Introduction: Extracorporeal wave lithotripsy (ESWL) is considered a first-line treatment for renal and ureteral stones up to 10–20 mm in diameter. Complications are uncommon, with a reported rate of 0–6% in the literature. Bowel perforation has only been described in a few case reports but requires rapid diagnosis and treatment. Methods: A review of the literature from PubMed/Medline, Embase, Cochrane, and Web of Science databases was performed including studies reporting bowel perforation secondary to ESWL between January 1990 and June 2022. Results: We found 16 case reports of intestinal perforation in the literature. Although some patients had previously undergone abdominal surgery or had inflammatory intestinal disease, others were without comorbidities that could lead to complications. Abdominal pain was the main symptom and imaging was required to confirm the diagnosis, which usually necessitated a surgical intervention. As regards the ESWL technique, it appears that the combination of a high energy level and the prone position constitutes a risk factor for these rare complications. At the authors’ centre, only one case has been reported among 24,000 ESWL procedures over 20 years: A 59-year-old female who underwent ESWL for a distal right ureteral stone presented acute abdominal pain and free intraperitoneal pelvic fluid on ultrasound. A CT scan revealed a small bowel perforation requiring open laparotomy with primary closure. Conclusions: In conclusion, although bowel perforation after ESWL is rare, progressive abdominal pain with tenderness at physical examination requires proper imaging evaluation to exclude bowel perforation and prompt intervention if required. Since its introduction in the 1980s . In the Complications are infrequent, occurring in 0–6% of patients according to the literature . The vasA review of the literature was performed from PubMed, Medline, Embase, Cochrane and Web of Science databases including studies published between January 1990 and June 2022. Two reviewers (A.F. and S.F) conducted the research in the databases previously mentioned. The search was performed by using the combination of the words “ESWL” and “bowel” or “intestinal” and “perforation” or “complications” and “urinary” or “urologic” and “stones”. Those keywords led to 16 results in which ESWL for urologic stones were complicated by colonic or small bowel perforation.A data analysis was performed to evaluate risk factors and preventive measures.A total of 16 cases have been reported in the literature since 1997 ,25,26,27Twelve patients were male, three were female, and one was of unknown gender. Patient age ranged from 29 to 78 years.The interval between the ESWL procedure and the onset of symptoms varied between a few hours and 2 days. All patients presented at the emergency department with a main complaint of acute abdominal pain with tenderness at physical examination. Moreover, fever was present in one-third (5/15) of the cases.During the 1990s, a KUB X-ray was performed for diagnostic imaging, whereas since then CT scan has been the main diagnostic tool. A surgical approach with bowel repair was needed in 15 cases due to the high morbidity of intestinal perforation or hemodynamic instability. The remaining case was managed conservatively without further complications; this treatment strategy was chosen because the patient was hemodynamically stable without signs of peritonitis.The location of the perforation varied according to the ESWL treatment area. In six of the sixteen cases ,18,20,22Perilesional findings during surgical exploration ,20,23 inRegarding the stone location prior to ESWL, there was only one renal stone , with urThe prone position was used in 11 cases, a combination of prone and supine in one, and supine in two ,16; in tAt the authors’ institution, just one case of bowel perforation has been reported after 24,000 ESWL procedures performed over 20 years; this patient needed open surgery and primary closure of the wound, as further discussed below.The incidence of bowel perforation after ESWL is unknown. Our literature review revealed reports of only 16 cases, although cases of gastrointestinal damage other than perforations have been described in single case series. These other complications have included gastric or duodenal erosions, ureterocolic fistula, gastrojejunal anastomotic dehiscence, small bowel obstruction and strangulation, cecal ulcers, sigmoid colon hematoma, peripancreatic hematoma, peripancreatic abscess, pancreatitis, and rectal bleeding ,28,29.Interestingly, most cases of intestinal perforation after ESWL are seen in males, and patient age varies greatly. The predominance of male cases can perhaps be ascribed to the higher incidence of urolithiasis in the male population. Although some of the patients that we identified had a medical history of abdominal surgeries or intestinal inflammatory disease, most had no relevant past medical history or risk factors. Nonetheless, patient selection should be made carefully, or complications are likely to occur in these cases.In this review, in the vast majority of cases 13/16) only one ESWL session was performed before intestinal perforation occurred. However, in one case it was reported that the stone was initially in the renal pelvis, where the first ESWL session was conducted . Additio/16 only Finally, there was one case  where obTherefore, a surgical approach with bowel repair was required in all cases except one patient . There wESWL treatment can affect either the small bowel or the colon, depending on the stone location. In our review, the mean stone diameter was 8.2 mm, and in only one case did the stone diameter exceed 10 mm. As regards the ESWL technique, it appears that the combination of a high energy level and the prone position constitutes a risk factor for these rare complications.The single case of bowel perforation after ESWL at the authors’ institution, where 24,000 ESWL procedures have been performed over the past 20 years, was in a 59-year-old female with a past medical history of dyslipidemia, chronic bronchitis, and a C-section. Initially, in the context of colic lumbar pain, she had been diagnosed as having a 17 mm right distal ureteral stone at her referring hospital. As the patient presented with moderate hydronephrosis, a right nephrostomy tube was placed, and she was referred to our centre for definitive treatment of the stone. Three weeks later, under sedation, she underwent a first ESWL session, resulting in partial fragmentation. The patient was placed in the supine position on a Lithoskop lithotripter , which delivered 4500 shocks to the stone with a total energy of 175 joules.9/L leukocytosis with neutrophilia (82%). She did not present fever, but abdominal pain was worsening despite analgesia. An abdominal ultrasound revealed a small amount of free intraperitoneal fluid. A CT scan with contrast was performed, resulting in the diagnosis of a small bowel perforation at the level of the terminal ileum with free abdominal fluid and a small amount of pneumoperitoneum.Four hours after the procedure, the patient returned to the emergency department due to discomfort and intense right abdominal pain. Physical examination revealed painful palpation and localized tenderness at the flank and right iliac fossa. A blood test showed 15,000 × 10The general surgery department evaluated the case and suggested exploratory laparoscopy, which revealed diffuse purulent peritonitis with possible perforation in the mesenteric margin of the terminal ileum as well as a hematoma in the mesojejunum and two lesions in terminal ileum serosa close to the main lesion. As the lesions could not be clearly assessed, the decision was taken to perform a mini-laparotomy, which confirmed the perforation identified by laparoscopy. Simple closure was performed without intestinal resection.During the postoperative follow-up, the patient remained hemodynamically stable and afebrile, progressively tolerating an oral diet. She was discharged from the hospital 5 days after the intervention. Follow-up at the first month was unremarkable. Two months later, a right ureteroscopy with laser dusting of the stone and double J stent placement was performed without abnormal intraoperative findings. During endoscopy, no alterations of the ureteral wall were found. Three weeks later, the double J stent was removed, and the patient has since been stone free with no complications.Risk factors for bowel perforation due to ESWL reported in the literature are previous abdominal surgery, prone position, placement of the ureter too close to the intestine, and the use of high energy levels .Prompt diagnosis of a bowel perforation is crucial to avoid further complications. Initial physical examination to assess abdominal acute pain and tenderness should be complemented with a general blood test and the performance of a CT scan. Once the diagnosis has been established, surgery seems to be an effective treatment, with good patient recovery. Stone treatment can be offered at the same time with ureterotomy and stone removal, but in most cases, treatment is deferred.Although bowel perforation is rare, and renal colic is the main complication after ESWL, patients with acute abdominal pain few hours after the procedure should undergo a proper physical exploration to search for peritoneal irritation. Furthermore, it usually requires accurate imaging evaluation. Imaging may enable the physician to rule out an intestinal complication or to initiate prompt intervention if required, bearing in mind the high morbidity of the condition. The combination of a high energy level and the prone position seems to constitute a risk factor for this rare complication.


