Consequently, the patient was operated on using a laparotomy. A mechanical bowel obstruction due to a gangrenous Meckel's diverticulum was confirmed during the operation. Meckel's diverticulitis with the tip attached to the ileal mesentery through a band. A section of the band was performed followed by a resection of the Meckel's diverticulum and an ileo-ileal anastomosis. The postoperative follow-up was uneventful.Case discussion: Meckel's diverticulum results from yolk sac persistence during embryonic development, often remaining asymptomatic. However, it can lead to symptoms like abdominal pain, diarrhoea, and fever when inflamed or infected. Treatment involves surgery (diverticulectomy) for severe cases with complications, with good prognosis but associated surgical risks.The diverticulum can present a life-threatening condition. The treatment is essentially surgical. This surgery should be performed emergently to enhance the prognosis. •Meckel's diverticulum arises from yolk sac persistence during embryonic development and is typically asymptomatic in most individuals.•Symptoms can occur when the diverticulum becomes inflamed or infected.•Diverticulectomy is the primary treatment with complications, offering a good prognosis but carrying potential surgical risks. It is a2A 28-year-old man, with no past medical history, presented to the Emergency Department with a 3-day history of abdominal pain and vomiting. The patient reported no other associated symptoms. The patient reported an episode similar to the current one two years ago. This condition was managed conservatively and resulted in a prompt resolution of his symptoms within 24 h of his presentation to the hospital. The patient remained asymptomatic thereafter with no consequent episodes till the current presentation. On the physical examination, the blood pressure was 80/40 mmHg. The abdominal examination found abdominal rigidity suggesting peritonitis. The patient's C-reactive protein was 210 mg/l. To better delineate the aetiology underlying the patient's presentation, an abdominal CT scan was performed and revealed multiple air-fluid levels in the small bowel suggesting a mechanical small bowel obstruction . The pre3Meckel's diverticulum is formed when a portion of the yolk sac fails to disappear during embryonic development. Meckel's diverticulum is a vestigial remnant that arises from the failure of the omphalomesenteric duct to close. The omphalomesenteric duct connects the yolk sac in the embryo to the early foregut through the umbilical cord. The diverticulum may vary in size and shape, and it may contain tissue resembling the stomach lining or pancreas . Most pe4The Meckel diverticulum is often asymptomatic. When it is complicated it can present a life-threatening condition. The treatment is essentially surgical. This surgery should be performed emergently to enhance the prognosis. The final confirmation of the diagnosis remains after the pathological examination of the operative specimen.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.Ethical approval is exempt/waived at our institution.This research received no specific grant from the public, commercial, or not-for-profit sectors.All the authors participated in the treatment of the patients, writing, and approving the manuscript.Mohamed Ali Chaouch, MD.No conflict of interest to disclose.


Glomus tympanicum is an extremely rare benign paraganglioma of the middle ear. The distinctive features of these tumors include their propensity for recurrence following treatment and their remarkably vascular nature, posing significant challenges to surgeons and necessitating the development of effective surgical techniques.A 56-year-old female presented with pulsatile tinnitus persisting for a year. Examination revealed a pulsating red mass in the lower section of the tympanic membrane. Computed tomography confirmed the presence of a mass occupying the middle ear, which was diagnosed as a glomus tympanicum tumor. The patient underwent surgical excision of the tumor, followed by diode laser application for coagulation at the site of the tumor. Histopathological examination confirmed the clinical diagnosis.Glomus tympanicum tumors are rare neoplasms that arise in the middle ear. The surgical management of these tumors varies depending on the size and extent of the lesion. Various techniques are available for excision, including bipolar cautery and laser. Laser has emerged as an effective method for reducing tumor mass and controlling intraoperative bleeding, with positive indications after surgery.Based on our case report, laser can be considered an effective and safe method for excision of glomus tympanicum, with positive indications for controlling intraoperative bleeding and reducing tumor mass. •Glomus tympanicum is a rare, neuroendocrine, highly vascular benign tumor of the middle ear.•Surgical resection is the treatment of choice for glomus tympanicum tumors.•Diode laser was applied to the vascular supply of the tumor, as well as to the site and mass of the tumor.•This method effectively controls bleeding and reduces the highly vascularized tumor mass.•Combining laser and surgery yields improved outcomes and greater maneuverability. It is the most common primary neoplasm of the middle ear and the second most common tumor of the temporal bone. Due to its highly vascular nature, glomus tympanicum poses a challenge during surgical intervention and has a tendency to recur after treatment, with a recurrence rate of 17.1 % after 10 years In this report, we present a case of glomus tympanicum tumor resection using a postauricular approach and a diode laser. This work is also reported in line with SCARE criteria which helped to improve the transparency and quality of this case report .2A 56-year-old female was admitted to the hospital due to low-frequency pulsating tinnitus in her right ear that had been present for a year and was continuous. The tinnitus was not alleviated by noise. She also reported constant moderate hearing loss in her right ear for the past year and intermittent right ear pain without any history of ear discharge or other ear symptoms. There was no history of acoustic or mechanical trauma. The patient had a history of tension headaches, which were relieved by analgesics. No symptoms related to the throat, larynx, or nose were reported.Upon clinical examination, a reddish mass was observed in the right ear, causing a bulge in the lower part of the tympanic membrane that was clearly pulsatile . The lefAn MRI was performed, which revealed a lesion measuring 5 × 13 mm near the cochlea with a high signal on T2 and clear borders and good enhancement after deleting the fat . The tumSurgical resection was performed, beginning with the stages of Myringoplasty with a graft from the fascia of the temporal muscle, and retroauricular incision established access to the tympanic membrane. After reaching the middle ear, a simple atticotomy was performed using a microcurette a, followHistopathology  Showed a3The retroauricular-transcanal approach is considered the optimal management for glomus tympanicum tumors that extend into the posterior mesotympanum (Class A2), as in the presented case. Studies have indicated that a stapedectomy-type transcanal approach can safely remove small glomus tympanicum tumors that are localized in the middle ear (Class A1), with visible margins and no tumor extension into the posterior mesotympanum. However, the retroauricular-transcanal approach and the modified procedure (glove finger flap technique), as performed in the presented case, offer a significant advantage by increasing the surgical field and allowing a wider exposure of the tumor through the ear canal. This facilitates better control of the ossicular chain and facial nerve, and the removal of glove finger skin flap enables better exposure and dissection of the windows' area and the facial nerve. Additionally, this approach facilitates the use of cautery during tumor dissection ,8.While microscopic ear surgeries are commonly performed for glomus tympanicum tumors, transcanal endoscopic ear surgeries are suitable for small tumors (modified Fisch and Mattox classification stage A1 tumors), but are not suitable for the presented case (A2). Also, we don't have the equipment of endoscopic ear surgery.Controlling bleeding during surgery is a crucial issue for glomus tympanicum tumors, particularly in stage A2-B1 tumors, which can present a challenge. Coagulation offers several advantages, such as bleeding prevention and hemostasis to keep the surgical field clean, as well as reducing tumor volume. It is mandatory to locate the pedicle of the tumor and coagulate the vascular supply, as this can reduce the tumor volume and manage the extension of the mass .In the presented case, a diode laser was used to shrink the tumor and coagulate the feeding vessels, as it is more effective in coagulation than traditional methods. The first study on the use of lasers in the excision of glomus tympanicum tumors was reported in 2004, which presented a series of nine patients who underwent successful resection of Type A glomus tympanicum tumors with the use of laser coagulation .Laser excision of glomus tympanicum tumors (Type A) provides good exposure with clear operating fields, minimal bleeding, and excellent surgical control. Good anatomical understanding combined with experience in using lasers ensures effective treatment of glomus tympanicum tumors with no complications and good long-term results. The advantage of laser is its capacity to minimize blood loss through progressive coagulation and shrinkage of the tumor volume. This allows for good visualization of the surrounding structures with minimal mechanical trauma and complete excision of the tumor with coagulation of the residual feeding vessel. This is facilitated with a concomitant reduction in the risk of recurrence. The diode laser emits laser light at a wavelength of 810 nm, which provides deeper penetration than the KTP laser and is similar to the Nd-YAG laser, offering efficient coagulation of blood vessels, similar to the KTP laser .4Glomus tympanicum tumors are rare, benign neoplasms that occur in the middle ear and are highly vascularized. Our experience suggests that the use of diode laser in the surgical management of glomus tympanicum tumors is a safe and effective alternative that may offer advantages over conventional surgical methods. However, further research is needed to evaluate the long-term outcomes and results of diode laser excision in the treatment of glomus tympanicum tumors.Ethical approval was taken from the University's Deanship.N/A. We received no funding in any form.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Ahmad Alkheder.This case report is not a first time of reporting, new device or surgical technique. So I would not need a Research Registry Unique identifying number (UIN).Patient's parent consent was taken for publishing this case and the 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.All data are available from the corresponding author on reasonable request.The case has not been presented at a conference or regional meeting.Ahmad Alkheder: Validation, Writing – review & editing, Visualization, Methodology, Software, Writing – original draft, Formal analysis. Amjad Ghareeb: Validation, Writing – review & editing, Visualization, Methodology, Software, Writing – original draft, Formal analysis. Mohammad Sadek Almasalmeh: Validation, Formal analysis, Writing – review & editing. Abdulmajeed Yousfan: Supervision, Writing – review & editing, Project administration.The Authors disclose no conflicts.


