Case Presentation. A 70-year-old woman presented with a 3-month history of diffuse intermittent abdominal discomfort, weight loss, and additional hair growth. Imaging investigations revealed a large 187 × 85 × 140 mm mass between the liver and upper pole of the right kidney which has displaced the adjacent structures. Hormonal evaluations detected high levels of cortisol and adrenal androgens. She underwent open adrenalectomy and right nephrectomy due to severe adhesion of the mass. Histopathological evaluations revealed adrenocortical carcinoma and the patient received adjuvant radiotherapy.  Adrenocortical carcinoma is a rare endocrine malignancy with a bimodal age distribution pattern that affects women more than men. More than half of the patients present with hormone excess manifestations such as Cushing's syndrome and virilization. Non-functional tumors usually are diagnosed incidentally following imaging studies due to a mass effect or metastatic disease. Surgical resection is considered the best curative treatment for these tumors.  Precise physical examination, hormonal evaluation, and imaging studies play a key role in differentiating malignant adrenal masses in all patients, especially in those with vague symptoms. Radical excision of the mass and appropriate adjuvant chemotherapy or radiotherapy improve the outcome for patients. Although this malignancy can develop at any age, it has a bimodal age distribution pattern which commonly affects patients under the age of 5 or in the 4Most patients present with signs and symptoms of hormone excess, especially hypercortisolism (50–80%). About one-third of patients have clinical manifestations of local tumor growth, and 20–30% of them are diagnosed incidentally following imaging studies for other reasons .In the pathological evaluation of adrenal tumors, size is an important and determining factor in the diagnosis of ACCs . These tDespite the limitation of knowledge about the treatment and prognosis of these patients due to its rarity, some progress has been made in this regard. Surgical resection of the tumor and suspicious lymph nodes is considered a potentially curative treatment. Adjuvant mitotane therapy is recommended for all patients who are at risk for recurrence or have high-grade or incompletely resected tumors. The addition of postoperative radiation therapy (RT) is also suggested for this group of patients .Herein, we present the case of a 70-year-old woman with abdominal discomfort, weight loss, and terminal hair overgrowth that was diagnosed with adrenocortical carcinoma.A 70-year-old woman, a retired teacher, presented with a 3-month history of abdominal pain. The abdominal discomfort has been intermittent and diffuse without any specific pattern. She has lost her appetite and her body weight decreased about 10 kg over this period. She has complained of malaise and occasional headaches. She denied nausea or vomiting, diaphoresis, palpitation, sleep disturbance, and abnormal uterine bleeding. She has also noted some additional hair growth on her chin, between the breasts, and on the lower abdomen. In her previous medical history, she had controlled hypertension and was on losartan, and she had no history of diabetes. She has also been hospitalized due to COVID-19 one month previously.On physical examination, she looked cachectic. Her blood pressure was 160/80 mmHg, and other vital signs were normal. On abdominal examination, she had no striae or central obesity. There was mild tenderness over the right upper quadrant and a non-pulsatile 15 cm mass was palpated under the liver. She had excessive terminal hair with a modified Ferriman–Gallwey score of 16. Lower extremities examination showed proximal myopathy in the pelvic girdle. Examination of the cardiovascular and respiratory systems was normal.The initial laboratory tests revealed an elevation in white blood cell count, fasting glucose concentration, and lactate dehydrogenase level. Other findings were all within the normal limits . ContrasLaparotomy was performed, and the right adrenal mass and kidney were excised due to severe adhesion of the mass to the right renal vein. The inferior vena cava has also been repaired. Macroscopically, the adrenal removed specimen measured 23 × 15 × 9 cm and weighted 1667 g. The tumor was solid, yellowish-gray, and well-defined with an intact capsule. Cross section of the tumor revealed a nonhomogenous nodular area with extensive necrosis. There was no evidence of neoplastic invasion to the capsule or external surface of the mass. Microscopic examination revealed polyhedral neoplastic cells in trabecular structures which were arranged in dense cellular sheets. Tumoral cells had giant and pleomorphic nuclei, vesicular chromatin, marked eosinophilic nucleoli, and large amounts of eosinophilic granular to clear cytoplasm. The mitotic activity was more than 6 in 50/high-power fields (HPF), and multifocal coagulation tumoral necrosis was observed. The capsular invasion was identified, but it was not extended beyond it. There was no evidence of tumoral involvement in the right kidney .The patient was observed in the intensive care unit for a few days after surgery. She was referred to the oncology ward with no surgical complications 9 days after surgery. Since the mass was completely resected and there was no evidence of distant spread of the tumor, she underwent adjuvant radiation therapy without chemotherapy. Follow-up thoracic, abdominal, and pelvic CT 3 months after surgery revealed no recurrence or metastasis, and all hormonal and biochemistry evaluations were within normal limits. 5 months after surgery, she is alive and back to normal in good condition.Adrenocortical carcinoma is a rare malignancy in the endocrine system, usually with a poor prognosis . The incStudies have indicated that more than 60% of ACCs are hormone-producing tumors and they can develop clinical syndromes of hormone excess. These tumors usually induce Cushing's syndrome (45%) in adults and are associated with glucocorticoid excess symptoms, such as weakness, and weight gain, which commonly develop over three to six months. About 25% of patients present with a mixed Cushing's and virilization syndrome, due to excessive secretion of both androgens and glucocorticoids and only fewer than 10% of them induce virilization symptoms, implying ACC rather than adenoma . Our patHormonal estimation including adrenal androgens and glucocorticoids levels may help to determine the adrenal source of the patient's signs and symptoms, providing tumor markers which are useful during patient's follow-up to assess possible tumor recurrence or residual tumor after surgery . In the CT scan and MRI are preferred imaging methods for evaluating the tumor size, local invasion, or distant tumor invasion. These tumors usually have the following features on CT scan: tumor size larger than 4 cm, inhomogeneous but well-defined suprarenal mass, displacing adjacent structure, heterogenous enhancement after IV contrast administration, and less frequent calcification and IVC tumor thrombus, especially in right-sided tumors [Fine-needle aspiration biopsy is not usually recommended for distinguishing adrenal carcinoma from a benign adrenal mass. However, it could be performed when there is a high suspicion of distant metastasis in adrenal glands . The WeiComplete surgical resection is the only potentially curative treatment for stage I to III ACCs . HoweverIn conclusion, ACC as a rare neoplasm is a great challenge for diagnosis and treatment. Although most adult patients have functional tumors, precise physical examination, hormonal evaluation, and imaging studies should be conducted for all suspicious patients to diagnose both functional and non-functional tumors and differentiate them from adrenal adenomas. Despite the lack of information about a certain treatment, surgical resection is recommended as a potentially curative treatment. Adjuvant chemotherapy or radiotherapy should be considered based on staging and histopathologic evaluation after surgery.


Brown tumor (BT), an uncommon focal lytic bone tumor, is a non-neoplastic and reactive process caused by increased osteoclastic activity and fibroblastic proliferation in primary or secondary hyperparathyroidism. Vertebral tumor causing neural compression is relatively rare, especially in the cervical spine.A 29-year-old man developed neck pain and arm radicular pain 4 months ago, with the level of serum calcium significantly higher than normal. Computed tomography scan of the cervical spine revealed an expansile lytic lesion occupying the C6 body, left pedicle, and left lamina of C5–6.Osteoclastoma according to imaging and histopathological results.A laminectomy of C5–6 was performed.One month later, he was re-hospitalized due to nausea and vomiting and the serum calcium, was still, kept at a high level. Additionally, the parathormone (PTH) was greatly higher than normal. BT with primary hyperparathyroidism due to the parathyroid tumor was considered. After the surgery of the right parathyroid gland was performed, serum calcium and PTH both decreased, and computed tomography showed good recovery.BTs might be misdiagnosed as other giant cell tumors, thus when giant cell tumors are considered, serum calcium and PTH examination may be needed to exclude BTs. It was found in <5% of patients with primary hyperparathyroidism while the incidence in secondary hyperparathyroidism is 1.5% to 13%.,4 BT can appear as solitary or multiple lesions of any bone and mainly involve extremities, sternum, clavicle, ribs, mandible, and pelvis.–7 Involvement of the spine is unusual, and cervical and multiple spine involvements are extremely rare. Due to it being rare, BT can be misdiagnosed with more malignancy spine lesions. Here we described a BT that was initially mistaken for osteoclastoma. To our best knowledge, this is the first male and cervical case of BT and multiple BT due to primary hyperparathyroidism. And the present report emphasized the importance of distinguishing BTs from other giant cell tumors of the bone and the relevance of measuring serum calcium and parathormone (PTH) before the diagnosis of osteolytic bone lesions. This can significantly impact the correct diagnosis and escape unnecessary surgery.Brown tumor (BT) is a rare benign focal lytic bone lesion that arises in the context of primary or secondary hyperparathyroidism.A 29-year-old man was hospitalized with a 4-month history of neck pain and radicular pain in both upper limbs. He had enjoyed good health until 4 months prior to this admission, when he began to suffer from progressive neck and arms pain, mostly on the left side. The pain was exacerbated by fatigue and movement and was eased during bed rest. On physical examination, the cervical muscles were very tender to palpation. On neurological examination, tendon reflexes were normal and symmetrical.2, and the electrocardiogram showed a shortened Q-T interval consistent with hypercalcemia.The fasting serum calcium varied between 2.98 and 3.51 mmol/L , and the following blood chemistry was found: blood urea 4.30 mmol/L, serum creatinine 70 μmol/L, serum uric acid 438 μmol/L, glomerular filtration rate 120.38 mL/min/1.73 mX-ray showed a normal cervical vertebral. Computed tomography (CT) scan of the cervical spine revealed an expansile lytic lesion occupying the C6 body, left pedicle, and the left lamina of C5-6 Fig. . MagnetiA biopsy from the C6 paravertebral soft tissue mass produced irregular red-brown fragments which were examined microscopically. It showed reactive fibroblastic tissue and increased osteoclastic activity with an accumulation of multinucleated giant cells, which was consistent with osteoclastoma Fig. A. A mistOne month later, the patient was re-hospitalized with nausea and vomiting. Over this period, he had lost 5 kg in weight. Abdominal CT Fig. A showed On the postoperative day 1, serum calcium and PTH level decreased to 2.66 mmol/L and 8.48 pg/mL, respectively. The patient had an uneventful postoperative course. Three-month  have hypercalcemia. Meanwhile, the serum parathyroid hormone of 15 patients has been collected and only 1 of them (6.7%) was normal. So, we can come to the conclusion that endocrine level can be an indicator to differentiate BT in patients with primary hyperparathyroidism from other giant cell lesions. In this patient, the pathological diagnosis was consistent with osteoclastoma, and we ignored his serum calcium, which resulted in a mistaken diagnosis.Clinical manifestation, pathological findings, and imaging characteristics of BT are generally nonspecific. It can imitate many other entities such as multiple myeloma, metastases, sarcomas, and other giant cell lesions. If the tumor involves the spine, we should take different management strategies. BT of the spine that causes nerve compression symptoms may require emergency surgical management. Treatments of 50 patients were collected. 41 of 50 patients  in our review underwent tumor resection and parathyroidectomy was performed in 36 of 50 patients . One patient was treated with percutaneous ethanol injection therapy and a patient did not accept the treatment of parathyroidectomy. After surgery, improvement of symptoms was observed in most patients and a patient died of numerous medical complications.For causes of the formation of BT, the primary treatment is the management of underlying medical disorders caused by hyperparathyroidism. The strategies for primary and secondary hyperparathyroidism are different. Parathyroidectomy is the gold standard treatment for BT with primary hyperparathyroidism. For secondary hyperparathyroidism, monitoring and preventing it with prolonged dialysis sessions is the best treatment.Our search in the literature demonstrated 51 spinal BT patients with primary Table . In summIn summary, the present report emphasized that in patients presenting with a vertebral lesion, BT should be considered in the differential diagnosis, especially when giant cell tumors are considered, serum calcium and PTH exam may be needed to exclude BTs. Tumor resection is required while BTs of the spine cause neurological symptoms.Conceptualization: Zirui Liu, Liang Zhao.Data curation: Zirui Liu.Investigation: Zirui Liu, Hao Yang, Ruipeng Song, Yang Zhang.Resources: Zirui Liu, Hongyu Tan.Writing – original draft: Zirui Liu.Writing – review & editing: Zirui Liu.