Retrograde intussusception (RI) is a rare long-term complication of gastric bypass surgery, which usually happens within the first few years after operation. The clinical presentation is vague with overlapping symptoms of bowel obstruction or ischemia. This is a case of a 37-year-old lady who presented with severe abdominal pain. She has background of Roux-en-Y gastric bypass surgery 23 years ago. She underwent emergency laparotomy, bowel resection and Roux-en-Y reconstruction due to finding of ischemic bowel segment. Unfortunately, she had recurrent presentation of RI after 6 months and similar operation was necessitated. She recovered well post-operatively, but there was no definitive cause established for the recurrence. While RI remains a rare diagnosis, clinicians should have high index of suspicion in encountering patients with acute abdomen post gastric bypass surgery. Early imaging is required for the diagnosis and surgical intervention is often warranted. Intussusception is a common condition in paediatrics age group. While adult intussusception is rare, it is often pathological due to the presence of lead points such as polyps, Meckel’s diverticulum and neoplasms . In mostA 37-year-old lady presented with 1-day history of sudden onset of severe generalized abdominal pain that was associated with multiple episodes of vomiting. She had occasional similar episodes before, but those were usually milder and were self-resolved. Her past surgical history includes RGYBP surgery 23 years ago and six caesarean sections. She had lost 11 stones of weight in 1 year after the gastric bypass surgery. On physical examination, her abdomen was distended and diffusely tender. Her blood investigation showed low Hb (85 g/dl), raised C-reactive protein (146) and normal white cell count. She had computed tomography (CT) scan  which coIntraoperatively, RI was found at jejuno-jejunal anastomosis involving a long segment of intussusceptum loop going through the jejuno-jejunostomy , resultiNevertheless, the patient re-presented 4 months later with similar symptoms. She reported having no issue with bowel after the previous operation. On presentation, her blood results were unremarkable with normal inflammatory markers and lactate. Repeated CT  again reRI is an uncommon complication of bariatric surgery with a prevalence of 0.07–0.6% . Most caet al. has proposed the theory of motility disorder of Roux limbs [Multiple hypotheses have been postulated regarding the pathophysiology behind RI. Hocking ux limbs . The theux limbs . On top ux limbs . With thux limbs , it is cCT scan is the preferred imaging modality for early identification of intussusception . CharactTo date, there is no definitive treatment recommended for adult intussusception due to the rarity of cases . GeneralRI, although rare, is an important diagnosis to be aware of when encountering patients with acute abdomen with history of gastric bypass surgery. There should be a low threshold for performing CT scan early in such patients as prompt diagnosis is imperative to prevent developing bowel ischaemia. Further management will be guided by the patient’s general condition and any doubt of bowel viability. Patients should be alerted about the possibility of recurrence and should seek early consultation in the presence of symptoms.The authors declare that there are no competing interests.