Cesarean scar pregnancies (CSPs) are a type of ectopic pregnancy that occur when an embryo implants within the fibrous scar tissue of a previous cesarean surgery. If not promptly detected and treated, CSPs can result in serious maternal complications, such as uterine rupture and hemorrhage. TVUS  represents the imaging of choice for the diagnosis of CSPs; however, recent studies proposed a complementary role of MRI due to its capability in soft tissue characterization that may impact the therapeutical decision-making process. The purpose of our study was to explore the role of MRI in the diagnosis and its impact on therapeutical options in CSPs. Our experience showed that MRI has a complementary role to TVSU in correctly diagnosing CSPs, identifying the type, and guiding the therapeutical approach. Cesarean scar pregnancy (CSP) is a type of non-tubal ectopic pregnancy that occurs when the gestational sac implants into a fibrous scar tissue of previous cesarean surgery (CS) . A uteriThe treatment of CSP represents a diagnostic dilemma, and diagnosis of CSP is generally made in the late first trimester when complications usually occur . CSP canThe specific etiology of CSPs remains unclear, although inadequate healing of the uterus may determine the thinning of the muscle layer that is present in up to 60% of patients with CSPs ,6,7,8. TParticularly, the diagnostic dilemma in CSP is to distinguish the invasive form from the superficially implanted type, in order to define a correct management strategy. The purpose of our study was to retrospectively examine patients in emergency settings at our institution with an ultrasound diagnosis of CSP who underwent MRI, to assess the diagnostic accuracy of MRI and its role in patient management.From May 2021 to May 2023, patients who were referred to our institution in ER settings with a diagnosis of CSP were included in the study. Medical and surgical records and TVUS and MRI findings were reviewed. Inclusion criteria were stable patients with a suspected or confirmed diagnosis of CSP at TVUS performed during the first trimester, who underwent MRI to confirm diagnosis and classify the type of CSP, in order to choose the better management strategy. Informed consent was waived because of the observational retrospective nature of the study, and the analysis used anonymous clinical data. The transvaginal ultrasonographic examination was performed using a 5 MHz transvaginal transducer. The TVUS diagnostic criteria used to reach a suspected or confirmed diagnosis of CSP were the following: (i) Empty uterine cavity with a trophoblast located between the bladder and the anterior uterine wall at the presumed site of the cesarean section scar; (ii) gestational sac that is ovoid and regularly shaped, rather than distorted and collapsed as can be seen in miscarriages; and (iii) thin (1–4 mm) or discontinuous or absent myometrium between the gestational sac and the urinary bladder wall on sagittal images of the uterus through the amniotic canal sac. Additional ultrasound findings, such as (iv) vascularity of the sac on color Doppler interrogation, which can help distinguish a CSP from the avascular sac of a terminated pregnancy; (v) presence of empty endocervical canal; and (vi) negative “sliding organ sign” when gentle pressure is applied to a seen sac at the level of the internal orifice of the uterus using the endovaginal probe, can help differentiate a CSP from an ongoing spontaneous abortion .®, Erlangen, Germany). The MRI protocol provides T1-weighted spin-echo (SE) pulse sequences in axial and sagittal planes, and T2 half Fourier acquisition single-shot turbo spin-echo (HASTE) in axial and sagittal planes. A multichannel receive-only surface coil was used to conduct MRI exams on a 1.5 T scanner , by the width (the distance of the base of the defect), and the remaining myometrium . The total myometrial thickness adjacent to the niche was measured next to the base of the defect (T) [A total of seven patients (aged between 28 and 43 years old) were included in the study. All patients were referred with a history of acute lower abdominal pain; two patients also presented metrorrhagia. All patients underwent laboratory test examinations that showed high levels of β-HCG and were first referred to the gynecological department to perform TVUS. At TVUS, a suspected diagnosis of CSP was formulated in five patients. In the others, two cases of ‘low-implanted pregnancy’ and one of pregnancy located near the CS were diagnosed. All patients were clinically and hemodynamically stable. They were admitted to the hospital and an MRI examination was performed within 48 h. MRI confirmed the CSP diagnosis in four out of seven patients. In two patients, a diagnosis of a ‘low-implanted pregnancy’, a pregnancy located near the CS scar, was formulated. In one patient, a diagnosis of a cervico-isthmic pregnancy was reached . CSP patients were also classified as a Type I or II of CSP following the classification proposed by Vial et al. : (i) TypParticularly, among CSPs, the MRI findings of three patients were consistent with the diagnosis of Type I CSP, while the other patient was diagnosed with Type II CSP. US and MRI findings were compared in all patients . In all A 30-year-old multiparous woman (five newborn) was referred to our institution for lower abdominal pain in the ER setting. She underwent three cesarean sections in the last three years. She underwent a TVUS examination that demonstrated an anteflexed uterus increased in size. The uterus and the cervical canal were empty. The hysterotomy scar from one of the previous cesarean sections appeared as a hypo-echoic line in the anterior lower wall. The gestational sac was visible at the isthmus within the anterior lower segment of the uterus embedded in the cesarean scar; the sac contained an 18 mm embryo without a heartbeat, indicating a pregnancy of about 8 weeks and 4 days. The myometrium layer was extremely thinned, less than 4 mm between the gestational sac and the bladder, and the trophoblast seemed to occupy the entire thickness of the myometrium a–d. The A 35-year-old woman in her fourth pregnancy (including two cesarean deliveries and a miscarriage) was admitted to our emergency department for severe abdominal pain. Beta-hCG levels at the time of presentation were 61601 UI/L . At the TVUS, the uterus appeared lined with an empty uterine cavity at the fundic level, while there was evidence of a gestational chamber of 37.5 × 24 mm at the isthmic level, with a thin layer of myometrium, less than 4 mm between the gestational sac and the bladder. The trophoblast seemed to occupy the entire thickness of the myometrium. The gestational sac was consistent for a pregnancy of approximately 6 weeks and 6 days. A condition of scarred pregnancy was suspected; therefore, an MRI was requested to determine the risk of an ingrown trophoblast and the possible involvement of the adipose layers between the uterus and bladder. MRI showed the implantation of the placental sac at the anterior wall of the uterine body, the site of a previous cesarean section, with a full-thickness invasion of the uterine wall. The placenta reached the uterine serosa, deforming and focally interrupting it anterolaterally a–d. The A 31-year-old woman, who had had twins with a cesarean delivery and was in her second pregnancy, was referred to our institution in an ER setting with significant blood loss . Three days before, an abortion diagnosis was made at another institution where she underwent hysterosuction and Methergin administration, then she was discharged. Beta human chorionic gonadotropin (β-hCG) levels were 9215 UI/L . TVUS showed an enlarged uterus and a gestational sac facing the scar of previous cesarean sections in the isthmic region. The myometrium layer was extremely thinned, with less than 4 mm between the gestational sac and the bladder, and the trophoblast seemed to occupy the entire thickness of the myometrium. The gestational chamber, which measured roughly 2.5 × 2 cm, was consistent for a pregnancy of approximately 7 