Introduction: Pyonephrosis is hydronephrosis accompanied by a bacterial infection in the kidney, causing suppurative destruction of the renal parenchyma; this condition is an emergency and usually associated with stones or chronic urinary tract infections. Urinalysis is typically inaccurate for establishing the diagnosis, as bacteriuria may not manifest due to ureteral obstruction. Case report: We reported a 55-year-old male patient with flanks pain and an account of stone expulsion. Based on history taking, physical examination, radiology examinations, and percutaneous nephrotomy, we concluded a diagnosis of pyonephrosis causing by Streptococcus agalactiae as known as Group B Streptococcus. Discussion: While both US and CT scan guided the early diagnosis, CT was more accurate as it is able to capture the renal function and the underlying cause of obstruction. Pyonephrosis was described as having a pus collection in the pelvicalyceal system, cortex thinning, and the appearance of stones. Conclusion: Pyonephrosis is a rare emergency, and many clinicians find it challenging to recognize since the presentations are frequently nonspecific. In order to prevent renal failure and the spread of bacteremia that entails life-threatening urosepsis, acquiring imaging knowledge (sonography and CT) and other findings are indispensable in determining this entity. Pyonephrosis is a kidney infection accompanied by urinary tract obstruction symptoms. This disease represents an emergency condition because it prompts damage to the renal parenchyma and bacteremia, commonly caused by chronic obstruction due to kidney stones in adults. The mortality rates of bacteremia and urosepsis are 25% and 50%, respectively, and 15% of patients present asymptomatically E. coli was the most common microorganism (67.6%) of all uropathogens Streptococcus agalactiae, also known as Group B Streptococcus (GBS), made up only 1%-2% of all cases Several examinations, such as urine analysis and urine culture, are mandatory to prove the presence of a bacterial infection in the urinary tract. The known Patients with pyonephrosis primarily present with flank pain, tenderness, and a high fever, frequently associated with a history of renal stone, recurrent infection, or surgery. Additional complaints have included fever and abdominal discomfort on many occasions When the lumen is filled with purulent material, pyonephrosis with severe obstruction can be difficult to detect because bacteremia tests are generally negative; therefore, timely imaging is required to determine the best diagnosis. According to literature, ultrasound (US) can show internal mobile collecting system debris (with or without a fluid-debris level) and renal stone, as well as dilated pelvicalyceal system and echogenic debris, which is the most common reliable sign of pyonephrosis ,6.An abdominal CT scan plays a vital role in depicting pyonephrosis. It displays the hydronephrotic component, which is characterized by the presence of pus and an immoderate fluid attenuation in the collecting system. We can also clearly appreciate the collecting system and renal dilatation. Furthermore, MRI provides little additional information over CT imaging; however, it may be preferred to avoid intravenous contrast medium administration in several cases Finally, a pus culture is a gold standard for infectious agent diagnosis. Once the diagnosis of pyonephrosis is established, an adequate antibiotic must be administered promptly, followed by drainage of the infected pelvis A 53 years old man presented to our center with right and left flank pain; a history of stone expulsion while urinating was also recorded several times measuring up to ± 1 × 0.2 cm, with no abdominal pain nor fever. A left flank mass was palpable during the physical examination and cystic mass pain. Urinalysis showed elevated ureic and creatinine levels, along with hematuria and pyuria.Afterward, an abdominal X-ray was conducted, picturing ground-glass opacity at the left upper-lower quadrant abdomen and 2 oval-shaped opaque shadows at the right side at the second to third lumbar vertebrae level. The subsequent sonography revealed moderate right hydronephrosis and hydroureter and severe left hydronephrosis with echogenic debris and undefined cortex border. Abdominal CT showed thick fluid (13-38 HU) filling the left pelvicalyceal system, suggesting pyonephrosis with severe left hydronephrosis, moderate right hydronephrosis, bilateral hydroureter, and 2 stones in the lower pole of the right renal measuring around ± 1.6 × 1.8 × 2.3 cm and 1.5 × 1.1 × 1.4 cm, and a stone in the proximal left ureter sizing ± 1.6 × 3.6 × 1.9 cm.Percutaneous nephrostomy catheter insertion guided by US for abscess drainage in left renal parenchyma produced ± 1200 mL of putrid exudate. Pus sample was cultured, resulting in GBS as the bacterial pathogen; therefore, an antibiotic was administered. Lithotripsy was performed several days onward, discovering ureterolithiasis and nephrolithiasis composed of phosphate, ammonium, calcium, and oxalate based on the stone analysis.According to literature, pyonephrosis commonly occurs from acute or chronic obstruction secondary to a kidney stone It is known that bacterial infection can lead to the development of struvite stones. However, according to other reports, bacteria produce citrate lyase causing a fall in urine citrate levels, leading to supersaturated urine and crystal formation, and eventually, increased calcium oxalate deposition US and CT imaging aid in the early detection of pyonephrosis; however, CT is more precise than US as it identifies renal function, causes of obstruction and abdominal pathologies such as hydronephrosis In our case, the plain radiograph pictured the ground-glass opacity at the left upper-lower quadrant of the abdomen. However, the abdominal x-ray was unable to distinguish pyonephrosis clearly. Therefore, following the literature, the US showed severe obstruction with pelvicalyceal system dilatation and echogenic material, suggesting pyonephrosis. The cause of the obstruction and dilatation can be determined using CT imaging. In the case study, pyonephrosis was manifested by thick fluid filling the pelvicalyceal system, alongside renal cortex thinning and renal stone in the left proximal ureter.Lastly, a percutaneous nephrostomy catheter was inserted, followed by a pus culture resulting in GBS. Percutaneous nephrostomy is necessary for antibiotics to penetrate the renal parenchyma, which was given upon admission. Several days later, the definitive surgery for renal stones was performed with a satisfying result and no postoperative complications .GBS' role as an uropathogen remains unclear. There is no difference in clinical manifestations between the upper or lower urinary tract infection (UTI) According to literature, most cases of GBS infection in adults had at least one risk factor, including cirrhosis, diabetes, stroke, breast cancer, decubitus ulcer or neurogenic bladder This manuscript described a new case associated with GBS infection; pyonephrosis is a rare emergency case which should be diagnosed and treated promptly. Radiology imaging aids in proper diagnosis and provides more valuable information for further treatment, namely guiding insertion of drainage. Furthermore, apart from being used as a diagnostic tool, radiology could contribute as a predictor of serious complications.Written consent has been obtained from the patient as no identifiable patient data were included in this case report.This study has met the ethical principle and received approval from the Research Ethics Committee of Dr Soetomo General Hospital, Surabaya.