Here we describe a 72-year old Caucasian woman who presented with progressive left hemiparesis and hemisensory deficits due to a pathology-confirmed tumefactive demyelinating lesion in the right frontoparietal region. Symptoms improved with glucocorticoids and plasmapheresis, but five months following initial presentation, the patient developed right visual field deficits and acute encephalopathy. Brain imaging revealed near resolution of the initial lesion with interval development of new multifocal tumefactive demyelinating lesions. This case highlights several atypical features associated with tumefactive demyelinating disease, including an older age of onset and recurrent, treatment-resistant lesions. Clinical and neuroimaging features which may be helpful in diagnosing this rare disorder are reviewed. Tumefactive demyelinating lesions (TDL) are described as large (>2 cm in diameter), tumor-like demyelinating lesions in the central nervous system (CNS). TDL represent a rare subtype of CNS inflammatory demyelinating disorders, though multiple sclerosis (MS) accounts for the majority of cases A 72-year-old right-handed Caucasian woman presented with a 5-week history of progressive left-sided weakness and numbness. Symptoms started approximately 1 week after receiving a second dose of mRNA COVID-19 vaccine (Moderna). Past medical history included obesity, hypertension, hyperlipidemia, nonalcoholic steatohepatitis and erythema nodosum. Neurologic examination revealed mild dysarthria, left facial weakness and moderate left-sided hemiparesis with hemisensory loss. Brain magnetic resonance imaging (MRI) demonstrated a large, right frontoparietal mass with partial ring-enhancement and mild local mass effect .Fig. 1InSerological studies for infectious causes  and autoimmune etiologies (including aquaporin-4 and myelin oligodendrocyte glycoprotein “MOG” antibodies) were unremarkable. Spinal fluid analysis revealed normal opening pressure, cell count, cytology, infectious studies, IgG Index, and no oligoclonal bands. Histopathology of the lesion biopsy demonstrated areas of reactive gliosis with dense infiltration of foamy, CD-68 positive macrophages (Luxol fast blue-periodic acid Schiff immunostain positive) predominately involving the white matter with relative preservation of axons identified with neurofilament immunostain. Findings were overall consistent with a non-neoplastic, demyelinating process.Following biopsy, a 7-day course of intravenous methylprednisolone was initiated followed by oral prednisone taper. The patient also received 5 sessions of plasmapheresis. She underwent 6 weeks of inpatient rehabilitation resulting in modest improvement of left hemiparesis; estimated Expanded Disability Status Scale (EDSS) was 6. Multiple sclerosis disease-modifying therapy was considered, but unfortunately the patient developed progressive confusion and right visual field deficits prior to starting any disease-modifying therapy, approximately 5 months from initial hospitalization. Repeat MRI showed decreased size of the right frontoparietal lesion with interval development of three new, partial rim-enhancing lesions involving the right frontal centrum semiovale, right occipital lobe and left anterior temporal lobe . Spinal Despite treatment with high-dose intravenous methylprednisolone and plasmapheresis, the patient continued to decline and ultimately required mechanical ventilation for somnolence and respiratory distress. Continuous EEG monitoring over 4 days demonstrated fewright frontotemporal epileptiform discharges, but no definitive seizures were captured. A repeat MRI brain demonstrated expansion of the multifocal lesions . DespiteTDL often present a diagnostic dilemma and may be mistaken for other space-occupying lesions. Patients with TDL commonly have no prior history of demyelinating disease making diagnosis even more challenging The underlying immunopathogenesis of this rare disorder remains unclear. These lesions may be seen in association with a spectrum of other neuroinflammatory disorders such as acute disseminated encephalomyelitis (ADEM), neuromyelitis optica, MOG antibody disease, or tumefactive variant of MS Although there is not a pathognomonic radiographic appearance of TDL, certain neuroimaging features may suggest tumefactive demyelination over radiologically similar lesions. TDL are classically 2 to 6 cm in size, and multiple lesions can occur simultaneously Contrast enhancement is mostly present, though patterns vary. An incomplete ring enhancement with an open rim facing the cortical  or ventricular  surfaces may be observed , arrows.Advanced MRI sequences can be of additional value. Blood-sensitive MRI sequences may demonstrate presence of a central vein within an inflammatory demyelinating lesion D and E Recurrence of TDL, as in the present case, is unusual. The majority (70%) of patients with TDL have future demyelinating episodes classic for relapsing-remitting MS after a median of 4.8 years Rarely, immunocompetent patients with PCNSL may present initially with TDL, the so-called ‘sentinel demyelinating lesion’ This case highlights several clinical complexities associated with tumefactive demyelination. Though uncommon, elderly patients can develop TDL. Helpful neuroimaging clues for the diagnosis of TDL include incomplete ring enhancement and disproportionately mild surrounding vasogenic edema and mass effect relative to the lesion size. Despite aggressive management, a subset of patients with TDL may experience relapses or a fulminant course.All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.All authors contributed to the study conception and design. Data collection, drafting of manuscript and figure preparation were performed by ELW. Interpretation of data and critical revisions of the manuscript were performed by MON. All authors have approved the final manuscript.Written informed consent for publication was obtained from the patient's husband.


Multiple endocrine neoplasia (MEN) is divided into MEN type 1 (MEN-1) and MEN type 2 (MEN-2). MEN-1 may be associated with thymic carcinoid tumors. We present a case of the surgical removal of a thymic carcinoid associated with MEN-1 via a single-incision port RATS.A 39-year-old male patient with multiple endocrine neoplasia type 1 (MEN-1) who had an anterior mediastinal mass was referred to our hospital. The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago. Chest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland with a maximum diameter measuring 22 mm. Thymic carcinoid tumor is classified as MEN-1 and has a poor prognosis, so we decided to remove the tumor. Single-incision port RATS was performed, and thymic carcinoid was confirmed in pathology.This report demonstrates that thymic carcinoid tumor removal is feasible and easy to perform via single-incision port RATS. Multiple endocrine neoplasia (MEN) is divided into MEN type 1 (MEN-1) and MEN type 2 (MEN-2). MEN-1 may be associated with thymic carcinoid tumors . Since 2A 39-year-old male patient with MEN-1 who had an anterior mediastinal mass was referred to our hospital. The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago. His vital signs showed no abnormalities. He had a temperature of 37.2 °C, blood pressure of 117/72 mmHg, heart rate of 100 bpm, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% in room air. Laboratory data revealed a serum antiacetylcholine receptor binding antibody level below 0.2 nmol/L , serum cancer antigen level 5 U/mL , serum α-fetoprotein level 3 ng/mL , serum human chorionic gonadotropin β subunit level below 0.5 mIU/mL , and serum soluble interleukin-2 receptor level 292 U/mL .2) was insufflated at a set pressure of 5 mmHg. Depending on the situation, the robotic instruments on the left and right arms were replaced and da Vinci® Vessel Sealer Extend  instruments were also used. Part of the thymic and pericardial fat including the tumor was dissected from the inferior side, and complete dissection was performed from the cranial side, resulting in the removal of the tumor. To prevent robotic arm collisions, the left and right forceps were moved vertically with the endoscope in between (Fig. Chest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland with a maximum diameter measuring 22 mm and without invasion into the surrounding tissues Fig. . Thymic een Fig. . Hematoxeen Fig. A–E. ThusThymic carcinoid tumors are usually associated with