weeks. The embryo had a weak and irregular heartbeat. The patient was hemodynamically stable and underwent medical therapy with ferric carboxymaltose (Ferinject 50 mg iron/mL solution for injection/infusion). She underwent MRI for diagnostic confirmation and to evaluate the cleavage point between the uterus and bladder. MRI confirmed the presence of the gestational chamber located at the passage between the body and the neck of the uterus at the right wall (from 6 to 11 o’clock). It was situated not far from the previous cesarean section scar. The serosa was focally interrupted throughout the myometrial wall, which was completely infiltrated a–d. The MRI is a multiparametric imaging modality that, unlike TVUS, permits the practitioner to investigate soft tissues with high sensitivity. MRI can be used also to guide the management of CSP. Cesarean scar pregnancies, which were once considered rare, are becoming more common due to the increase in elective cesarean surgeries and improved diagnostic capabilities with transvaginal ultrasound. Although the exact pathogenesis is still not fully understood, the presence of deep chorionic villi within the uterine wall as a result of the dehiscence of a scar likely results in a further invasion of the extravillous trophoblast into the uterine wall, giving it greater access to the deep myometrium. The anterior lower uterine region is believed to have poor vascularity, which may impede healing after a cesarean surgery in some women, making this area vulnerable to small dehiscent tracts or defects where the trophoblast can implant. ,8,16. CPTVUS is still the preferred imaging method for CSP diagnosis; however, MRI is becoming more important in examining CSPs due to its improved soft tissue characterization and anatomical information. MRI images may clearly demonstrate the location of the CSP gestational sac implant, the depth of invasion of the muscle layer, and the interactions between surrounding tissues and the cesarean scar. All these features suggest a potential pivotal role of MRI in the diagnosis and in the choice between the various therapeutic options. Our experience showed the potential role that MRI may have in the diagnosis and classification of CSP, being able to easily confirm uncertain diagnoses and identify the correct type of CSP in each patient. However, further studies are needed to better clarify the role of MRI in early CSP diagnoses and to evaluate a combined imaging approach in high-risk patients and in patients with doubtful TVUS findings.


Phyto-trichobezoar is a rare disorder characterized by the formation of mass in the gastrointestinal tract (GIT) by the ingested inedible material, mostly hair and thread. The ingestion of hair is a rare psychiatric disorder called trichotillomania, which is more common in girls. An 11-year-old girl presented with clinical features of GIT obstruction, which were diagnosed to be Rapunzel syndrome by computed tomography. The phyto-trichobezoar was removed en masse by the anterior gastrotomy, which extended beyond the duodenum. The girl, after recovery, was counseled and treated for subclinical depression. RapunzeInstances of small bowel obstruction attributed to a bezoar comprise interwoven hair and cotton threads manifest as exceedingly uncommon occurrences. The documentation of such cases within the pediatric demographic is notably sparse . It can An 11-year-old girl presented with a history of vomiting, abdominal discomfort after eating, abdominal pain, loss of weight, and poor oral intake for six months duration. The presentation was insidious in onset, but symptoms progressed rapidly over the last two months. The child was unable to eat, was vomiting continuously, and had constipation. Vomitus was yellow-colored, foul-smelling, non-blood-tinged, and non-projectile. Her parents also noticed that occasionally the child ate inedible material like threads and hair.There was no history of any major medical or surgical intervention in the past. Besides, there was no history of similar complaints to her or any of her acquaintances. She was a student and usually stayed home after school. A detailed history of possible child abuse was unremarkable.On general examination, she was undernourished for her age and anemic, with vital signs such as a pulse rate of 89 beats per minute, a respiratory rate of 16 breaths per minute, a temperature of 98.4 degrees Fahrenheit, and a blood pressure of 110/70 mm Hg. There was no clubbing, icterus, cyanosis, edema, or lymphadenopathy. Examination of the scalp was suggestive of a small bald patch at the occipital region.The local examination of the abdomen was suggestive of a firm mass, which was felt in the epigastric region. It was tender to touch and palpable in the epigastric area, along with localized guarding. Bowel sounds were audible. Her per rectal examination was unremarkable. Her routine blood investigations were remarkable for a hemoglobin of 12.0 g/dL. A plain radiograph of the abdomen was suggestive of the absence of a normal gastric shadow of swallowed air, obliterated by an opacity of soft tissue mass in the stomach  at the outpatient psychiatry session. Her parents claimed that her behavioral symptoms had improved. She is on regular follow-ups to monitor for relapses.Rapunzel syndrome represents a rare medical disorder characterized by the accumulation of significant quantities of ingested hair within the gastric compartment, accompanied by the formation of an elongated appendage that extends from the stomach into either the small or large intestine . TrichobIndividuals afflicted with trichobezoars often exhibit concurrent trichotillomania, characterized by a compulsion to pull out one's own hair, and trichophagia, the act of ingesting the extracted hair. Trichotillomania was originally documented in 1889 by the French dermatologist Hallopeau, and its prevalence is estimated to range between 0.6% and 1.6% based on the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) ,11. OnlyThe precise mechanism behind the accumulation of hair within the stomach has not been comprehensively elucidated. In a comprehensive analysis of case series pertaining to trichobezoars, Debakey and Oschner posited that the origin of this phenomenon arises from the entrapment of hair within the creases of the gastric lining. Due to its inherent resistance to digestion, pliancy, and lubricious attributes, hair becomes ensnared within the mucosal folds, initiating a cascade wherein additional strands become intertwined, leading to a gradual augmentation in size .The most prevalent clinical presentations encompass abdominal pain 37%), nausea and vomiting (33.3%), gastrointestinal obstruction (25.9%), and peritonitis (18.3%). Infrequently, patients have exhibited symptoms such as weight loss (7.4%), anorexia, hematemesis, and intussusception. Cases managed conservatively have shown unfavorable outcomes, thus prompting the recommendation of surgical intervention upon the establishment of a preoperative diagnosis. Surgical removal is typically executed through gastrostomies and enterotomies, as deemed necessary. Long-term psychiatric follow-up is deemed essential. In instances where trichotillomania is suspected but not disclosed by the patient, a follow-up endoscopy or contrast study might be recommended. Many individuals within this cohort report experiencing parental dissatisfaction, bereavement, or familial issues. Thus, offering parental or spousal counseling forms an integral facet of treatment, contributing to the prevention of recurrence %, nausea.An 11-year-old girl with features of gastrointestinal tract (GIT) obstruction was diagnosed with Rapunzel syndrome by computed tomography. The phyto-trichobezoar was removed completely by anterior gastrotomy, and she was counseled and treated for subclinical depression. A psychiatric evaluation is mandatory for all patients, with a long-term follow-up for recurrences. From our experience, Rapunzel syndrome is rare but can be diagnosed with high clinical suspicion and imaging for successful and prompt management.