Phosphaturic mesenchymal tumors are rare neoplasms, frequently presenting with osteomalacia. These neoplasms usually grow at a slow rate and are associated with unspecific symptoms.In this study, we present the case of a 70‐year‐old woman who had been suffering from musculoskeletal pain, hypophosphatemia, and spontaneous fractures. Positron emission tomography with Gallium showed increase uptake in a subpleural lesion.The patient underwent surgical excision of the subpleural lesion with a non‐intubated uniportal video‐assisted thoracoscopic surgery approach. Osteomalacia is linked to an increased circulating level of FGF‐23, produced by the PMT, which reduces renal reabsorption of phosphate and inhibits 25‐hydroxyvitamin D1‐α‐hydroxylase function.Historically, thoracic surgery has always been performed under general anesthesia using a double‐lumen endotracheal tube, which allows one‐lung ventilation. In recent years, new anaesthesiologic techniques have been developed with a specific interest in nonintubated (spontaneously ventilated) procedures. Nonintubated thoracic surgery (NITS) is performed under loco‐regional anesthesia, specifically intercostal/interpleural/paravertebral blocks or epidural anesthesia. The development of minimally invasive techniques like multiportal and uniportal video‐assisted thoracic surgery (VATS) has encouraged improvements in postoperative pain management, reduction of postoperative complications and hospital stay. The combination of the uniportal approach and nonintubated anesthesia results in a minimal impact on the patient.268Ga‐DOTATATE PET/CT) confirmed a pathological uptake in a subpleural lesion near the eighth right rib , the following laboratory abnormalities were found: low serum phosphorus Table , an imprb Figure . The patb Figure . The posb Figure . In addib Figure . In the 3PMT is tumor of the soft tissue and bone that, in some cases, appears as a paraneoplastic pathologic TIO. This condition was first described by McCance in 1947.According to the literature, 46% of the cases of TIO occurred in females and 54% in males, with an average age of 45.3 years at the time of diagnosis.In the majority of patients (57%), the tumor arises in bones, while in the remaining 34% cases it originates in soft tissues.Tumors are usually located in the femur (22.7%), skull (20.7%), ankle and foot (8.8%), pelvis (8.2%), tibia or fibula (6.5%), and arm (6.5%). The intrathoracic localization is uncommon.In order to locate the culprit tumour, the whole body functional imaging tests should be conducted first. 18‐fluoro‐deoxy‐glucose (F‐18 FDG) Positron Emission Tomography/Computed Tomography (F‐18 FDG PET/CT) is a very sensitive but not very accurate diagnostic tool.The best accurate imaging currently available involve the use of radiolabelled tracers for somatostatin receptors (SSTRs) commonly expressed by PMTsSince then, many authors have reported the combination of NITS with thoracoscopic techniques. Rocco et al. have described the technique of resection of pulmonary nodules in awake patients, even in an ambulatory setting.Despite all these advantages, NITS has some contraindications such as obesity, neurological conditions, uncontrolled gastroesophageal reflux, central hypoventilation syndrome, persistent cough or mucus retention, hemodynamic instability, and severe hypoxia/hypercapnia.This case report describes a classic case of osteomalacia induced PMT. By using the NITS technique, it was possible to have the patient autonomously positioned on the operating table, reducing the risk of further bone fractures during lateral decubitus mobilization. A minimally invasive uniportal approach was used to reduce peri‐ and postoperative pain and the risk of iatrogenic rib fractures.The key point of this case report is to highlight the effectiveness of combining the NITS technique with the VATS uniportal approach, which has proven to be an optimal strategy, minimizing peri‐operative complications and hospital time.The authors have stated explicitly that there are no conflicts of interest in connection with this article.Michele Ferrari: Conceptualization; formal analysis; methodology; resources; writing‐original draft; writing‐review & editing. Alessandro Palleschi: Conceptualization; formal analysis; methodology; resources; supervision; writing‐original draft; writing‐review & editing. Francesca Bartoli: Conceptualization; formal analysis; methodology; resources; supervision; writing‐original draft. Federico Polli: Conceptualization; data curation; methodology; writing‐original draft. Elisabetta Armiraglio: Conceptualization; formal analysis; investigation; resources; writing‐original draft; writing‐review & editing. Antonina Parafioriti: Conceptualization; formal analysis; investigation; methodology; resources; writing‐original draft; writing‐review & editing. Giorgio Alberto Croci: Conceptualization; formal analysis; methodology; resources; writing‐original draft; writing‐review & editing. Davide Tosi: Conceptualization; formal analysis; methodology; project administration; supervision; writing‐original draft; writing‐review & editing.The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed patient consent was obtained to publish this report.Video S1 Surgical excision of the subpleural lesion with a nonintubated uniportal video‐assisted thoracoscopic surgery approach.Click here for additional data file.https://drive.google.com/drive/folders/14G2TfTybZNuP3CPtZ2E9efEVyzzb_0Wk?usp=sharingClick here for additional data file.


To compare the diagnostic performance of international hepatocellular carcinoma (HCC) guidelines with gadoxetic acid-enhanced MRI (EOB-MRI) and contrast-enhanced Computed tomography (CECT) and their impact on liver transplant (LT) allocation in cirrhotic patients with explant histopathology correlation.In this prospective single-centre ethics-approved study, 101 cirrhotic patients were consecutively enrolled with informed consent from the pre-LT clinic. They underwent CECT and EOB-MRI alternately at three monthly intervals until LT or removal from LT list. Two abdominal radiologists, blinded to explant histopathology, independently recorded liver lesions visible on CECT and EOB-MRI. Imaging-based HCC scores were assigned to non-treated liver lesions utilizing Liver Imaging Reporting and Data System (LI-RADS), European Association for the Study of the Liver (EASL), Asian-Pacific Association for the Study of the Liver (APASL) and Korean Liver Cancer Association-National Cancer Center (KLCA) guidelines. Liver explant histopathology was the reference standard. Simulated LT eligibility was assessed as per Milan criteria (MC) in reference to explant histopathology.One hundred and three non-treated HCC and 12 non-HCC malignancy were identified at explant histopathology in 34 patients . Higher HCC sensitivities of statistical significance were observed with EOB-MRI for LI-RADS 4 + 5, APASL and KLCA compared to LI-RADS 5 and EASL with greatest sensitivity obtained for LIRADS 4 + 5 lesions. HCC sensitivities by all guidelines with both EOB-MRI and CECT were significantly lower if all histopathology-detected HCCs were included in the analysis, compared to imaging-visible lesions only. A significantly greater variation in HCC sensitivity was noted across the guidelines with EOB-MRI compared to CECT. No significant differences in simulated LT eligibility based on MC were observed across the HCC scoring guidelines with EOB-MRI or CECT.HCC sensitivities are variable depending on scoring guideline, lesion size and imaging modality utilised. Prior studies that included only lesions visible on pre-operative imaging overestimate the diagnostic performance of HCC scoring guidelines. Per-lesion differences in HCC diagnosis across these guidelines did not impact patient-level LT eligibility based on MC.The online version contains supplementary material available at 10.1186/s40644-022-00497-9. Several international scientific societies focused on liver diseases have developed guidelines for the diagnosis and management of HCC –4. WhileImaging also plays a critical role in determining the LT eligibility in HCC patients with several criteria developed across the world for optimizing LT allocation. The Milan Criteria (MC), based on the size and number of HCC diagnosed by imaging, have been well-studied and demonstrated to be effective for this purpose . This fuSeveral prior studies have compared various international HCC scoring guidelines , 7, 9–11This was a prospective, single-institution HIPAA compliant Institutional Ethics Board approved study. The patients were enrolled consecutively after informed consent between November 2017 and April 2021, as per inclusion criteria: (a) liver cirrhosis (b) enlisted for LT with a high probability of undergoing transplantation within 12 months (c) diagnosed or suspected HCC with priority Model for End-stage Liver Disease (MELD) score. Exclusion criteria were: patient age less than 18 years, low glomerular filtration rate (GFR) (< 30 mL/min/1.73 m2), high total bilirubin (> 3 mg/dl), pregnancy, contraindications to EOB-MRI such as pacemaker or a ferromagnetic implant, history of contrast allergy, previous radiation, local or systemic treatment for HCC, and those delisted from the transplant list. The imaging alternated between EOB-MRI and CECT at three monthly intervals until LT.). Patients also underwent EOB-MRI with a 1.5 T  or 3 T  MRI scanner with multichannel phased array coils (16 or 32 channels) using a standard liver EOB-MRI protocol . CECT protocol and parameters are summarized in . Two faculty abdominal radiologists, with 5 and 3 years of experience independently reviewed the images. They were blinded to the explant histopathology results but were aware that the cohort comprised of cirrhotic patients enlisted for LT.The readers evaluated all included EOB-MRI and CECT and characterized non-treated liver lesions using LI-RADS version 2018  [All the liver explants were examined by a pathologist with more than 15 years of experience in hepatobiliary disease. The explant livers were sectioned in to 5-mm thick slices in the sagittal plane, and all the suspicious macroscopic nodules at gross examination, any bulging nodule and any lesion macroscopically different in color compared to intervening liver, underwent histopathological evaluation. Nodule size was measured on gross examination. If a lesion detected on pre-operative imaging could not be identified on the sections, further thinner slices were cut from the corresponding regions. Final histopathological assessment included diagnosis, tumour size, segment location, degree of tumour differentiation, presence of microvascular or macrovascular invasion, presence of capsule and degree of necrosis. Tumour staging was reported according to the 8r (AJCC) . All livA study investigator correlated the non-treated liver lesions recorded by each reader on EOB-MRI and CECT with those seen at explant pathology by matching lesion size and liver segment location. Lesions were considered to match if the difference between histologically and radiologically measured size was less than 10 mm, and no other lesions of similar size were seen in the vicinity. Lesions were grouped into < 1 cm and > 1 cm in size for analysis. Cholangiocarcinoma and