MEN-1 . Thymic RATS is gaining popularity due to the many benefits offered by robotic surgical systems. As a result, RATS procedures have seen a rapid increase in Japan. The dedicated robotic instruments of the robotic surgical system are capable of motions with 7 degrees of freedom under three-dimensional view. Even in a mediastinum packed with intertwined organs, the robotic surgery system can execute surgical maneuvers smoothly and naturally . RATS ha2 insufflation to maintain a sufficient distance from the tumor, they were unable to maintain an airtight environment. Their technique of employing cross-arm technology was useful in safely preventing collisions and achieved good clinical and excellent cosmetic results. Since the mediastinum is a tightly packed organ with a narrow space, the working space of robotic instruments needs to be expanded. Thus, CO2 insufflation is helpful in expanding the working space, and our technique makes this step easy. Subsequently, the robotic instruments were operated the same as in a normal RATS operation without using cross-arm technology.Ishikawa et al.  reportedThis case report had some important limitations: First, although some authors agree on the use of aggressive attempts similar to the approach for thymoma, in this case, a part of the thymic and pericardial fat including the tumor was resected. Second, the indication of this single-incision total port RATS may be controversial. This procedure may require extensive experience of RATS when manipulating a wide range of operative fields such as thymectomy or when removing larger tumors. Furthermore, skilled surgeons may have been able to perform the surgery via uniport VATS. Nevertheless, the procedure outlined in this report is feasible, easy to perform, and provides dexterity during the procedure. Furthermore, since a new robotic surgery system via a single port has already been reported, this procedure may be easier to perform.2 insufflation was performed, and an airtight environment was maintained by inserting ports into three different intercostal spaces through wound protectors. Our case thus provides further confirmation that robotic-assisted surgical systems can be successfully used for surgical intervention in MTs, given the complete resection, and uneventful postoperative course achieved in this case.This report demonstrates that thymic carcinoid tumor removal is feasible and easy to perform via single-incision port RATS. Since the mediastinum is a tightly packed organ with a narrow surgical field, CO


Pheochromocytomas are rare tumors located in the adrenal medulla, that derives from the chromaffin cells and produce catecholamines. They are an uncommon cause of hypertension, and only 50% of the patients present symptoms compatible with this pathology. Here we describe the case of a 70-year-old woman with a history of anxiety, hypertension and palpitation, who had an unspecified nodule in the right adrenal gland. Laboratory studies revealed an elevated urinary metanephrines secretion. A diagnosis of pheochromocytoma was made and an adrenalectomy was performed. Our aim is to highlight the diagnosis of this rare tumor and how its early management can prevent morbidity and mortality. The global prevalence of hypertension (defined as blood pressure higher than 140/90 mmHg) is high all over the world, and it is responsible for great cardiovascular morbidity and mortality. However, 3-10% is due to secondary hypertension, with a potential of cure, so it is important to consider secondary causes, if the clinic and course of the disease suggest it [6 population/year. This tumor is known for causing hypertension, however, it is an uncommon cause of hypertension, and occurs in less than 1% of hypertensive patients [Pheochromocytoma is a rare neoplasm with an incidence of 1-4/10patients . This tupatients ,3. The dA 70-year-old woman was referred by her family physician because of recurrent abdominal pain and the evidence of a suprarenal nodule with 31 mm of diameter in an abdominal CT scan (Figure Catecholamine-secreting tumors are a rare neoplasm, occurring in approximately 0.1 to 1% of hypertensive patients . PheochrThe clinical presentation varies, alternating from an adrenal incidentaloma to hypertensive crises with associated cerebrovascular or cardiac complications. Only 4% of adrenal masses incidentally found are known to be pheochromocytomas, the most common are benign adenomas . In the The diagnosis of this pathology requires both proof of excessive release of catecholamines and anatomical documentation of the tumor . Once a Surgery is the treatment of choice for these tumors, curable for more than 90% of patients. The preoperative preparation is essential to reduce the perioperative morbidity and mortality in these patients ,5. AlphaPheochromocytomas are rare neuroendocrine tumors responsible for less than 1% of hypertensive cases. Only 50% of individuals will present symptoms compatible with this tumor and, in most cases, the symptoms will be paroxysmal. Surgery is curative for pheochromocytomas but long-term surveillance is necessary.


Squamous cell carcinoma (SCC) arising in a Zenker diverticulum (ZD) is an extremely rare entity. Approximately 50 cases have been reported worldwide. We report a case of a 74-year-old man who presented to our institution with chronic regurgitation, dysphagia and halitosis. The patient was initially seen in 2015 at which point he reported a 10-year history of these symptoms and was diagnosed with ZD. A barium swallow was done revealing a large posterior esophageal diverticulum with significant residual contrast within the diverticulum lumen. Given these findings, he was taken for open surgical excision where a SCC was identified. Although it is extremely rare for a SCC to occur in a ZD, patients with ZD must undergo regular surveillance endoscopy of the esophagus and the diverticulum itself to identify any suspicious mass or lesion arising in within. Squamous cell carcinoma (SCC) arising in a Zenker diverticulum (ZD) is an extremely rare entity. Approximately 50 cases have been reported worldwide . The inc2. Physical examination and laboratory values on admission were normal. The patient never smoked and does not drink alcohol.This is a case of a 74-year-old man with a history of diabetes mellitus and hyperlipidemia, who presented to our institution with chronic regurgitation, dysphagia and halitosis. The patient was initially seen in 2015 at which point he reported a 10-year history of these symptoms and was diagnosed with ZD . He had Pre-operative computed tomography imaging demonstrated a 5.0 × 4.4 × 2.4 cm diverticulum off of the proximal posterior esophagus, consistent with a ZD. In addition, a barium swallow revealed a large posterior esophageal diverticulum with significant residual contrast within the diverticulum lumen. Given these findings, the patient was taken for open surgical excision or Zenker diverticulectomy. A large exophytic and ulcerated mass was identified within the diverticulum . The speGross examination revealed a fungating, exophytic, ulcerated, firm mass measuring 3.2 × 2.5 × 1 cm with a white cut surface involving the full thickness of the esophageal wall and grossly abutting the serosal surface. Microscopic examination showed a moderately differentiated SCC, invading the submucosa . The surIn 1679, Abraham Ludlow made the first observation of a pouch that herniated through the esophagus . Later, Risk factors for developing ZD include advanced age and male gender . The preet al. in 1904 [The first case of SCC arising in ZD was described by Halstead  in 1904 . To makeTreatment is aimed at symptomatic relieve. Surgical excision either by open surgical or endoscopic techniques is readily available. Nowadays endoscopic staples diverticulectomy is the preferred approach. Ultimately, treatment choice should be driven by the patient’s conditions including diverticula size and comorbidities; and the surgeon’s expertise and preference .In conclusion, SCC arising in ZD is a very rare entitiy. High clinical suspicion is important to rule out a malignant transformation. Larger and more complicated diverticula should be excised. Definitive diagnosis is made by microscopic examination. Once excised, after simple diverticulectomy and clear margins, patients are expected to remain disease free. If recurrence were to happen, that would require further evaluation for malignancy.