Reactive pituitary hyperplasia can develop as a pituitary (pseudo) macroadenoma in the case of primary hypothyroidism. Hypothyroidism-induced pituitary hyperplasia (PHPH) can be managed medically. Surgery should not be performed if this condition is misdiagnosed as an adenoma. Primary hypothyroidism is a well-known cause of children's slow linear growth. Anterior pituitary enlargement is a rare symptom of severe or long-term illness (pituitary pseudotumor). Thyroid-stimulating hormone-secreting adenomas (TSHomas) are the rarest type of pituitary adenomas, with most endocrinologists seeing just a few cases throughout their lives. In most situations, the diagnosis is difficult, and patients may be referred after presenting with a condition of excessive thyroid-stimulating hormone secretion or a pituitary tumor.In this case study, we describe a 3.5-year-old girl who was referred to our hospital for a surgical assessment of a suspected pituitary neoplastic lesion. It was later determined that the suspected lesion was really pituitary hyperplasia brought on by primary hypothyroidism. Levothyroxine was started, and the dose was increased. The patient was advised to follow up to see if pituitary macroadenoma had responded to levothyroxine supplementation.Pituitary enlargement (pseudotumor of the pituitary gland) is a rare complication of primary hypothyroidism. Early diagnosis and treatment are critical for children with severe primary hypothyroidism to maintain their final height, as late diagnosis nearly always leads to a decline in adult stature. Pituitary macroadenoma secondary to severe hypothyroidism does not need risky and expensive surgical intervention. Because PHPH is rare in children, more credible information is needed to have a better knowledge of how the disease progresses and to develop scientific diagnostic criteria. Hypothyroidism is a well-known cause of children's poor linear growth. Pituitary enlargement (pituitary pseudotumor) can occur when hypothyroidism is persistent or severe. Pituitary hyperplasia (PH) can occur as a result of excessive thyrotropin-releasing hormone (TRH) levels, which stimulate pituitary thyrotroph cells, causing the pituitary gland to enlarge . The pitPregnancy, puberty, and endocrine disorders are all examples of physiological and pathological events that can cause pituitary hyperplasia . Niepce In this case study, we describe a 3.5-year-old girl who was referred to our hospital for a surgical assessment of a suspected pituitary neoplastic lesion. It was later determined that the suspected lesion was really pituitary hyperplasia brought on by primary hypothyroidism.A 3.5-year-old female child was brought with concerns of not being able to walk since inception. This was associated with complaints of the baby being floppy and hypotonic in nature. No other history of any known illness or of previous hospitalization was given apart from the baby being admitted to a NICU on the third day of life for jaundice and apparently requiring a blood transfusion, as narrated by the mother. The mother also had a history of first-trimester abortion and was going on to need medical attention for secondary infertility. No history of any known disease in the parents or anyone else in the family was found. The child had a global development delay with only being able to sit with support, cooing occasionally, only being able to scribble if handed a pen, having evident stranger anxiety, and not being able to wave goodbye. On physical examination, the patient had coarse facies, flat feet, almost rocker bottom feet Figure , and a tShe weighed about 10 kg and had only achieved a height of 78 cm at 3.5 years of age with a head circumference of only 45 cm, all well below the third centile for the given age and sex. The child upper segment to lower segment ratio was 1.29 with midparental height being 148 cm. The patient was evaluated routinely along with a complete thyroid panel. An MRI of the brain with gadolinium contrast was also done as an adjunct to rule out common causes of developmental delay in a private clinic. MRI of the brain suggested a homogenously enhancing extra-axial mass lesion noted in the sellar and suprasellar lesion measuring about 16 x 11 x 11 mm, which was causing widening of the sella, giving it a figure of 8 appearance. This lesion was also reported to cause a mass effect, abutting the adjacent carotid artery laterally and the optic chiasma superiorly, likely to be a pituitary macroadenoma  and the dose was increased to 50 mcg/day (5 mcg/kg/day) after seven days. An improvement in the mental status was observed in the child after starting levothyroxine. The patient was discharged and was advised for a follow-up MRI of the brain after two months to see if pituitary macroadenoma is responding to thyroid supplementation.Primary hypothyroidism in children is characterized by a variety of symptoms and signs, the most common of which are a slowing of height growth and an increase in body weight . BecauseDesai et al. in 1996 reported the first case of hypothyroidism in children linked to pituitary enlargement . Low thyThe clinical manifestations of PHPH include symptoms of hypothyroidism , menstrual disorders, galactorrhea, and infertility . Growth Pituitary hyperplasia following primary hypothyroidism in children is characterized by hypothyroidism-related symptoms, such as short stature, tiredness, and myxedema, as well as prolactin-related symptoms, such as menstruation problems and galactorrhea . In chilSellar masses in children can be caused by a variety of conditions, such as craniopharyngeal neoplasms, intracranial germ cell tumors, pituitary adenoma, and pituitary hyperplasia . PituitaAlthough there are no obvious signs of hemorrhage, necrosis, or cystic fibrosis, intracranial MRI imaging demonstrates diffuse development of the anterior lobe of the pituitary gland with homogenous T1 and T2 signals. A dome-shaped blunt edge change might be seen as a sign of sellar extension. The extension is uniformly enhanced, with a peak enhancement that is comparable to that of the normal pituitary gland. The posterior lobe of the pituitary gland has a high signal intensity in normal circumstances. The pituitary stalk may become normal or thickened but not distorted as the disease progresses, with a suprasellar extension forming a gourd-shaped appearance, most likely extending on the suprasellar cistern or occasionally compressing the optic chiasm, but rarely invading the cavernous sinus or skull bone .Following treatment with levothyroxine, the size of the pituitary gland had been reported to be normalized on subsequent imaging scans. However, rather than starting at the full anticipated replacement dose, it may be preferable to gradually raise the amount of levothyroxine over time in individuals with severe clinical signs of hypothyroidism . This isFrom this case, we infer that early diagnosis and treatment are critical for children with severe primary hypothyroidism to maintain their final height, as late diagnosis nearly always leads to a decline in adult stature. Because PHPH is not common in children, more credible information is needed to have a better knowledge of how the disease progresses and to develop scientific diagnostic criteria. Even though thyroid hormone replacement therapy can improve these symptoms, some children with severe dysplasia or short stature still struggle to grow properly. Accurate diagnosis may save the patient from undergoing needless neurosurgical procedures. As a result, substantial study is required for early diagnosis of PHPH in children.