mixed HCC-cholangiocarcinoma tumors were considered non-HCC tumors. Two separate analyses were performed (i) A “real-world scenario”  wherein all lesions detected on histopathology were included and those HCCs not seen on imaging were categorized as false-negatives (FN) or (ii) A “matched scenario” . wherein only the lesions detected on imaging with corresponding histopathology correlation were included for analysis.At our institution, prospective LT allocation is determined as per Extended Toronto Criteria (ETC), which offers LT irrespective of HCC size or number but requires absence of: macrovascular invasion, extrahepatic disease, systemic cancer-related symptoms and poor tumor differentiation . Thus, wp-value  of less than 0.05 was considered statistically significant. Inter-reader concordance was computed as per pairwise unweighted kappa coefficients.The diagnostic performance analysis was performed on a per-lesion basis while LT eligibility was assessed at a patient level. The diagnostic performances and accuracies of LT eligibility by HCC guidelines were compared with a test for two proportions. Correction for multiple testing across pairwise comparisons was calculated using the Holm’s method. The degree of variability in the diagnostic performance of CECT and EOB-MRI across the guidelines was compared with Levene’s test. A  comprised of 115 non-treated liver lesions in 34 patients with a mean age of 66 years (age range 55–73 years). Chronic HCV was the most common cause of liver disease. Majority of patients underwent deceased donor transplant. A total of 115 liver lesions  were noted at histopathology, with per-patient lesion count of 1 to 15 and lesion size range of 2 to 35 mm. Reader 1 (R1) and Reader 2 (R2) identified 78 and 80 lesions, respectively, on EOB-MRI while 46 and 42 lesions were identified, respectively, on CECT.The study cohort comprised of 101 enrolled patients, from which 60 patients with 241 liver lesions underwent LT. 26 patients with 136 liver lesions were excluded due to previous HCC therapy. The final patient cohort The sensitivity for HCC diagnosis varied based on the HCC guideline, lesion size and visibility on imaging in reference to histopathology. Overall, significantly higher sensitivities were realised for both readers in the matched scenario compared to the real-world scenario.In reference to all lesions > 1 cm on histopathology, the sensitivity for HCC diagnosis was significantly higher by LI-RADS 4 + 5 (63.1%), KLCA (60.7%) and APASL (59.5%) compared with LI-RADS 5 (35.7%) and EASL (32.1%) for R1. Similar trends were observed for R2, albeit without statistical significance. In reference to only imaging-visible lesions > 1 cm, LI-RADS 4 + 5 again had the highest sensitivity (98.1/81.0% for R1/R2), followed by KLCA (94.4/79.3% for R1/R2) and APASL (92.6/79.3% for R1/R2) with each demonstrating statistically significant differences versus EASL and LI-RADS 5 (Supplementary Table p = 0.047). Similar trends were observed with R2, with statistically significant differences between APASL (73.6%), and LI-RADS 5 (40.3%) and EASL (40.3%). KLCA did not demonstrate statistical significance against other guidelines  with statistically significant differences against LI-RADS 5 (29.1/28.2% for R1/R2) and EASL (26.2/28.2% for R1/R2). The next highest sensitivities for R1 were observed in APASL (63.1%) and KLCA (49.5%), which were significantly higher than LI-RADS 5 and EASL. For R2, similar trends were observed except that the differences between KLCA and, LI-RADS 5 and EASL, were not statistically significant. In reference to imaging-visible lesions only regardless of size, R1 had significantly higher HCC sensitivity for LI-RADS 4 + 5 (95.9%) compared to LI-RADS 5 (41.1%), EASL (37.0%) and KLCA (69.9%). LI-RADS 4 + 5 (75.0%) also demonstrated the highest sensitivity for R2, with statistically significant differences noted against LI-RADS 5 (40.3%) and EASL (40.3%). The next highest sensitivities in R1 were noted with APASL (89.0%) and KLCA (69.9%), which were significantly higher compared to LI-RADS 5 and EASL. APASL demonstrated higher sensitivity than KLCA  for R1 compared to the other guidelines, which all had the same sensitivity (28.0%). For R2, EASL again showed the lowest sensitivity (18.8%), while LI-RADS 4 + 5 demonstrated the highest sensitivity at 21.9%. If only imaging-visible lesions > 1 cm were included in the analysis, the sensitivity for R1 increased to 43.8% with EASL and 81.2% for the remaining guidelines. For R2, the sensitivity improved to 58.1% with EASL, which again remained the lowest, and 67.7% with LI-RADS 4 + 5, which remained the highest  and the highest sensitivities with LI-RADS 4 + 5 and APASL (31.1%). A similar trend was noted for R2 with EASL being the lowest 17.5%) and LI-RADS 4 + 5 being the highest (23.3%). If only imaging-visible lesions were included, for R1 the HCC sensitivity improved to 33.3% with EASL, still persisting as the lowest while increasing to 76.2% with LI-RADS 4 + 5 and APASL, which maintained the highest positions. For R2, the sensitivities improved to 47.4% with EASL and 63.2% with LI-RADS 4 + 5. Statistically significant differences in HCC sensitivities were observed for R1 in the imaging-visible lesions of all sizes between EASL, APASL and LI-RADS 4 + 5. No additional statistically significant trends were derived amongst the HCC sensitivities with CECT . In comparison, R2 obtained highest accuracy for LI-RADS 5 and APASL with both EOB-MRI and CECT .The inter-reader concordance between the two readers across various HCC guidelines ranged from fair to moderate (k = 0.30–0.43) for EOB-MRI and moderate to good (k = 0.54–0.70) for CECT .In this prospective study, we assessed the impact of various international guidelines on HCC diagnosis and LT eligibility with EOB-MRI and CECT in reference to explant histopathology. We addressed some of the key shortcomings of prior studies through prospective explant histopathological correlation in the entire included patient cohort. Additionally, we did not exclude any patients based on liver lesion size, number, or invisibility on pre-operative imaging, with the specific aim of providing results for a real-world scenario.Overall, regardless of lesion size and visibility on imaging, we observed the highest sensitivities for HCC on EOB-MRI for LI-RADS 4 + 5, KLCA and APASL respectively, which were all greater than LI-RADS 5 and EASL. The inclusion of LI-RADS 4 category as HCC, not surprisingly, improved the sensitivity with EOB-MRI likely secondary to inclusion of ancillary features. Particularly, the inclusion of hepatobiliary phase hypointensity, which expands the washout definition similar to APASL and KLCA guidelines, likely played a major role . In contTwo prior studies, by Jeon et al. and Clarke et al., investigated the diagnostic performance of various guidelines on EOB-MRI, with explant histopathological correlation , 18. In We observed greater variances in the HCC sensitivities across guidelines with EOB-MRI compared to CECT. This was particularly evident in all lesion categories regardless of size and visibility on imaging for one of the readers. This is also concordant with the lack of statistically significant differences in HCC sensitivities across the guidelines with CECT compared to EOB-MRI. We suspect that the increased variability observed with EOB-MRI may be partly related to the higher number of imaging sequences and lesion characteristics being assessed, further compounded by greater inter-reader differences. Thus, we surmise that the differences in HCC diagnosis across various guidelines are further accentuated with EOB-MRI compared to CECT. This has not been adequately investigated or reported in previous studies.In our study, while there were significant differences in HCC sensitivities and specificities between EOB-MRI and CECT across the guidelines at a per-lesion level, this did not translate into statistically significant differences for per-patient LT eligibility as per MC. While LI-RADS had higher accuracies for simulated LT eligibility with both readers, the differences were not statistically significant compared to other guidelines. This contrasts the results of Jeon et al., who observed the highest accuracy for unsuitable LT candidates with KLCA guidelines based on MC . Seo et Our study has several limitations. Our study sample size was small, limiting strong inference of results. However, this study was prospective and included explant histopathology correlation for the entire study cohort. The study population only consisted of cirrhotic patients on LT list. This may introduce a selection bias and limit the applicability of the study to only LT candidates, which is still of value in our opinion. Furthermore, the prospective imaging and histopathological assessment were focused primarily on HCC detection and diagnosis. Hence, benign lesions and non-HCC malignancies were possibly underrepresented in the study population, limiting the implication of specificity results. Future studies with inclusion of more benign lesions would be helpful in the assessment of specificities obtained amongst the various guidelines. Additionally, we calculated the HCC scores based on only a single timepoint without the use of threshold growth, which plays an important role in LI-RADS. This may have underestimated the sensitivity of LI-RADS in our study. Furthermore, there was interobserver variability amongst the readers particularly with EOB-MRI, which likely had an impact on the variances observed across the different guidelines. Finally, the number of lesions detected by CECT were significantly lower than EOB-MRI, and while this applied to both readers, it should be factored into the interpretation of overall results.In conclusion, highest sensitivities for HCC diagnosis by EOB-MRI in cirrhotic patients listed for LT were observed with LI-RADS 4 + 5, APASL and KLCA. True sensitivities suffered significantly if all HCCs identified on histopathology were included regardless of their visibility on pre-operative imaging. This is reflective of the real-world scenario and suggests that prior literature, primarily focused on imaging-visible lesions only, may have overestimated the diagnostic performance of HCC guidelines. Further, the utilization of EOB-MRI may accentuate the differences in HCC diagnosis across various guidelines. However, at a patient level, the differences in HCC diagnosis due to various guidelines do not significantly impact the accuracies for LT eligibility as per MC with EOB-MRI and CECT.Additional file 1: Supplementary Table 1. CECT quadriphasic liver protocol (Aquilion 64). Supplementary Table 2. Protocol for gadoxetic acid-enhanced liver MRI (Gd-EOB-MRI). Supplementary Table 3. LI-RADS v2018 – Major and Ancillary Features with EOB-MRI. Supplementary Table 4. Differences between sensitivities for scoring guidelines for EOB-MRI for lesions > 1 cm . SupplementaryTable 5. Differences between sensitivities for scoring guidelines systems forEOB-MRI for lesions of all sizes . Supplementary Table 6. Differences between sensitivities for scoring guidelines for CECT all lesions size > 1 cm . Supplementary Table 7. Differences between sensitivities for scoring guidelines for CECT for lesions of all sizes .