Primary pulmonary lymphoma (PPL) is a rare entity with the most common presentation as mediastinal lymphadenopathy. The most common form of PPL is Mucosa-Associated Lymphoid Tissue Lymphoma (MALToma) which is an extranodal B-cell lymphoma originating from the mucosal layers involving different organs such as the gastrointestinal tract as well as the lung. Herein, we present a case of a 51-year-old woman with progressive dyspnea for 6 months and no prior medical history. The computed tomography (CT scan) revealed bilateral multifocal consolidation and ground-glass opacities as well as interlobular septal thickening. Bronchoscopy was normal and CT-guided biopsy of lung consolidations was conclusive of MALToma. Complete extrapulmonary evaluations inducing bone marrow aspiration were unremarkable. The primary pulmonary MALToma is an extremely rare entity that presents with non-specific symptoms and a wide variety of CT findings such as mediastinal, hilar lymphadenopathy, and single or multiple lung nodules ranging from 2 to 8 cm. the disease has a favorable prognosis, so prompt diagnosis is essential. Primary pulmonary lymphoma is a very rare neoplasm that accounts for 0.4% of all lymphomas In July 2022, a 51-year-old woman with the complaint of progressive dyspnea and dry cough for 6 months was referred to Masih Daneshvari hospital, Tehran, Iran. She had no prior medical conditions and did not smoke. On admission, the temperature was 37°C, with a pulse rate of 75 bpm/min, blood pressure of 120/85 mm Hg, respiration rate 20/min, and oxygen saturation of 93% in room air. Bilateral scattered crackles were the only abnormal physical examination.Non-contrast CT of the chest showed bilateral multifocal consolidation and ground-glass opacities as well as interlobular septal thickening . BronchoThe lung parenchyma, including bronchi mucosa and peribronchial interstitium, was obliterated by the lymphocytic cells. In addition, apparent lymphoepithelial lesions were also seen. The neoplastic cells showed positive immunoreaction by CD20 B, CD43 C, CD79a,Complete extrapulmonary evaluations were implicated, and abdominal CT and neck ultrasonography showed no evidence of lymphadenopathy or hepatosplenomegaly. Furthermore, a bone marrow biopsy was performed, which was unremarkable. These findings support a diagnosis of low-grade B-cell NHL that was mostly consistent with marginal zone lymphoma; therefore, primary MALT lymphoma was diagnosed. The patient was referred to an oncologist for proper treatment.Pulmonary NHL is a rare entity occurring 1:313,000 annually with <1% of all NHLs, in which MALT lymphoma is seen in more than two-thirds of cases Lung B-cell lymphoma is the most common type of primary pulmonary lymphoma (70%-80%) Some laboratory findings such as anemia, thrombocytopenia, and an elevated level of LDH are often found. In addition, monoclonal immunoglobulin (Ig) and C-reactive protein levels are usually elevated MALT-lymphoma has heterogeneous imaging findings, most of which are nonspecific. However, some features such as hilar or mediastinal lymphadenopathy may contribute to the proper diagnosis. Single or multiple lung nodules ranging from 2 cm to 8 cm with or without air bronchogram are commonly found in lower lobes which account for up to 70% of cases In most cases, positron emission tomography (PET)-CT shows increased fluorine-deoxyglucose (FDG) uptake correlating with tumor size; therefore, it can be utilized in both initial diagnosis and follow-up Bronchoscopy is usually unremarkable although bronchial edema, inflammation, stenosis, or narrowing caused by external compression can be observed Transbronchial biopsy has high sensitivity and specificity The most common treatment option for localized or peripheral masses is surgical resection. It is usually combined with radiotherapy. Rituximab is indicated for the treatment of patients with unresectable or widespread dissemination of tumors Primary pulmonary MALT lymphoma is a rare lung NHL with a favorable prognosis. It usually has nonspecific clinical manifestations and radiological findings. Detailed histopathological evaluation is vital for proper diagnosis. Awareness of this entity is essential for a physician to correctly diagnose the disease in the proper clinical setting.This observational retrospective study was approved by Shahid Beheshti University of Medical Science institutional ethics committee.Informed consent was obtained from the patient.