The authors performed a systematic review, in accordance with the PRISMA guidelines, across multiple databases, including all original studies published until November 2022, focusing on External auditory canal cholesteatoma (EACC) after radiation therapy (RT) for nasopharyngeal cancer (NC). Inclusion criteria were original articles reporting on secondary EACC after RT for NC. Articles were critically appraised to assess level of evidence using the Oxford Center for Evidence-Based Medicine criteria. Overall, 138 papers were identified and after duplicate removal (34 papers) and excluding papers not in English, 93 papers were assessed for eligibility; finally, only five papers were included and summarized with the three cases coming from our institution. These mainly involved the anterior and the inferior part of the EAC. The mean time of diagnosis after RT was the largest series of 6.5 years (with a range from 0.5 to 15.4 years). Patients undergoing RT for NC have 18 times a higher risk of developing EACC compared to the normal population. EACC is probably one of the most underreported side effects, because patients may present variable clinical findings, which could lead to misdiagnosis. Early diagnosis of RT related EACC is advised to enable conservative treatment. External auditory canal cholesteatoma (EACC) represents a very uncommon disease , with a Available epidemiologic data allow an estimation that patients undergoing RT for nasopharyngeal cancer have a 18 times higher risk of developing EACC compared to a normal population .First described by Toynbee in 1850 .In 1980 this clinical entity was well defined and differentiated from keratosis obturans. Keratosis obturans usually presents as hearing loss and acute pain due to the accumulation of large plugs of desquamated keratin in the auditory canal. EACC has a different mode of presentation leading to otorrhea, with a chronic and dull pain which is consequent to an invasion of squamous tissue into a localized area of periositis in the canal wall .The recent technological advances in RT, with consequent therapeutic gains in terms of prognosis for patients affected by head and neck cancer, come with an increased possibility of RT related long-term side effects: xerostomia, osteoradionecrosis, fibrosis, skin changes and ear structures damage .Even though not very frequent, EACC is probably one of the most underreported side effects in clinical practice , becauseThe diagnostic criteria proposed in the literature for RT-related EACC are clinical and pathological evidence of the accumulation of keratin debris, hyperplasia of the external auditory canal epithelium, and bony erosion .We present three patients affected by EACC and who had a history of nasopharyngeal carcinoma treated with RT alone or combined with chemotherapy. We also present the first systematic review on this topic.All patients were treated according to the principles of good clinical practice and signed written informed content for publication of their cases. The systematic review portion of this study was performed according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines . No publA systematic review of all articles present in the main medical databases, such as PubMed (NLM NIH), Scopus (Elsevier and Cochrane library (Wiley)), was performed. The time period considered included all the published articles available within the databases from their inception until November 2022. Additionally, a manual search of the relevant literature in otolaryngology and radiotherapy meetings and citation chaining were performed in order not to miss any relevant case.The search strategy included a combination of the following terms: “Radiotherapy” or “Radiation Therapy” and “Cholesteatoma”. The inclusion criteria were original articles specifically reporting on secondary EACC  after RT for NPC , including both prospective and retrospective studies. Reviews, letters to the editor, articles not in English, conference papers, and papers with mixed cases other than NPC were excluded. Two independent authors, a radiation oncologist (BF) and an otorhinolaryngologist (AL), screened citations in titles and abstracts in order to identify appropriate papers. Eligible citations were retrieved for full-text review. Articles were critically appraised to assess level of evidence using the Oxford Center for Evidence-Based Medicine criteria .The extracted data included: author, publication year, country, number of patients, age, sex, RT dose, RT technique, time from RT to EACC diagnosis, side, and location within the EAC.Data from the selected cases were collated and processed using the Data Analysis Tool Pak loaded in Excel to calculate descriptive statistics.In May 2022 a 57-year-old male presented with a history of left otorrhea and recurrent ear pain for about ten months. He had already undergone several courses of antibiotic therapy on the recommendation of his general practitioner without benefit. He also reported a history of recurrent bilateral ear infections from a young age and a known bilateral hearing loss, more severe on the left.The patient also reported a history of nasopharyngeal undifferentiated carcinoma diagnosed when he was 45 and treated with RT with a dose of 66 Gy in 30 fractions.Physical examination with otomicroscopy revealed purulent discharge and white skin-like material in the left EAC. The patient underwent ear cleaning under microscopic guidance, finding hyperplasia of the EAC mucosa, an erosion of the anteroinferior wall of the left EAC and a small anterior tympanic perforation, as shown in The audiometric exam revealed a moderate degree of neurosensory hearing loss on the right  and a profound degree on the left , with bilateral loss of frequencies above 2000 Hz.High-resolution computed tomography scan of the temporal-bone showed a soft tissue density located in the hypotympanic region of the middle ear cavity and in the floor of the EAC, with related bone erosion of the anteroinferior wall of the left EAC. The lesion did not cause erosion or mass effect on the ossicular chain .The injury, causing erosion of the anteroinferior wall of the EAC and extension to the adjacent temporo-mandibular joint (TMJ), without complications, was staged as IIIa, according to the classification of HN et al.   approach using a rigid endoscope with a 3 mm diameter and 0° viewing angle to explore the tympanic cavity and a canaloplasty to remove the lesion located on the EAC anteroinferior wall. During the exploratory tympanotomy, the ossicular chain and the tympanic cord were identified, and mucous secretions were aspirated. The tympanic cavity was free from cholesteatomatous disease. The tympanic perforation was reconstructed by myringotomy. The patient underwent endoscopic canaloplasty with reconstruction with fascia. The final histology of the removed lesion on the EAC inferior wall revealed EACC.In March 2022, a 65-year-old male presented with a long history of right otorrhea and bilateral hearing loss, more severe in the right ear. He had already undergone antibiotic therapy without clinical benefit. The patient also reported a history of nasopharyngeal undifferentiated carcinoma diagnosed when he was 46 and treated with chemoradiotherapy with a total dose of 70.2 Gy in 39 fractions, with concomitant cisplatin.The physical examination with otomicroscopy revealed both tympanic membranes intact, the right one slightly opaque. Furthermore, in the right ear, bone erosion of the inferior wall of the EAC was found.The audiometric exam revealed a moderate degree of neurosensory hearing loss on the left  and severe degree on the right  with bilateral loss of frequencies above 2000 Hz.The high-resolution computed tomography scan of the temporal-bone showed a thin layer of soft and erosive tissue on the right inferior wall of the EAC. The lesion did not involve the middle ear cavity .The lesion was staged as II according to the classification of HN et al.   and a severe degree on the left , with bilateral loss of frequencies above 4000 Hz. The high-resolution computed tomography scan of the temporal-bone showed a soft and erosive tissue on the anterior wall of the left EAC. The lesion did not involve the middle ear cavity .The lesion, causing erosion of the anterior wall of the EAC and extension to adjacent TMJ without complications, was staged as IIIa, according to the classification of HN et al.  . The total dose ranged from 42 Gy to 74 Gy and, with regard to the techniques used, either 2D or IMRT were reported.EACC represents a relatively unusual disease as compared to middle ear cholesteatoma. This pathology may be spontaneous , or consequent to other conditions (secondary EACC) .The possible causes of secondary EACC described are chronic inflammation, stenosis, late complications of temporal bone trauma, ear surgery, and radiation therapy .Our cohort consists solely of males with unilateral pathology involving predominantly the anterior and the inferior parts of the bony EAC, in line with the papers of Yu et al. , Sapmaz The responsible factors for EACC development suggested in the literature were hypoxia and the expression of angiogenic factors .After RT, a decrease in blood vessels associated with fibrosis increase within the irradiated skin area may occur .Yu underlines that the EAC floor is characterized by a lower vascularization than the vascular strip of the EAC roof. Therefore, this may explain why the predominant invasion of RT-related EACC is in the inferior part of the EAC .The effects of RT on the EAC have been a matter of great interest for several decades; in fact, the pathologic changes noted may be divided into two distinct categories: bony changes and soft tissue changes .RT for nasopharyngeal cancer is by far the most relevant clinical example for secondary EACC development, because typically these patients are young, have good prognosis and receive high doses to large volumes .Up to 13.8% of patients receiving RT for head and neck tumors are expected to develop external ear radiotherapy-induced morbidity .The available evidence is too scarce to draw any definitive conclusion; however, apparently the initial stage of the NPC does not seem to influence the risk of developing secondary EACC .However, it is reasonable to believe that the lower doses delivered by volumetric techniques, which allow the sparing of normal tissue as much as possible, should be associated with lower incidence of EACC compared to older techniques such as 2D .In addition, it is desirable that modern techniques such as Intensity modulated radiotherapy (IMRT) for nasopharyngeal cancer should reduce post-irradiation external ear disorders’ late toxicity, possibly by identifying clinically validated dosimetric constraints .The most commonly reported side effects associated with EACC after RT include otalgia, fullness and itching .In our experience, the cardinal symptoms of RT-related EACCs were otorrhea, hearing loss and otalgia. Similar studies by Hn et al. , Dubach Owen et al. describe that the average presentation latency of ear side effects due to RT is 5 years  . In the In our series, the average presentation latency of EACC was 14 years after RT for nasopharyngeal carcinoma with a range between 9 years and 20 years.We decided to stage the EACCs according to the HN  and NaimThe surgical strategy used for these three patients was TEES, as its efficacy and security regarding the exposure and eradication of both primary and secondary EACCs is widely described ,33.In particular, for EACC limited to the EAC (up to Naim stage III), TEES represents the appropriate surgery, as tissue damage is minimized and consequently the median healing time decreases as compared to retro-auricular or endaural surgical approaches .Moreover, an endoscopic approach to canaloplasty is described as safe and minimally invasive with significantly fewer postoperative complications as compared with microscopic procedures.The 0° viewing angle allowed optimal visualization of the tympanic membrane in all three cases presented, in line with the larger series published in the literature .An endoscopic approach allows an improved view of the end of the instruments, a minimally invasive approach and a decreased operative time .Our systematic review of EACC after RT for nasopharyngeal cancer was limited to retrospective case series and case reports. Only 20 patients were identified in the literature. Therefore, the scantiness of data does not allow the drawing of any conclusive evidence. However, to our knowledge, this is the first systematic review to examine EACC incidence in patients receiving RT for nasopharyngeal cancer.


Solitary fibrous tumors are very rare in the pleura, and they are generally found incidentally. Even though they can potentially become malignant and metastasize, they have minimal clinical symptoms and can still be benign. Due to the low incidence of these tumors, there is no standard of therapy beyond surgical resection. We present an asymptomatic case of a large, rapidly expanding solitary fibrous tumor of the pleura in an elderly female.  A solitary fibrous tumor of the pleura (SFTP) is rare and generally found incidentally; it accounts for <5% of all pleural tumors . SFTP isThis article was previously presented as a meeting abstract at the 2023 MI-ACP Resident and Student Day on May 12, 2023.A 76-year-old female, who is known hypertensive and has a history of >80 pack years of smoking history, osteoarthritis, and numerous falls, presented to the ED for falls and right-sided body pain. She was unable to provide information due to her altered mental status. Her daughter endorsed that her cognition had declined from a baseline of being alert and independent in the past 30 days with an unclear inciting factor.On initial presentation, she was found to be hypertensive and ill-appearing with regular respiratory effort. Her physical exam was significant only for lower extremity edema and weakness, contributing to her falls. Her initial labs in the ED were significant for a hemoglobin of 7.8 g/dl (baseline of 12.5 g/dl in 2018), and her D-dimer was elevated to 3.49 ug/mL fibrinogen equivalent units. Computed tomography (CT) of the head showed bilateral subdural hematomas with mild mass effect and no midline shift. A CT pulmonary abdomen pelvis was ordered due to the elevated D-dimer and was found to be negative for pulmonary embolism but revealed a 12 cm heterogeneously enhancing solid mass throughout the anterior inferior right hemothorax, suspicious for an SFTP. The mass encased the right middle lobe bronchovascular structures and moderately compressed the superior vena cava/right atrium, mildly displacing the heart slightly to the left, with no invasion of the chest wall or mediastinum  done in 2017 that showed no acute process Figure . A subseA biopsy was not done due to the risks associated with the procedure, including airway compression and bleeding. It was concluded that this mass was likely a solitary fibrous tumor due to its rapid onset, morphologic presentation, and potential for malignancy. The patient began declining rapidly through respiratory distress and hypoxia, thought to be due to a likely pulmonary embolism in the setting of malignancy. She continued to become more hypoxic, and the decision was made to pursue comfort care.We present a rare case of a solitary fibrous tumor. Although it is typically benign, it holds significant malignant potential. Remarkably, it often presents either asymptomatically or with minimal pulmonary symptoms ,5. ArounSFTPs are rare and often found incidentally. They generally do not present with clinical symptoms despite their size, as seen in this case. Currently, the reported cases categorize these tumors as unresectable or treated with surgery only. It would be beneficial to do additional future studies on the benefits of targeted therapies in patients that are not surgical candidates. These tumors can still have significant malignant potential and can adversely affect nearby structures, warranting further investigation.