The mesenteric cyst (MC) is a rare entity, a benign lesion that causes the growth of an abdominal mass and other clinical presentations. The presentation of MC during pregnancy is even less frequent.A 34-year-old Mexican woman presented with a mesenteric cyst treated with laparotomy aspiration during the 16th week of pregnancy; the pregnancy was resolved by cesarean section without problems. Nevertheless, 17 months later, the lesion recurred. New assessment and surgical treatment with complete excision are performed without evidence of further recurrence.This case is essential due to the low frequency of association between pregnancy and mesenteric cyst. Incomplete resection, aspiration, and marsupialization of the lesion carry a high risk of recurrence. Therefore, the opportune moment to perform a complete resection of the lesion and avoid complications should be evaluated during pregnancy.MC should be considered a differential diagnosis in cystic lesions during pregnancy. Imaging studies, complete surgical resection, histological evaluation, and follow-up are necessary for adequate treatment. •Mesenteric cysts are rare lesions, and their presentation is more variable during pregnancy.•An incomplete resection carries an essential risk of recurrence.•The ideal treatment includes preoperative imaging, complete excision, histopathological evaluation, and follow-up.•The mesenteric cyst could be complicated with acute abdomen, intestinal obstruction, and mesenteric ischemia. Tomography and magnetic resonance imaging are helpful for the relevant preoperative information on anatomical location, organs involved, size or dimensions, and content characteristics The association of MC with pregnancy or puerperium is even less frequent. Only a few cases are reported, and the last reported cases were from five years ago 2Written informed consent was obtained from the patient and the husband to publish this case report and accompanying images.32), no smoker, two pregnancies, two cesarean sections, does not suffer from other diseases, no relevant family history, does not take any meds, no smoking, drugs, or alcohol, and has no allergies. She began her condition four years before her second pregnancy with progressive heartburn symptoms, gastroesophageal reflux (GER), and urinary incontinence; the patient associated these symptoms with her obesity problem until abdominal growth and abdominal mass were presented. For a better understanding of the case, the timeline of critical clinical events is given:A 34-year-old Mexican housewife suffers from obesity due to excess calories . A contrast-enhanced abdominal tomography revealed a recurrence of a cystic lesion on the left flank measuring 25 × 16 × 28 cm, non-septated, without enhancing the contrast medium, showing displacement of bowel loops and uterine body  was decided in December 2021. The patient was prepared by fasting for 8 h, anti-embolic stockings 30 min before the procedure, Ceftriaxone 1 g, and Ondansetron 8 mg IV were used. During the surgery, the cystic lesion was found to be unilocular, covering a large part of the peritoneal cavity, causing displacement of intestinal loops and compression of the splenic flexure of the transverse colon against the retroperitoneum. Five liters of straw-colored fluid were drained, allowing resection of the lesion, using a Harmonic® scalpel (Harmonic Focus ± shears Ethicon Johnson-Johnson), adhered by loose adhesions and vascular pedicle from the mesentery of the splenic flexure of the transverse mesocolon (LC Type 1). The procedure was completed with concurrent appendectomy and the surgical time was 1.5 h, a minimum amount of blood loss. The first author performed the surgery, an attending physician, a certified general and bariatric surgeon with five years of experience, and a medical intern as the first assistant. The pathological analysis reports an appendix of 6 × 0.05 cm with appendicitis; ovoid cystic lesion 36 × 25 cm composed of a pseudostratified epithelium, capsule with fibroconnective tissue, lymphocytes, and plasma cells, and histocytes. The final diagnosis was a simple mesothelial cyst .Fig. 2InDuring her post-surgical recovery, they used Ondansetron 8 mg iv every 12 h, Omeprazole 40 mg iv every 24 h, Metamizole 1 g iv every 8 h, Ketorolac 30 mg iv every 8 h, Ceftriaxone 1 g iv every 12 h and 60 mg of subcutaneous Enoxaparin. There were no postoperative complications, and the patient was discharged home with oral Cephalexin 500 mg every 8 h, oral Acetaminophen 500 mg every 8 h, and subcutaneous Enoxaparin 60 mg every 24 h for seven days. Four months later, continues the outpatient follow-up; the patient presents a resolution of symptoms and expresses complete satisfaction with the improvement in her quality of life and grants their consent to publish the present case, saying that it is helpful to resolve future similar issues. In addition, she had no evidence of recurrence of the lesion by control abdominal tomography.4According to Perrot M n = 16) showed that patients presented with abdominal pain (62 %), abdominal mass (43 %), and intestinal obstruction (6 %). The locations of the lesions were retroperitoneum (31 %), sigmoid mesocolon (25 %), and small intestine mesentery (25 %) Lymphangiomas are more frequent in children under 12, and mesothelial cysts are in young women Complete enucleation of the lesion by laparotomy or laparoscopy is the treatment of choice. Aspiration and marsupialization are associated with the risk of recurrence and infection. In the case of retroperitoneal involvement of large vessels, complete resection of the lesion is unlikely. The best option is partial resection with marsupialization into the peritoneal cavity n = 12). Sessile cysts (LC Type 2) that affect the intestinal lumen and mesenteric irrigation cause intestinal obstruction and mesenteric thrombosis (n = 2). In other cases, it presented as ultrasound findings (n = 1), threatened abortion (n = 1), and epigastric pain with irradiation to the right hypochondrium (n = 1). Obesity and MC with a displacement of intra-abdominal structures can exacerbate GER and urinary incontinence due to increased intra-abdominal pressure The association between MC and pregnancy is rare, and only a few reported cases are reported. The mesenteric cyst is more common in women of childbearing age and can occur at any week of pregnancy or puerperium n = 2). Complete resection of the lesion was reported in all cases: cyst resection (n = 13), cyst resection plus small intestine segment (n = 4), cyst resection plus small intestine segment plus concomitant appendectomy (n = 1) and cyst resection plus concomitant appendectomy (n = 1). The timing of resection was laparotomy during pregnancy (n = 8), laparotomy resection during the puerperium (n = 4), laparoscopic resection during pregnancy (n = 2), resection during cesarean section (n = 1), diagnosis during pregnancy and recurrence, resection by laparotomy (n = 2). According to the LC, type 1 (n = 8), type 2 (n = 4), type 3 (n = 3), type 4 (n = 0) and not reported (n = 2). MC locations in order of frequency were ileal mesentery (n = 8), retroperitoneum (n = 3), lesser omentum plus transverse mesentery (n = 1), jejunal mesentery (n = 1), transverse mesentery (n = 1) and not reported (n = 3). According to the histological types of Perrot M n = 7), lymphangioma (n = 6), enteric cyst (n = 2), simple cyst lymphatic (n = 1) and mucinous cystadenoma (n = 1). Mucinous cystadenomas usually originate from the ovaries; very few cases affect other organs such as the pancreas, liver, spleen, and mesentery The MC treated with marsupialization and drainage initially, including in our case, presented recurrence (5MC should be included in intraabdominal cyst lesions during pregnancy as a differential diagnosis since they are more frequent in young women. Imaging studies, complete resection, histopathology evaluation, and follow-up are necessary for treatment. In cystic lesions >20 cm, during pregnancy, the timing of complete resection by laparoscopy or laparotomy should be assessed to avoid complications and rule out malignancy and recurrence. Type 3 or 4 MC has a high recurrence rate if they are not completely resected.Written informed consent was obtained from the patient and the husband to publish this case report and accompanying images. On request, a copy of the written permission is available for review by the Editor in Chief of this journal.Not commissioned, externally peer reviewed.Written informed consent was obtained from the patient and the husband to publish this case report and accompanying images.Moreover, the ethical approval has been exempted by our institution, considering that the case was written using retrospective and anonymous data.This research received no specific grant from the public, commercial, or not-for-profit funding agencies.Francisco Aguilar-Espinosa.This is a case report, and it is not registered.FAE: Data collection, interpretation, writing paperRSV: InterpretationHAGB: data collectionCRRR: data collectionEDBJ: Writing paper and final revision.All authors declare no conflict of interest.


We present a case of pelvic paraganglioma that presented with heart failure as the primary symptom.A 35-year-old man was admitted to hospital due to heart failure. Contrast-enhanced pelvic CT showed mass shadows in the posterior wall of the bladder and multiple enlarged lymph nodes in the retroperitoneal area. Ultrasound-guided puncture was performed, and the pathologic diagnosis was extra-adrenal paraganglioma. The patient refused any chemotherapy and died within six months of diagnosis.The possibility of neuroendocrine-related tumors, for example paragangliomas, should be considered in young patients with heart failure, especially those with concomitant hypertension and diabetes. Paragangliomas are extra-adrenal non-epithelial neuroendocrine tumors originating along the sympathetic and parasympathetic nerve chains . The WHOA 35-year-old man was admitted to the hospital in May 2019 with chief complaints of fatigue and cough for 15 days, and dyspnea for 5 days. The patient had developed a bout of cold 15 days back followed by general malaise and fatigue, and had felt better after self-medication. 5 days ago, he developed dyspnea with no obvious cause, accompanied by chest tightness, and could not lie supine at night. Dyspnea was mainly in the supine position, and was relieved in sitting and standing position; in addition, there was significant reduction in activity tolerance. He had a history of hyperhidrosis for more than 10 years, which had aggravated in the last 4 years.4 years ago, he was found to have hyperglycemia and high blood pressure, both of which were not well controlled. His father died because of bone cancer at the age of 30 (details are unknown). On physical examination, he was conscious and well oriented with a blood pressure of 147/102 mmHg, and heart rate of 122 beats per minute. No rales were heard in bilateral lungs. The heart rhythm was regular and no abnormal murmur was heard in the precordium. Mild edema was found in lower extremities.At admission his BNP level was 350.50 pg/mL. Blood gas analysis showed type I respiratory failure. His 24-h urinary VMA level was 331.5 µmol/L . Serum levels of aldosterone, cortisol, adrenocorticotropic hormone (16:00), metanephrine and norepinephrine were normal, while adrenocorticotropic hormone (8:00) was high slightly.  and their intermediate metabolites  and terminal metabolites (e.g. vanilmandelic acid) is an important basis for the qualitative diagnosis of paraganglioma , 6. The 123I-MIBG and PET-CT are invaluable in locational diagnosis of paraganglionoma. In particular, 123I-MIBG has the highest specificity (95–100%) because it is an epinephrine analogue and can be absorbed by pheochromocyte catecholamine vesicles [Ultrasound, computed tomography, magnetic resonance imaging, vesicles . In thisIn a case of rectal paraganglioma reported by Yu et al. , the tumIn 2017, the WHO proposed the term “metastatic paraganglioma” instead of “malignant paraganglioma”. The 2014 Endocrine Society clinical practice guidelines for pheochromocytoma and paraganglioma suggest that 10–17% of pheochromocytomas and paragangliomas are malignant, of which the proportion of paragangliomas is higher . MalignaParagangliomas are also categorized as benign and malignant. The distinction between benign and malignant is different from that in other tumors, and it does not depend on pathological diagnosis. At present, the diagnosis of malignant paraganglioma mainly depends on the presence or absence of intravascular tumor thrombus, local invasion, or lymph node metastasis. A study showed that histopathological findings of abundant intratumoral necrosis, vascular invasion, cystic invasion, and strong mitotic activity suggest the possibility of malignancy . Some stThis case was malignant paraganglioma, which was considered metastatic based on multiple retroperitoneal enlarged nodules (approximately 59 × 34 mm in diameter) detected on abdominal and pelvis enhanced CT. Bone ECT showed multiple spots, slices and strips of nuclide enhancement in the skull, vertebra, bilateral ribs, bilateral scapula, left upper humerus, pelvic bone, and right upper femur. These findings were suggestive of bone metastases.Surgery is still the main treatment modality. Hypertension should be adequately controlled before surgery to prevent intraoperative hypertensive crisis or arrhythmia. Hemalatha reported a patient with retroperitoneal paraganglioma who died during the surgery because of hypertensive crisis . RadiothThe possibility of neuroendocrine-related tumors, for example paragangliomas, should be considered in young patients with heart failure, especially those with concomitant hypertension and diabetes. Better characterization of the disease can facilitate early diagnosis and help improve treatment outcomes.