Benign metastatic leiomyoma (BML) is a histologically benign disease with invasive biological behavior. Most patients are women of childbearing age with a history of uterine leiomyoma. The progress of the disease is relatively slow, the prognosis is good, and most patients can survive for a long time. The lung is the common metastatic site, and BML with metastatic lesions outside the lung is very rare. A 37-year-old woman with multiple BML in the abdominal wall and pelvic cavity after uterine leiomyoma surgery was admitted to our hospital. Combined with the clinical data of this case and reviewing the relevant literature, this paper discusses the pathological characteristics, diagnosis, differential diagnosis, and treatment of BML. Benign metastatic leiomyoma (BML) is an extremely rare benign leiomyoma with invasive biological behavior. The disease was first proposed by Steiner , and mosA 37-year-old female was admitted to our hospital for palpable masses in the lower abdominal wall for 2 years. The masses had grown rapidly in recent half-year, and the bigger was about 3 cm in diameter.The patient had touched the active masses located in the lower end of the incision on the lower abdominal wall, with a diameter of about 1 cm and no tenderness since 2 years ago. The masses consciously increased before the menstrual period and narrowed after the menstrual period. The patient felt the masses had grown rapidly in recent half a year and the bigger was about 3 cm in diameter. She had a regular menstrual cycle and no previous history of oral contraceptives and other hormone drugs, without abdominal pain, abnormal vaginal bleeding, frequent urination, anal distension or other discomfort.The patient had a history of laparotomy and myomectomy about 10 years ago, without the use of a power morcellator. It was finally confirmed as uterine myoma, about 8 cm in diameter in the posterior wall of uterine. The histopathology showed the myoma was in rich cell type, with red degeneration. In 2013, the patient underwent one cesarean section in an external hospital and abdominal wall foreign body resection was performed simultaneously. The postoperative pathological was reported multiple leiomyoma with active cell proliferation .The patient denied the history of diseases such as hypertension, diabetes, and heart disease. Her personal and family history were unremarkable.The ultrasonography showed a 1.5 cm × 1.8 cm × 1.5 cm hypoechoic mass in the posterior wall of the uterus and a 3.8 cm × 2.5 cm × 1.8 cm irregular mass behind the uterus. Color Doppler flow imaging (CDFI) showed a strip-like blood flow signal. In the subcutaneously muscular layer of the lower abdominal wall incision, there also were multiple solid masses with blood flow signal showed . For furLaboratory examinations for CA125, CEA, CA724, HE4, CA199 showed no deviation from normal values. Other blood test results were all in the normal spectrums.The patient underwent an exploratory laparotomy. We noted multiple solid nodules scattered located in the fat layer, fascial layer, intramuscular tissue, and peritoneal layer along the incision, varying in size from 0.5 to 4 cm. After entering into the abdominal cavity, there were extensive pelvic adhesion and multiple nodules found on the edge of greater omentum (3 cm in size), in the posterior wall of the uterus (3 cm in size), and in the uterorectal fossa (4 cm in size) close to rectum. Others were found in the left-posterior wall of uterine (2 cm in size), and on the surface of the right sacral ligament (2 cm in size), which were close to the ureter and surrounding tissue . The actThe macroscopic tissue showed multiple solid nodules . In micrThe final diagnosis was a BML of abdominal wall and pelvic cavity, in rich cell type.The patient supported and cooperated with our treatment very much. Up to now, there is no sign of recurrence or new lesions found by imaging examinations. The patient has no conscious discomfort, and feels so grateful for our operation.Up to now, the etiology and pathogenesis of BML are not clear. Among the proposed hypotheses, lymphovascular spread theory is most commonly accepted, which thinks the tumor cells can be spread along the blood or lymph vessels during the operation. Iatrogenic peritoneal seeding theory from ruptured leiomyoma in myomectomy or hysterectomy is more reasonable to explain the incidence of pelvic BML , 7, justThe symptoms of BML vary with the locations of metastasis, and most of them have no obvious clinical manifestations, which can be found during physical examination. When the lung is affected, patients may have cough, chest pain, hemoptysis, hemothorax, pneumothorax, and even dyspnea . The pat18F-FDG PET-CT is helpful for distinguishing BML from some confused malignant tumors, which show strong or high 18F-FDG uptake on PET  is commonly used for auxiliary diagnosis of pulmonary BML. For the suspicious lesions located in the pelvic cavity, abdominal cavity, and other extrapulmonary sites, ultrasonography or MRI can be useful . A few re on PET , 17.Pathology and immunohistochemistry are the gold standard for diagnosis. According to the literature, the histopathological morphology of the tumor at the metastatic site is similar to that of the primary tumor of the uterus. Under the microscope, the tumor cells are composed of bundle or palisade spindle smooth cells, with mild cell morphology, braided arrangement, no obvious nuclear atypia and mitosis, and rare necrotic tissue , 19. ImmThe lung is the organ most frequently affected by BML, and there need differential diagnosis among PBML and other similar diseases occurring in the lung, such as pulmonary lymphangioleiomyomatosis (LAM) , solitarDue to the rarity of this entity, there is no unified treatment standard for the disease at home and abroad. For patients with surgical indications, such as single or localized lesions, surgical treatment is still the first choice , and cloIf surgery is accepted, the specific surgical methods should be individually executed. For the postmenopausal patient with pulmonary nodules or hysteromyoma found at the same time, it is a feasible to accept hysterectomy and bilateral salpingo-oophorectomy with biopsy of lung lesion. For the young premenopausal women, only surgical castration by bilateral oophorectomy is an alternative therapy. However, studies have reported that prophylactic resection or diagnostic resection are not recommended .Surgery cannot completely change the pathophysiological basis of BML. Combined drug treatment should be paid attention to prevent and reduce recurrence. For patients who are not suitable or refuse surgical treatment, drug treatment options can be selected, such as long-acting GnRHa and new oral small molecule gonadotropin releasing hormone (GnRH) receptor antagonist. The latter blocks the GnRH signal pathway by competitively binding GnRH receptor in pituitary reversibly reduces the secretion of ovarian sex hormone, estradiol (E2), and progesterone  to reducIn this case introduced by us, the metastasis sites were located in the abdominal wall, greater omentum and pelvic cavity, which were rarely reported. Given the age and wishes of the patient, the surgeons only excised the visible lesions as completely as possible, without hysterectomy or bilateral ovaries. But considering its history of recurrence and multiple operations, it is recommended to supplement GnRHa treatment after operation, and should be followed up for a long time. The possibility of new lesions in other systems cannot be ignored.To date, there are no standardized guideline-based treatments for BML. However, patients usually can have a favorable prognosis to accept a comprehensive treatment, based on the indolent nature of BML . More imThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.YL and KL were involved in the case design. YL completed the manuscript. TX and MW performed editing pictures. LJ, QL, and KL participated in improving the manuscript. All authors read and approved the final manuscript.This work was supported by the China Medical University and the data permitted by the patient.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.