A diabetic lady in her 40s was referred to surgical oncologists with epigastric pain associated with vomiting. Computed Tomography (CT) Abdomen with contrast demonstrated a mass arising from the head of the pancreas with the absence of dorsal pancreas, confirmed on magnetic resonance cholangio-pancreatography (MRCP). A core needle biopsy was done, and the tumor was revealed to be a solid pseudopapillary epithelial neoplasm.She underwent sub-total pancreatectomy preserving the duodenum and ventral pancreas as there was adequate free margin; however due to the tumor abutting the anterior wall of the portal vein, it was resected, and reconstruction was done using a peritoneal graft. The patient made a good recovery without any significant post-operative events. Agenesis of the dorsal pancreas is a rare congenital malformation and its association with solid pseudopapillary epithelial neoplasms (SPEN) is extremely rare ,2. SurgeWe report a female patient of 47 years of age, a diabetic, with agenesis of the dorsal pancreas, diagnosed to have a SPEN arising from the head of the pancreas involving the anterior wall of the portal vein, who underwent duodenum and ventral pancreas preserving subtotal pancreatectomy with type 2 portal vein resection and reconstruction using a peritoneal graft.Clinical presentationA 47-year-old female patient with a history of diabetes managed with oral hypoglycemic agents (T. glibenclamide 5 mg thrice daily and T. metformin 500 mg thrice daily), had presented with dull aching epigastric pain of two months duration which radiates to the back. It was intermittent which progressed to being continuous and was associated with nausea and vomiting of non-bilious nature. She had similar complaints before, and an ultrasound was done which showed features suggestive of chronic pancreatitis; therefore, she was managed conservatively. On examination, vitals were stable. General physical examination was unremarkable. Abdominal examination revealed tenderness in the epigastric region.InvestigationsAt the time of referral to surgical oncologists, endosonography was done which revealed a hypoechoic lesion in the head of pancreas measuring 24x22mm with calcification abutting the superior mesenteric vein but the body and tail could not be visualized. Endoscopic ultrasound-guided fine needle aspiration cytology (FNAC) was done which revealed features suggestive of pancreatic epithelial neoplasm. Following this, a triphasic contrast-enhanced computed tomography (CECT) scan showed a tumor arising from the head of pancreas with 180-degree abutment of the anterior wall of the portal vein with loss of fat planes Figure , 1B. TheOn MRCP, the dorsal pancreatic duct (of Santorini) and the minor duodenal papilla could not be visualized. However, the ventral pancreatic duct (of Wirsung) and the common bile duct (CBD) were normal Figure . The disThe serum amylase and lipase and tumor markers  were normal. A core needle biopsy from the tumor was reported as a solid pseudopapillary epithelial neoplasm. Our final diagnosis was agenesis of the dorsal pancreas associated with solid pseudopapillary epithelial neoplasm.TreatmentHer case was reviewed in a multi-disciplinary team meeting with other oncological departments and opinion from vascular surgeons was sought. As the tumor was arising from the head of pancreas without dorsal pancreas, she was planned for total pancreatectomy, portal vein resection and reconstruction, and possible hepatic artery segmental resection/reconstruction to achieve R0 resection.On laparotomy through chevron incision, there was a hard tumor occupying the anterior part of the head of pancreas and the rest of the pancreas was replaced by fat with no peritoneal metastasis. As our initial plan was to perform a total pancreatectomy, the first step of surgery was to preserve the right gastroepiploic vein to maintain the venous circulation of the stomach if the splenic vein required ligation. The right gastroepiploic vein was dissected and freed along the lateral border of antro-pylorus, head of the pancreas up to the origin from the superior mesenteric vein (SMV) after ligating the gastro-colic trunk. A Kocher manoeuvre was performed. SMV was identified, looped, and traced up to the portal vein. Dissection of the common hepatic artery was commenced from the origin and the artery was looped. Meticulous dissection continued along the common hepatic artery and the artery was separated from the tumor. The gastroduodenal artery, which was adherent to the tumor was separated by meticulous dissection and taped Figure , 2B. SupThe posterior superior pancreaticoduodenal artery was sacrificed to expose the head of pancreas and the distal/intrapancreatic part of CBD Figure . The disOnce the transection of the pancreas was completed, the tumor was freed from the adjacent structures except for the infiltrated part of the portal vein just above the porto-splenic junction Figure . All venNo therapeutic anticoagulation was used except for a prophylactic dose of enoxaparin sodium given for five days as per our routine local postoperative practice. The post-operative recovery was uneventful, and the patient was discharged on postoperative day 5 Figure , 4B. TheOutcomeAt one month after the surgery, she came for a follow-up with no complications. At 18 months of follow-up, she was noted to be doing well with no gastrointestinal complaints. Abdominal scans were done at each follow-up to ensure venous patency.The significance of this article is reporting on agenesis of the dorsal pancreas and associated SPEN, a description of the technique of duodenum and ventral pancreas preserving subtotal pancreatectomy with portal vein resection, and a detailed technique on peritoneal graft for portal vein reconstruction.Agenesis of the dorsal pancreas is a rare congenital malformation, where the dorsal pancreatic bud fails to form the body and tail of pancreas ,2. It caSPEN of the pancreas is rare and considered to be a tumor with a low malignant potential . HoweverAssociation of agenesis of the dorsal pancreas with SPEN is extremely rare . A triphA retrospective cohort study was published in 2022 which compared the outcomes of pancreatic head-sparing enucleation for patients with solid pseudopapillary tumors associated with agenesis of the dorsal pancreas with pancreatic resections for patients with SPEN without agenesis of dorsal pancreas (ADP) in Taipei. There were three patients in the first (study) group and 25 patients in the second (control) group. There were no significant differences between the two groups in terms of pre-operative characteristics, operative measures, surgical morbidity, and post-operative complications. No lymphovascular and perineural invasion was noted in the three cases of SPEN with ADP. However, there are limitations to this study. First, the small sample size and selection bias in both groups. Second, the biases arising from the presence of different options for pancreatic resection for different locations of the tumor in the control group were inevitable. Third, a patient in the study group underwent R1 resection, for reasons not specified .In a systematic review of sub-total pancreatectomy; parenchyma-sparing, limited head resections can be considered for benign or low-grade tumors ,14. A prAs achieving R0 resection is paramount to improve long-term outcomes in a case of locally aggressive SPEN, it is necessary to perform vascular resection or multi-visceral resection if required . AlthougA systematic review conducted by Lapergola et al. concluded that the peritoneal graft is viable, safe, inexpensive, versatile, easily adaptable to vascular defects, not requiring extra operating time, and is a rapidly available option for vascular reconstruction during abdominal surgeries. It can be used for unplanned lateral wall vascular reconstruction, and it would reduce the reluctance of surgeons to perform vascular reconstruction when oncologically deemed ,16. ThisAgenesis of the dorsal pancreas is an extremely rare congenital malformation. Its association with solid pseudopapillary epithelial neoplasm is extremely rare. Sub-total pancreatectomy with preservation of duodenum and ventral pancreas should be considered in cases wherein sufficient tumor-free margins can be achieved, with a precise understanding of surgical anatomy and a proper surgical plan. This surgery could prevent the complication of pancreatic insufficiency.Peritoneal grafts should be considered as an alternative for vascular reconstruction, especially in operations for abdominal malignancies abutting or invading vascular structures. These are versatile grafts, that can be harvested easily without any further incision and can be used for portal vein reconstruction without any major complications.