Duodenal neuroendocrine tumors (NETs) account for <3% of all gastrointestinal NET. Most lesions are small-sized and are located in the first or second duodenal part. Tumoral grading, evaluated by Ki67 index, strongly influences patient’s outcome. Endoscopic resection is recommended for lesions measuring <2 cm, while pancreaticoduodenectomy should be the treatment of choice for large duodenal NET; Whipple procedure should be preferred in case of duodenal origin and contiguity with gastric antrum. Involvement of surrounding structures, as well as the presence of resectable liver metastases, does not contraindicate surgical resection. Herein we report a case of a 68-year-old male, presenting with an extensive mass of the descending pre-ampullary duodenal part, with involvement of the right colon and the presence of a pericholecystic single liver metastasis. In spite of such advanced disease, surgery on the patient was successful, with an uneventful postoperative outcome. Duodenal neuroendocrine tumors (NETs) are relatively rare ; they are classified according to different hormonal content, with about 28% of all NETs being nonfunctional. More than 90% of all duodenal NETs arise in the first and second parts of the duodenum ,2. NodalWorld Health Organization (WHO) 2019 NET grading classification is closely related to tumoral behavior and strongly influences patient’s prognosis : as Ki67Alteration in biomarker levels, such as serum chromogranin A and neuron-specific enolase, provides information on diagnosis and prognosis; upper endoscopy with biopsies and endoscopic ultrasound confirm diagnosis and degree of local spreading . CurrentA 68-year-old male was admitted to our Ward Unit reporting dyspepsia, weakness with weight loss and abdominal pain. Neither previous abdominal surgery nor a family history of cancer was referred. Patient complained of pain on the right flank ; canalization and food intake were described as regular. A large mass occupying the right abdomen was easily detected. Basic laboratory panel revealed anemia (Hb 9.8 g/dl) without leukocytosis or jaundice. Body mass index was 19.5 and KPS 70%. AngioCT revealed a neoplasm measuring 11 × 8.5 × 8 cm arising from the upper duodenal-pancreatic angle . EndoscoAfter bilateral subcostal incision, both ascending colon and root of transverse mesocolon appeared infiltrated, while Kocher’s maneuver and dissection of hepatic pedicle confirmed no involvement of main vessels. Given the duodenal origin of the NET and contiguity with gastric antrum, a typical Whipple procedure was preferred; both right-sided hemicolectomy and atypical segment V liver resection were associated to main procedure . Soft paThe postoperative course was uneventful (Clavien-Dindo grade 1); during ICU stay, the patient received two blood transfusions and started enteral feeding. He was transferred to our ward on postoperative day (POD) 5; maximum amylase level in the drainage was 725 IU/l on POD 3, without any signs of clinical activity (Grade-A Pancreatic Fistula). Bowel movement started on POD 4 and oral intake on POD 7; drains were removed between POD 8 and POD 10 and patient was discharged on POD 13. At pathological examination, the lesion appeared rounded and multinodular in shape, without cleavage between pancreatic head and ascending colon; cut surface was firm, fleshy and pink to grey in color . Histolo0/34).Pancreaticoduodenectomy should represent the treatment of choice for large duodenal NET, with Whipple’s procedure preferred to pylorus preserving techniques given duodenal origin . InvolveEndoscopic resection is recommended for lesions measuring <2 cm . Tissue


Teaching Point: Epipericardial fat torsion is a little-known and uncommon condition with sometimes subtle findings making general awareness essential for detection and for confident diagnosis. Figure 1). Further laboratory blood tests could exclude pulmonary embolism and infectious disease with low D-dimer and absence of systemic inflammation. With this suspicious clinical picture and diaphragmatic tenting, a thoracic computed tomography (CT) without intravenous contrast was requested. The mass-like image on the chest X-ray corresponded to a low density (–80 Hounsfield units) nodular structure with a surrounding soft tissue attenuation rim on the left diaphragmatic dome with a diameter of 2 cm and adjacent lung atelectasis . A clear connection to the mediastinum  was demonstrated, which raised the suspicion of an epipericardial fat torsion. An indication for surgery was retained for definite diagnosis and pain relief. Surgery showed no diaphragmatic defect but revealed a twisted epipericardial fat pad with necrosis adhering to the diaphragmatic side of the left lower lobe . At histology, circumscribed adipose tissue with ischemic necrosis, granulation tissue, hemorrhage, and multinucleated giant cells were seen. The patient had an uneventful recovery and was able to leave the hospital three days later in good general condition.A 21-year-old woman presented to the emergency department with acute left-sided stabbing chest pain with radiation to the left shoulder. The suddenly arising pain was related to inspiration and to supine position but remained absent during expiration. No significant prior medical history or medication intake was noted, and the patient reported no other symptoms. She denied leg swelling or pain, recent flight travel, or smoking. Physical examination and electrocardiogram were unremarkable. A chest radiograph depicted a non-specific left-sided diaphragmatic mass with tenting of the diaphragmatic cupola (This case is an illustration of an atypical localization of an epipericardial fat torsion and necrosis. Clinically epipericardial fat necrosis presents with acute unilateral chest pain, more frequently left-sided, without significant biochemical abnormalities . Imaging


Onchocerca lupi is a zoonotic parasite of carnivores reported in countries from Europe, North America, Asia and Africa. In Romania, canine ocular onchocercosis was first reported in dogs in 2016 from Târgovişte (Dâmboviţa County) and Oneşti (Bacău County) and more recently, it was detected in an adult stray dog exported to UK from an unspecified location in Romania.A 4-years old male mongrel dog was referred to a private veterinary clinic in Năvodari (Constanţa County), Romania due to ocular disorders. The dog was originally from a public dog shelter in Balş (Olt County) and transferred in June 2020 to a dog shelter in Medgidia (Constanţa County). A cytological examination followed by surgical removal of the granuloma localized at the internal angle of the right eye, and molecular identification of the extracted nematode were done.O. lupi. Two doses of moxidectin and imidacloprid were administered after the surgery. No relapse observed after a period of follo-up of 11 months.The cytological examination confirmed a parasitic granuloma. Skin biopsy and PCR confirmed the infection with Onchocerca lupi is present in dogs from Romania with its actual distribution remaining unknown. Onchocerca lupi, a zoonotic filarioid parasite of carnivores, having a wide geographical distribution (Canis lupus) from Georgia , in the southern region of Romania  at a low altitude (132 m a.s.l.) with a continental-temperate climateThe dog received local treatment with 1% prednisolone eye drops for 10 consecutive days and an oral systemic treatment with tablets, 10 mg/day prednisolone  for 7 consecutive days. Additionally, the dog received a first dose of oral milbemycin oxime + praziquantel , according to the label, followed by another similar dose after 10 days administered by the veterinarian.The clinical evolution of the dog was followed by the shelter workers. However, due to the persistence of the ocular nodule, 3 months after the initial treatment, the dog was referred again to the same private clinic (May 2021). A fine-needle aspiration from the conjunctival mass was done, followed by cytological examination using Diff Quick stain.After the cytopathological diagnosis, the nodule was surgically removed , followiFor histological examination, fixed conjunctival and subconjunctival tissues with nodular lesions were paraffin-embedded. Ten serial 3 μm-sections were cut and processed for routine hematoxylin and eosin (HE) staining.cytochrome c oxidase subunit I (cox1) gene, using universal Spirurid primers , as previously described , by means of a multiplex PCR amplifying partial regions of the cytochrome c oxidase subunit 1 (cox1) gene, as described in the literature , according to the manufacturer's instructions. The nematode fragment was characterized by amplification and sequencing of a ~670 bp fragment of the escribed . The seqterature .The dog received 2 spot-on doses of moxidectin and imidacloprid , 1 month apart. A second skin biopsy was performed 4 months after the surgery (October 2021). The dog was continuously followed by visual inspection by the dog keepers and regulated check-ups at the private clinic.The clinical examination of the dog revealed a good general condition apart from the subconjunctival nodule on the surface of the sclera at the internal angle of the right eye . A more The examination of the aspirate revealed the presence of macrophages, epithelioid cells, a few multinucleated giant cells, reactive fibroblasts, plasma cells, small lymphocytes, and a few squamous epithelial cells. The presence of larval nematodes (ca. 105 μm in length and 7–8 μm in width) concluded the diagnosis of a parasitic granuloma .The subconjunctival tissue was markedly expanded by numerous, variably sized, well delimited, and encapsulated inflammatory nodules . They weO. lupi isolates [genotype 1–according to , 6 months before the nodule became visible (December 2020), and eleven months before the larvae were detected in the skin (May 2021). However, the actual date of positivation of skin for microfilariae could not be estimated, as no previous biopsies were done.The present clinical case provides new information on the spread of zoonotic O. lupi is not known, but some reports in humans suggest it to be even as short as 30 days . In both two counties, the presence of the assumed to be vectors (family Simuliidae) was reported  and the O. lupi is still unknown, the possible arthropod vector is considered to be represented by Simuliidae flies, which are known to be present in Romania  can be found in the article/supplementary material.Ethical review and approval was not required for the animal study because it was not necessary as the used protocol did not imply any procedures which ask for ethics approval.GD performed the skin-snip analyses, conceived the study, and wrote the manuscript. ST performed the sample prelevation, did the surgery, and was responsible for the follow-up. DS performed the cytological examination. AI performed the molecular work and revised the manuscript. MT performed the histological diagnosis. AM coordinated the study and critically revised the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We report a case of recurrent primary intraventricular synovial sarcoma of the brain with no extracranial primary, initially reported as a haemangiopericytoma. We believe this is the first reported case of primary intraventricular synovial sarcoma at this site.SS18 gene rearrangement consistent with synovial sarcoma. Retrospective fluorescent in-situ hybridisation analysis of original histology also revealed a SS18 gene rearrangement consistent with a diagnosis of synovial sarcoma.A 27-year-old male presented to hospital with a new onset of seizures. Imaging revealed a left ventricular trigone mass with surrounding oedema. He underwent a left occipito-temporal craniotomy and resection with the histology reported as haemangiopericytoma. Resection was followed by adjuvant radiation treatment. Seven years later follow-up imaging revealed a 4 mm contrast enhancing lesion in the previous surgical bed. The patient underwent resection. Histological analysis of the recurrence revealed a spindle cell tumour with a Synovial sarcoma should be included as part of the differential diagnosis for patients presenting with intraventricular spindle cell tumours in the brain. Synovial sarcoma (SS) is a soft tissue sarcoma that mainly occurs as a deep soft tissue tumor of the extremities. The incidence peaks in the fourth decade with a median age at diagnosis of 35, and has a slight male predominance . It freqA 27-year-old male presented to hospital in 2013 with a new onset of seizures. Magnetic Resonance Imaging (MRI) demonstrated a 3 cm mass within the left ventricular trigone with surrounding oedema  gene rearrangement was performed using an 18q11.2 SS18 (SYT) break-apart probe. This confirmed the presence of an SS18 gene rearrangement consistent with synovial sarcoma  retreatment to brain, 54 Gy in 30 fractions  gene from chromosome 18 to one of three homologous genes, SSX1, SSX2, and SSX4 on the X chromosome. The resulting fusion oncogene is thought to disrupt epigenetic control and mesenchymal differentiation through the SWI/SNF chromatin remodelling complex [Synovial sarcoma initially derived its name from a histologic resemblance to synovial cells . There a complex . The exa complex  or stem  complex .NAB2-STAT6 fusions were identified as an almost pathognomonic finding in solitary fibrous tumour/haemangiopericytoma [Synovial sarcoma is associated with local recurrence and distant metastases. Metastases can occur in 50–70% of cases, with most metastases developing in the lung (80%) followed by bone 10%) and liver (5%) % and liv. Intracrricytoma , 16. Nucricytoma  and was ricytoma , 19. Perricytoma . Prognosricytoma , 22. GivThis case report is significant for two reasons. Firstly, we believe this is the first reported case of primary intraventricular synovial sarcoma in the brain. Secondly, it highlights the need for extensive work up, including molecular testing where appropriate, of spindle cell tumours in the central nervous system. Synovial sarcoma represents a rare diagnostic pitfall that can mimic both hemangiopericytoma and meningioma – particularly when occurring at an unusual site. This is compounded by some overlap in the immunohistochemical profile of these tumours. In light of the ongoing significant advances in the molecular classification of all tumours, but CNS tumours in particular, patients with spindle cells tumours in the cranial cavity who present with recurrent disease should be reassessed with the full spectrum of immunohistochemical analysis and genetic testing necessary to ensure an up-to-date diagnosis.