Mature cystic teratomas of the ovary (MCTO) are a type of germ cell tumor that may contain well-differentiated tissues developed from three germ cell layers and constitute about 20% of ovarian germ cell tumors. They are rare ovarian tumors with an annual incidence variable from 1.2 to 14.2 cases per 100,000 that occur mainly in women of reproductive age. They are frequently benign with a slow growth rate, even if they can undergo a malignant transformation in about 1–2% of cases.Here, we present the case of an elderly woman referred to gynecological first aid for acute abdominal pain and showing a giant and unusual MCTO at rapid growth with malignant transformation in squamous cell carcinoma (FIGO stage Ia). The patient underwent pelvic mass removal trough emergency longitudinal midline laparotomic incision with intraoperative frozen pathologic examination. A complete surgical staging during the first surgery was performed. After about 9 years of follow-up, she died of non-oncological reasons without recurrence.Present case highlights that CMTO with malignant transformation should always be suspected in elderly women in presence of pelvic mass at rapid growth, even if in absence of other clinical and ultrasonographic signs of malignancy. An intraoperative frozen pathologic examination may drive the best treatment. Mature cystic teratomas of the ovary (MCTO) are a type of germ cell tumor that may contain welldifferentiated tissues developed from three germ cell layers, i.e., ectoderm, mesoderm, and endoderm –4. They MCTOs are rare ovarian tumors with an annual incidence largely variable from 1.2 to 14.2 cases per 100,000 –11. HoweA 73-year-old (S.M. 24–08-39) woman presented at the gynecological first aid of the Grande Ospedale Metropolitano di Reggio Calabria  on the 22nd May 2012 referred with acute abdominopelvic pain. Her weight and height were, respectively, of 55 Kg and 155 cm. A detailed history with particular emphasis on gynecological data was taken. The woman was virgo, had a laparotomic appendectomy in childhood, had no pregnancy, and had been in menopause since the age of 50 years, receiving medication for hypertension. No other clinically relevant datum resulted from her medical and family history.There was no history of weight loss or loss of appetite. Bowel and bladder habits were normal. The physical examination  showed a palpable abdominopelvic mass with abdominal tenderness. The woman reported an increasing abdominal girth during the last 2 months. During the clinical examination, the patient had also nausea and vomiting. At admission, she was tachycardic (95 bpm) and tachypneic (16 breaths per minute). Initial transabdominal ultrasound examination was performed in an emergency. A pelvic mass consisting of a uniloculated cyst of about 24 cm of maximum size with multiple small mobile hyperechoic internal lesions was observed Fig. . No  was also confirmed at microscopy. No local and/or distant metastasis was detected in all samples  sent for definitive microscopic examination. No cancer cells were also detected at the cytologic examination of the intracystic fluid and of the peritoneal washing. Thus, a Ia stage ovarian cancer according to the International Federation of Gynecology and Obstetrics (FIGO) was diagnosed.After 30 days from hospital discharge, a computer tomography (CT) of the abdomen was performed confirming no disease. In consideration of the definitive histological report, the multidisciplinary group suggested only clinical follow-up. Follow-up visits were performed every 6 months for the first 3 years and subsequently yearly. The patient died of myocardial infarction on May 10, 2021.The current case regards an elderly patient referring to gynecological first aid for acute abdominal pain due to rapid growth of giant and unusual MCTO with malignant transformation in squamous cell carcinoma. The diagnosis was intraoperatively made and she underwent complete stadiation during the first surgery. She was followed up for about 9 years and died for non-oncological reasons.The case may be interesting for several reasons. First of all, MCTOs are rare ovarian tumors with an annual incidence variable from 1.2 to 14.2 cases per 100,000 that occur mainly in young women and are rare in postmenopausal age –10. ConvThe malignant transformation is a challenge for gynecologic oncologists since the preoperative detection is very difficult because the diagnostic accuracy of the imaging techniques is very low. The malignant transformation is usually detected post-operatively based on definitive histopathologic findings . On the An emergency longitudinal midline laparotomy was performed in our case study for acute abdominal pain. This was probably due to the partial torsion of the ovary. This is the most frequent complication of the CMTO with an incidence ranging from 3 to 21% most commonly occurring in CMTO with intermediate size and less frequent in case of CMTO of large dimensions , 6, as wFinally, our case was also unusual for the macroscopic appearance of the CMTO. The lesion here described was composed of ectodermal  and mesodermal tissue  Figs.  and 5. EThe current case report confirmed that squamous-cell carcinoma in CMTO may be found, even if very rarely, in patients aged more than 50 years and with ovarian tumors more than 100 mm in size .In conclusion, our case highlights that CMTO may occur also in elderly women and that a malignant transformation should always be searched in presence of pelvic mass at rapid growth, even if in absence of other clinical and ultrasonographic signs of malignancy.


Aortoesophageal fistula (AEF), secondary to thoracic pseudoaneurysm as a result of upper gastrointestinal bleeding, is a rare condition and will be undoubtedly lethal without prompt surgical intervention. The estimated annual incidence of primary AEFs and secondary AEFs is about 0.0015% and 0.6%–2%, respectively. The challenges of the therapy posed by AEF are control of the hemorrhage, arterial reconstruction in an infection field, control of sepsis, and re-establishment of the alimentary tract. We present a case of a 58-year-old man who suffered from chest pain and hematemesis and was finally diagnosed with pAEF caused by descending thoracic pseudoaneurysm. Our team successfully deployed an endovascular stent graft and esophageal stent to seal ruptured thoracic aorta and esophageal defects, which provided a new surgical strategy for aortoesophageal fistula in the endovascular era. Aortoesophageal fistula (AEF) was first described by Dubreuil  in 1818.A 58-year-old male with a history of poorly controlled hypertension and hyperuricemia presented to a local hospital with complaints of chest pain for the past 1 month; then, aspirin was prescribed due to the change in the ST–T segment. The symptoms were still persistent, and he was admitted to the first-aid room of our institution with an episode of massive hematemesis from the last 12 h. He denied a history of abdominal pain, alcoholism, past history of gastrointestinal (GI) bleeding, or any significant past medical history. On physical examination, his heart rate (HR) was 86 beats/min with blood pressure (BP) of 138/81 mmHg, and the other laboratory indexes were unremarkable. Workup showed decreased hemoglobin (100 g/L) and hematocrit (0.295L/L), C-reactive protein (CRP) of 49 mg/L , and without coagulopathy. Surprisingly, plasma ammonia was normal. There was no history of melaena but persistent chest pain and normal plasma ammonia, which aroused our strong suspicion of an AEF. So, esophagigastroduodenoscopy (EGD) was canceled, and emergent computed tomography (CT) and angiography of the