Splenogonadal fusion is an infrequent cause of testicular or scrotal swelling with less than 250 cases reported. We report the case of a 27-year-old male who presented with painless scrotal swelling. The sonography showed a homogeneous, well-encapsulated left extratesticular mass, which was surgically removed. The gross examination revealed a grey-brown tissue below the left testis. The microscopy of the grey-brown mass revealed splenic tissue, and the testis showed maturation arrest, resulting in the diagnosis of splenogonadal fusion. These can be easily mistaken for a tumor, especially in this age group. Reporting such an entity increases awareness among clinicians, radiologists and pathologists, which will aid in preventing an orchiectomy for these patients. SGF usually presents as a scrotal or abdominal mass and is usually benign;3 however, it is often confused with testicular tumors. SGF may be associated with testicular tumors when associated with cryptorchidism.4 Putschar and Manion5 in 1956 classified splenogonodal fusion as the continuous and discontinuous types based on a connection between the testis and spleen. The continuous type is relatively common and is associated with several congenital anomalies like micrognathia, macroglossia, anal atresia, and pulmonary hypoplasia.6 Preoperative diagnosis is challenging due to its rarity, lack of distinct imaging findings,7 and restriction of testicular FNACs and biopsy with the fear of tumor seeding and hence mandates an orchiectomy in most cases.Splenogonadal fusion (SGF) is a rare congenital anomaly that results from an abnormal fusion between the spleen and the gonads between the 5-8 weeks of gestation when the splenic anlage is close to the left urogenital ridge.A 27-year-old man was referred for evaluation of a palpable, mobile, and painless left scrotal mass. The patient did not report any history of trauma or cryptorchidism. No external anomalies/malformations were noted. The physical examination lacked scrotal inflammatory signs. The mass was located inside the scrotum beneath the epididymis attached to the testis and was slightly painful on palpation. The border between the solid mass, testis, and epididymis was vague. The laboratory results were unremarkable. Serum alpha-fetoprotein, beta HCG, and lactate dehydrogenase levels were normal. The sonography showed a homogeneous, well-encapsulated left extra testicular mass with a cord showing the same echogenicity as that of the testis. The patient underwent exploratory left inguinal orchiectomy, and the mass was excised along with the spermatic cord.The specimen was preserved in 10% formalin and was sent to the department of pathology post-fixation. Grossly, the specimen showed a grey-brown mass attached to the inferior pole of the testis .The length of the cord and the testicular measurements were normal. The cut surface showed the inferior aspect of the testis and a part of the epididymis attached to the grey-brown mass . The epiParaffin-embedded H&E-stained sections from the mass showed a well-circumscribed lymphoid tissue covered with a thick fibrous capsule organized in follicles and separated by sinuses to form red and white pulp with intertwining fibrous septae.  and 2B. Owing to the histological diagnosis, malignancy was ruled out. However, the patient is still in a half-yearly follow-up. The patient is doing well without any complaints.2 in 1883, the first detailed review of 30 SGF cases was published by Putschar and Manion5 in 1956, wherein an SGF classification system was established. SGF can be continuous (55%), wherein there is an anatomical continuation between the spleen and the gonad, or discontinuous type (45%), wherein an anatomical continuity is lacking. Though there is no prognostic difference between the two groups, the continuous type is associated with congenital anomalies. Cryptorchidism and inguinal hernias are the most commonly associated anomalies.6 The other anomalies reported are cardiac defects, limb bud abnormalities, micrognathia, hypoglossia, craniosynostosis, and spina bifida. In our case, the patient had no associated congenital anomalies or cryptorchidism; however, the testicular tissue showed maturation arrest. No reports of maturation arrest associated with splenogonadal fusion were found. Splenogonadal fusion limb defect syndrome (SGFLD), characterized by SGF with skeletal and limb defects, has perinatal mortality of 40-50%.7 In 1990, Carragher8 reviewed 123 SGF cases, with 70% of pediatric cases. Subsequently, Malik and Liu9 in 2013 published a review of 61 additional SGF cases. Chen et al.10 reviewed another 40 cases in 2021. Though first reported by Bostroem11 SGF is predominantly seen on the left side. SGF is more commonly reported in children and adolescents. More than 50% of the case reports are under 10 years of age, and 70% are under 20.6SGF is seen predominantly in males with a male: female ratio of 15:1. This is due to the superficial location of the male gonads compared to females. One case is reported in a genotypic XY but phenotypic female.4 Few cases are diagnosed post-mortem during an autopsy.9The clinical presentation is non-specific and cannot point toward a definitive preoperative diagnosis. They usually present as a testicular or abdominal mass and may be an incidental finding as most of them are asymptomatic. They can rarely present as an acute emergency with torsion, rupture, or malignant transformation.12 Torsion presents with acute pain and can be ruled out with imaging in most cases, and tumors usually have vascular changes even in Ultrasonogram and are accompanied by biochemical and tumor markers. These subtle changes, with a high index of suspicion can help to come to a preoperative diagnosis. Due to the fear of tumor seeding, testicular FNACs are also generally avoided. Besides, the incidence of SGF is also too low to consider it as a differential diagnosis in every scrotal swelling.In cases of continuous SGF in a middle-aged man with complete descent of the testis, as in our case, it is almost impossible to come to a preoperative clinical diagnosis as it can easily be confused with torsion, tumors, and infections. Though there were 1 or 2 instances where a preoperative diagnosis of SGF was made based on imaging, resulting in testis preserving surgeries, in most of cases, SGF patients undergo an orchiectomy as they mimic a testicular tumor.13 Malignant lesions show more disorganized vascularity and would be expected to show washout of ultrasound contrast compared to SGF. Doppler visualizes a vascular mass in the testis's upper pole in SGF along with a normally located spleen and can help confirm the diagnosis of SGF. Imaging through 99m Tc-sulfur colloid liver spleen scan detects accessory spleen, which is even more reliable for SGF diagnosis.14 On table FNAC and Frozen section can also help in preoperative diagnosis. Laparoscopy is a very reliable diagnostic and therapeutic method; however, the discontinuous types can still cause doubts about a malignant tumor without a frozen section.The testis can be spared by detailed radiological evaluation pre-operatively using B-type Ultrasonography (USG), Computed Tomography (CT), and Magnetic Resonance Imaging (MRI) and a high index of suspicion by the treating physician. Clinicians and radiologists can make it a norm to always comment if the spleen is in the left hypochondrium; in any scrotal swelling evaluation In children aged between one and five years, the ultrasonography reveals a low reflectivity micronodular pattern in both SGF and the normally located spleen due to the development of the lymphoid system and white pulp follicles.10 In the absence of an associated malignancy, complete excision of the spleen is all that is needed; however, unnecessary orchiectomies are reported. Carragher8 reported that 37% of the 123 cases had an unnecessary orchiectomy, whereas Chen et al.10 31 years later, still reported 34% unnecessary orchiectomy in their review. Kadouri et al.15 proposed a diagnostic algorithm for chronic testicular nodule  with the help of tumor markers and scrotal ultrasound. They propose that in cases of high tumor markers an orchiectomy should be performed; in cases with normal markers, and inconclusive ultrasonographic examination, a Tc 99 Scintigraphy can be done; and in cases with normal markers and suspicious sonogram, surgical exploration should be done. A missense or a frame-shift mutation in the gene encoding SET binding protein 1 (SETBP1) (c.2608G>A [p.Gly870Ser]), and a mutation in the oligophrenin-1 gene (OPHN1) are identified in these patients and could be a vital pathways to be targeted for therapy in the future.10SGF, which presents as cryptorchidism, requires separate two-stage laparoscopic staged Fowler-Stephen orchiopexy.SGF is an important differential diagnosis to be considered in an indolent testicular or scrotal mass; as they are usually benign, a preoperative diagnosis can help the surgeon to preserve the testis in these young males.