We present a case of a bronchogenic cyst in the retrorectal space that was successfully treated with a unique sacrococcygeal surgical approach, thus avoiding abdominal access. This report aims to enhance the literature with our technique and to help the scientific community in treating future retrorectal bronchogenic cyst cases. A 19-year-old man presented to the hospital with testicular pain refractory to over-the-counter analgesics. A cyst lesion in the presacral region was found during pelvic magnetic resonance imaging. We identified the cyst’s epithelium as the respiratory type, containing ciliated pseudostratified columnar epithelium with foci of squamous metaplasia. The bronchogenic cyst is abnormal from the primitive foregut, and its location on the retrorectal site is rare. Patients with this type of lesion are usually asymptomatic, and discovery is commonly incidental during imaging exams. Excision is advised, and the prognosis is good after retroperitoneal bronchogenic cyst removal. Our description of the topic is essential to assist future similar cases. A bronchogenic cyst is a congenital abnormal formation from the primitive foregut . During Before the fusion of pleuroperitoneal membranes, a part of the tracheobronchial tree can be separated entirely and migrate, giving rise to a retroperitoneal bronchogenic cyst . HoweverOverall, the presence of tumors in the retrorectal space is rare . Most ofThe current study presents the case of a bronchogenic cyst in the retrorectal space of a 19-year-old man, which was successfully resected by a sacrococcygeal surgical approach.A 19-year-old man presented to the hospital with testicular pain refractory to over-the-counter analgesics. The patient denied any past medical condition or any congenital affections. The patient denied previous imaging investigation or surgical intervention of the abdomen or pelvis. The physical exam including digital rectal examination, genital and testicular evaluation, and abdominal palpation did not show any important findings that would lead to a diagnosis. The family medical history investigation was not indicative of any rare syndrome or specific neoplasia. Due to the chronic character of pain and a very slow progression of symptoms, we discarded the following conditions from the differential diagnosis: testicular torsion, epididymo-orchitis, or orchitis. The genital physical exam was not indicative of a testicular tumor. Urinalysis and complete blood count were also normal. The patient was admitted to the surgical ward for further workup. Pelvic magnetic resonance imaging (MRI) revealed an incidental finding of a homogenous retrorectal cyst measuring 5x4x4 cm in front of the sacrum without any signs of invasion into the surrounding structures (Figure The neurosurgical and proctology team recommended surgical resection. After written informed consent was obtained from the patient, an open surgical excision was performed with an intergluteal cleft incision. After coccygectomy, we found the cystic lesion adhered to the deep planes and close to the colon with dense intracystic content Figure . FollowiFrom the surgical piece Figure , histopaAfter three weeks, the patient remained asymptomatic and an MRI was performed, which confirmed no cyst recurrence. Follow-up visits continue every eight months to evaluate reoccurrence and symptomatology, which have both been negative to date.Patients with bronchogenic cysts are usually asymptomatic  but can Commonly, the use of radiological modality facilitates preoperative differential diagnosis . AbdominMost bronchogenic cysts are lined at least partially by ciliated cuboidal to the pseudostratified columnar epithelium and are usually filled with mucus . BesidesDespite its benign nature, surgery is the treatment for bronchogenic cysts . Early cAfter resectioning the retroperitoneal bronchogenic cyst, the prognosis is favorable, and there have been no documented recurrences . Even thOur case stands out because of the singularity of the lesion, a retrorectal bronchogenic cyst. Until this moment there is not any data about the exact incidence or prevalence of sacral location of bronchogenic cyst, demonstrating its rarity. However, two similar cases can be found in the previous literature, confirming the uniqueness of the present case. Ko et al. reported a similar sacral location of a congenital bronchogenic cyst, but due to its intraspinal site, the lesion also had subarachnoid space invasion . PasquerOur study reports a case of a rare presentation of a retrorectal bronchogenic cyst, which we removed by a sacrococcygeal surgical approach to avoid abdominal access and a more invasive procedure. The uniqueness of this case is because of the particular clinical presentation of a bronchogenic cyst; therefore, the description of the topic is necessary to enhance the literature with our technique and to help the scientific community in future similar cases.


Anastomotic aortic false aneurysm with consequent erosion of vertebral bodies is a very rare event that needs prompt treatment. We report the case of a 71-year-old man with an aortobifemoral graft that was complicated by an uninfected proximal anastomotic pseudoaneurysm with double focal vertebral body erosion. A 77-year-old male patient underwent open repair with an aortobifemoral graft for abdominal aortic aneurysm (AAA). Five years later on imaging follow-up, abdominal contrast medium-enhanced multidetector computed tomography MDCT; with axAfter multidisciplinary agreement, the patient underwent endovascular endoprosthesis deployment at the level of the proximal anastomosis. Due to the asymptomatic status of the focal vertebral erosion lesions, and in the absence of signs of osteoporosis, the patient did not need to undergo any additional vertebral procedures.The postoperative course was uneventful, with continuous negative blood culture results. MDCT follow-up exams demonstrated exclusion and reduction in size of the anastomotic pseudoaneurysm, with stability of vertebral lytic lesions.Anastomotic false aneurysm is a rare but possible clinical and anatomical complication after AAA open repair.In suspicion or confirmation of anastomotic pseudoaneurysm of infectious nature, a surgical revision is the indicated procedure. On the contrary, an endovascular treatment becomes a first-line procedure in noninfected cases.In conclusion, in our case we decided to perform an endovascular treatment given the noninfectious nature of the aortic anastomotic pseudoaneurysm with the aim of excluding the pseudoaneurysm sac, with goals of endo-sac pressure reduction, decreased sac volume, and finally prevention of progression in vertebral body erosion.


IntroductionCentral nervous system (CNS) lesions are rare and histologically heterogenous, and carry serious potential for patient morbidity and mortality. A retrospective epidemiological review of CNS neoplasms is of great importance for future research because it can demonstrate the changes in the spectrum of CNS lesions of a population, unveil the possible associated risk factors, and indicate the potential therapeutic methods for various neoplastic and non-neoplastic lesions. Neurosurgeons have always shown an obsession with a good neuropathological diagnosis in intracranial and extracranial lesions. This obsession need not be overemphasized as it helps the clinician plan an adequate surgical/treatment strategy to optimize outcomes and minimize morbidity.MethodsThis study included a spectrum of 160 biopsies of patients with space-occupying lesions of the CNS during a period of two years (2019-2021). All the cases were studied and analyzed, and their histological typing/grading was done. The cases were graded and categorized according to the 2016 WHO Classification of CNS Tumors.ResultsAmong 160 cases, the study showed a slight male preponderance of 100 (62.5%) cases. The maximum number of cases, 37 (23%) cases, was in the age group of 41-50 years. Clinically, the commonest complaints were headache and seizures. The most common location of tumor was supra-tentorial, comprising around 96 (60%) cases, of which 27 (28%) cases were located in the frontal lobe. There were four (2.5%) cases that had non-neoplastic lesions and the rest 156 (97.5%) cases had neoplastic lesions. Malignant lesions outnumbered the benign lesions, comprising of 82 (51.25%) cases. Among the neoplastic lesions, the highest cases were of astrocytoma, 48 (30.76%) cases, followed by meningioma, 42 (26.92%) cases. Also, 21 extremely rare and unusual cases were encountered.ConclusionThe present study reflects the diversity of histopathological spectrum of CNS lesions in our center. In-depth studies from across various hospitals are required to have representative data on the incidence, epidemiological profile, and etiology of CNS lesions in India. Central nervous system space-occupying lesions (CNS SOLs) are defined as any lesion in the cranium with varied etiology such as infectious, neoplastic, vascular malformation, or inflammatory. CNS SOLs are exceptionally heterogenous histologically and are mightily fatal, thus accounting for substantial morbidity and mortality worldwide. Malignant and non-malignant CNS tumors contain a diverse constellation of more than 100 histological subtypes with distinct epidemiology, clinical features, treatments, and outcomes . The annTherefore, tertiary hospital based studies for various parameters, most importantly various histological subtyping, solve this riddle and create a pathway for timely and prompt neurosurgical intervention ,4.This article provides an overview of non-malignant lesions, neoplastic lesions, benign and malignant CNS tumor incidence, different histological subtypes, anatomic site, sex, and varying clinical features, along with 21 unexampled lesions that are sparsely encountered and documented.This study included a spectrum of 160 biopsies of patients with SOLs of CNS admitted to the Department of Neurosurgery during a period of two years (2019-2021). The sample size included all 160 biopsies (N=160). All surgical sample of suspected CNS neoplasm operated in the Department of Neurosurgery were received in the Department of Pathology. The tissue was fixed with 10% formalin and processed in graded alcohol and xylene, and then paraffin blocking and cutting was performed according to standard guideline and stained with routine H&E stain. The cases were diagnosed, graded, and subtyped with immunohistochemistry (IHC) wherever needed as well. The inclusion criteria contained cases of CNS SOLs of all age groups from the brain and spinal cord. All the cases were studied and analyzed, and their histological typing/grading was done. The cases were graded and categorized according to the 2016 WHO Classification of CNS Tumors.The department received a total of 160 cases of SOLs of the brain and spinal cord. It showed a slight male preponderance 100 (62.5%) cases in the group  cases, was seen in the age group of 41-50 years, followed by 51-60 years and 31-40 years age group, comprising of 31 (19%) cases and 28 (17.5%) cases, respectively  cases, among which 27 (28%) cases were located in the frontal lobe and 14 (15%) in the temporoparietal lobe  cases of non-neoplastic lesions, comprising of epidermoid cyst, granulomatous lesion, and lipomeningomyelocele. The rest 156 cases were of neoplastic lesions. Malignant lesions outnumbered the benign lesions, comprising of 82 (51.25%) cases. The malignant lesions constituted 74 (46.25%) cases  cases, followed by meningioma, 42 (26.92%) cases. Also included were cases of metastatic deposits, schwannoma, choroid plexus papilloma, medulloblastoma, adenoid cystic carcinoma of orbit, ependymoma, embryonal tumor nos metastasis, pituitary adenoma, and craniopharyngioma  of D4-D5, subependymal giant cell astrocytoma (SEGA), adenoid cystic carcinoma of orbit, ganglioglioma, anaplastic oligodendroglioma, gangliocytoma with pituitary adenoma, psammomatous meningioma at the level of thoracic vertebrae, meningioma with rhabdoid differentiation, gliosarcoma, anaplastic meningioma, metastatic squamous cell carcinoma, IDH-mutated anaplastic astrocytoma with clear cell morphology, cavernous angioma, embryonal tumor not otherwise specified (NOS), mucin-secreting metastatic carcinoma, embryonal CNS tumor NOS, and few other rare entities were also diagnosed Table .A vertebral lesion put us in a diagnostic dilemma for multiple pathologies, where the 68-year-old male presented to us without lymphadenopathy, with D7-D8 extradural lytic lesion and epidural mass causing cord compression, with raised serum protein levels on serum electrophoresis. The patient was confused as a case of multiple myeloma, which was later on diagnosed as extranodal intradural Rosai-Dorfman disease.A 45-year-old female patient presented with pain in the thoracic region, bilateral lower limb weakness, and bladder and bowel dysfunction. MRI of the thoracic spine revealed an L2-L4 extradural SOL. An L2-L4 Laminectomy and transversectomy were performed. Histopathology examination confirmed the diagnosis of PNET.A 40-year-old female who presented with progressive bilateral lower limb weakness, urinary incontinence for two months, and inability to walk for 15 days was identified histologically as a case of psammomatous meningioma.We also received a biopsy from a 36-year-old male who presented with chronic headache and two episodes of seizures who was further labelled as a rare case of atypical meningioma with rhabdoid differentiation.A 23-year-old male who was misdiagnosed as a case of anaplastic astrocytoma on intraoperative cytodiagnosis during frozen section was diagnosed as a case of ganglioglioma on final histopathology report and IHC study.Another 51-year-old female who presented with unilateral facial palsy, a previously operated case of oligodendroglioma who also received four cycles of chemotherapy and radiotherapy four years prior to presentation, was identified as a case of anaplastic oligodendroglioma on histopathology.An 18-year-old male presented to the Neurosurgery Outpatient Department with a history of seizures for three years. The patient underwent plain axial computed tomography (CT) scan, which revealed cortex-based lesion in the parafalcine right anterior frontal region suspecting a neoplastic etiology. A histopathology diagnosis of cavernous angioma mixed or hybrid type was made.An eight-year-old female with a known medical history of tuberous sclerosis presented with recurrent headaches. Radiological workup revealed a homogenously enhancing mass in the left lateral ventricle with eccentric calcification and obstructive hydrocephalus. Final histopathology report concluded with a final diagnosis of SEGA.A 36-year-old female patient presented with headache and unilateral weakness for a month. MRI of the brain revealed a dural-based extra axial solid T2 hypo-intense lesion in the right frontoparietal region, and a diagnosis of meningioma was made. Yet, histopathology and raised angiotensin-converting enzyme (ACE) levels confirmed a diagnosis of sarcoidosis.A 48-year-old male presented with chronic headache and episodes of generalized tonic-clonic seizures for four months. Radiologic investigation revealed a complex left parieto-occipital heterogeneous mass lesion with cystic and solid components. Histopathology and IHC confirmed gliosarcoma.A two-year-old female presented with generalized tonic-clonic seizures for three days. Radiological examination revealed high-grade cerebellar lesion. Final diagnosis with histopathology and IHC confirmed a CNS embryonal tumor NOS.A retrospective epidemiological review of CNS SOLs is of utmost importance as it can demonstrate the changes in the spectrum of these lesions in a population, reveal the varied topography and possible associated risk factors, and also suggest a potential therapy method for these lesions.In the current study, attempts were made to document the spectrum of CNS tumor according to the 2016 WHO Classification of CNS Tumors. Out of the 160 CNS lesions, neoplastic outnumbered the non-neoplastic lesions. Other studies in India conducted by Khonglah et al. and Naik et al. showed 86.13% versus 13.87% and 91% versus 9% distribution of lesions of neoplastic versus non-neoplastic pathology, respectively ,6.Only four lesions were non-neoplastic, comprising of epidermoid cyst, granulomatous lesion, and lipomeningomyelocele. The rest 156 cases were neoplastic lesions. Among the neoplastic lesions, malignant lesions dominated the count. The highest number of cases was of astrocytoma followed by meningioma.The age range considered was from the first year of life to 70 years. The most frequently involved age group was found to be that of 41-50 years, showing an incidence of 37 cases. The male‑to‑female ratio was 1.6:1. Studies conducted by Khonglah et al, Naik et al., and Hamdani et al. showed a ratio of 1.1:1, 2:1, and 1.2:0.8, respectively .,14.13,14Rhabdoid meningioma is a rare aggressive variant of meningioma and regarded as WHO grade III type. Histologically, it has abundant eosinophilic cytoplasm, cytoplasmic inclusion with eccentrically placed vesicular nuclei, and prominent nucleoli Figure . It has Gangliogliomas are rare tumors of the CNS. They can occur anywhere in the CNS but are usually found in the temporal lobe of children . On histAnaplastic oligodendrogliomas usually develop secondarily via progression from a low-grade oligodendroglioma. The histological features are cellular, mitotically active, and diffusely infiltrating gliomas composed of neoplastic cells showing morphological features indicative of oligodendroglia cells, i.e., the classical fried egg appearance or perinuclear halo/clearing seen on histopathology as a fixation artifact ,18.Cerebrovascular malformations are non-neoplastic lesions resulting from focal anomalies in the development of cerebrospinal circulation. Many surveys suggest that cavernous angiomas are present in 0.5% population. They tend to be asymptomatic, but in 40% cases they can be symptomatic. Cavernous angiomas of hybrid variant are uncommon and remain exceptional. They can be either familial or sporadic ,20. In oHistopathological examination of an intraventricular lesion revealed large polygonal to elongate cells resembling astrocytes or ganglion cells with abundant, finely granular eosinophilic cytoplasm, bright pink cellular processes, large round/oval nuclei, and prominent nucleoli . NecrosiSarcoidosis is an inflammatory granulomatous multisystem disease with an unknown etiology. Neurosarcoidosis is an extremely rare cryptogenic neuroinflammatory manifestation of sarcoidosis . HistopaGliosarcoma is an unusual subtype of glioblastoma characterized by biphasic cell population, constituting a definite, separate glial and sarcomatous differentiation on histology . HistopaCNS embryonal tumor NEC (not elsewhere classified) or NOS are assigned to those lesions in WHO Classification of CNS Tumors that lack a specific morphological and molecular alteration. They are poorly differentiated neoplasm with round-to-oval nuclei, high nuclear-to-cytoplasmic ratio, and frequent mitoses. Thus, an integrated, categorical layered diagnostic report is helpful for transparent and effective communication of relevant tumor characteristics. Histopathology of SOL in our patient showed normal neuroglial tissue with fragments of highly cellular tumor. The tumor comprised of diffusely lying cells with large round hyperchromatic nuclei and scant cytoplasm. Extensive tumor necrosis was also observed. There was no rosette formation observed. IHC revealed synaptophysin positivity in thin rim of cytoplasm and high Ki67 index of 70% Figure . Thus, aCNS neoplasms have been currently classified and graded on the basis of molecular cytogenetics in WHO CNS Neoplasms 2021, along with histology and IHCs . NeurosuConclusions are evident with evidence provided and summarizes that CNS lesions are heterogeneous, comprising a large spectrum of different tumors, inflammatory lesions, and infections and that these entities have further distinct biological background and disease course. Histopathological study helps in knowing their epidemiology and burden of disease in the community. Likewise, we observed a male predominance, with those in the age group of 41-50 years with maximum incidence, and highest tumor burden in astrocytoma followed by meningiomas. From a practical point of view, an accurate diagnosis of brain tumor is possible after careful assessment of histomorphological features along with clinical and radiological imaging findings. Though established histopathological examination is the mainstay or gold standard for diagnosis, IHC also has also played a major role in subcategorizing the exact diagnosis and improvising the field of neuropathology. The present study thus reflects the diversity of histopathological spectrum of CNS lesions from our center. In-depth studies from across various hospitals are required to have representative data on the incidence of CNS lesions in our country. These could then be used to provide the baseline data to better understand the epidemiological profile and etiology of primary brain tumors so that prompt neurosurgical intervention could benefit the patients in the long run.