thorax (ACT) were performed. The aortogram revealed the presence of pseudoaneurysm (size 40 × 60 mm) in the descending thoracic aorta . UrgentlAEF is a subtype of aortoenteric fistula since the lesion primarily involves the thorax rather than the abdomen, which constitutes approximately 10% of all aortoenteric fistulas . pAEF moA review of the literature in PubMed reveals nine published reports of nine primary AEFs caused by pseudoaneurysm or aneurysm who underwent the endovascular stent-graft repair . Of thesThe patient, who was in the first-aid room at that moment, said only his wife was with him and his children were abroad. He experienced fear and anxiety from vomiting blood and chest pain, which would have been worse for him if he had undergone conventional general anesthesia. The patient was conscious during the procedure, and our staff were always comforting and encouraging, making him feel relaxed during the procedure.in situ aneurysm repair, stent implantation is less invasive, especially in the acute phase of the disease. There are a variety of tubes for in situ replacement, including autologous veins, polytetrafluoroethylene grafts, cryopreserved allografts, and antibiotic-bound grafts. So, stent implantation showed its convenience. However, the mediastinum is a potential infection area and may cause a severe infection of vascular stents, which is the biggest limitation we are most concerned about. To our knowledge, there was no case reported to date about this scheme of operation. Large series cases and long-term follow-ups will be necessary to further establish the prospect of the proposed combined treatment of pAEF.In this case, our successful experience demonstrates the feasibility of the operation of pAEF using an endovascular stent graft and an esophageal stent. Compared to the traditional surgical treatment that includes resection or exclusion of aneurysms combined with external anatomical bypass surgery or


Initial laboratory and imaging investigations, including an abdominal X-ray and computed tomography scan, were suggestive of an intestinal obstruction; however, these were not helpful in assigning a presumptive cause. A laparoscopic exploration was offered after a repeated abdominal X-ray showed an air-fluid level. Intraoperative findings revealed an ischemic closed loop obstructed by a fibrous band of Meckel's diverticulum. Resection and anastomosis of the bowel was performed, and the patient was discharged on day 3 post-operative with no complications.Surgical resection performed by open or laparoscopic approach is the recommended treatment for patients with symptomatic Meckel's diverticulum. Generally, a wedge resection of the Meckel's diverticulum is performed, and occasionally part of the ileum is resected by end-to-end anastomosis, as was the case in our patient.We believe early surgical intervention is crucial for a favorable outcome. Thus, surgeons should consider complicated Meckel's diverticulum in patients presenting with signs and symptoms of small bowel obstruction. •Intestinal Obstruction Caused by Meckel's Diverticulum Band are extremely rare in adult.•Obstruction Caused by Meckel's Diverticulum Band may present a challenging clinical diagnosis.•Surgical resection remains the treatment of choice and plays a potentially curative role. The con2This work has been reported in line with the SCARE 2020 criteria . A 57-yeOn physical examination, he was alert and oriented and his vital signs were stable. His abdomen was soft to palpation, mildly distended and tender, especially in the right lower quadrant. A digital rectal examination revealed hard stools in his rectum. Bowel sounds were heard in the periumbilical area and were normoactive.9/L and hemoglobin concentration of 15.9 g/L. Lactate and alkaline phosphatase levels were 2.00 mmol/L and 59U/L, respectively. An abdominal X-ray showed multiple air fluid levels and a computed tomography (CT) examination of the abdomen showed a high-grade obstruction with a transition zone within the distal ileum (The results of paraclinical investigations were unremarkable. A complete blood count revealed a white blood cell count of 10 × 10al ileum . There wThe patient was admitted to the surgical ward and a nasogastric tube was inserted. Intravenous fluids, prophylactic antibiotics, and analgesia were administered, and abdominal X-rays and abdominal girth measurements were performed daily.One day after admission, the pain and vomiting resolved but his abdomen was still distended. Additionally, he had no bowel motions or flatus. Gastrographin small bowel follow-through was performed on the second day of admission to assess patient improvement and the effectiveness of conservative treatment, and it showed high-grade intestinal obstruction. The results of further laboratory investigations were unremarkable. However, an abdominal X-ray showed an air-fluid level prompting us to offer a laparoscopic exploration on the third day of admission.Intraoperative findings revealed an ischemic closed loop obstructed by a fibrous band of Meckel's diverticulum . Resecti3Most patients with Meckel's diverticulum do not present any symptoms, and the risk of these patients developing complications is approximately 4–7% . PatientThe patient in our case reported a sudden onset of abdominal pain and vomiting and initial imaging investigations, including an abdominal X-ray and CT scan, were not helpful in reaching a presumptive diagnosis. While complementary studies have been reported to be of little or no value in reaching a diagnosis, these may be helpful in complicated cases, with CT being the best imaging modality in these patients . A contrSurgical resection performed by open or laparoscopic approach is the recommended treatment for patients with symptomatic Meckel's diverticulum. Generally, a wedge resection of the Meckel's diverticulum is performed, and occasionally part of the ileum is resected by end-to-end anastomosis , as was Laparoscopy was performed in our case; however, traditional laparotomy and laparoscopy have similar outcomes in patients with symptomatic Meckel's diverticulum . Accordi4Overall, a Meckel's diverticulum band is an uncommon cause of intestinal obstruction in patients with Meckel's diverticulum. Surgeons may be faced with the challenge of establishing the diagnosis preoperatively due to its unspecific clinical presentation, leading to a delay in diagnosis. Early surgical intervention is crucial, as this may result in a favorable outcome. Thus, clinicians should consider complicated Meckel's diverticulum in patients presenting with signs and symptoms of small bowel obstruction. Laparoscopic intervention is a safe and feasible way to treat complicated Meckel's diverticulum.Not commissioned, externally peer-reviewed.This report was approved by the hospital's Institutional Review Board.None.Dr Abdullah Alzarea and Dr. Alaa Aljohani wrote the manuscript. Dr. Hanan Qabani collected the data and compiled references. Dr. Ali and Dr. Rami supervised and guided the writing process. All authors read and approved the final manuscript for submission.Not applicable.The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The authors declare that they have no conflict of interest.


Seminal vesical cyst (SVC) together with ipsilateral renal agenesis known as Zinner's syndrome is a rare congenital malformation mostly asymptomatic and is detected in second to fourth decade of life presenting with symptoms of bowel and bladder neck irritation/obstruction. Diagnosis is based mainly on various imaging techniques with MRI being the confirmatory. Recent management includes laparoscopic excision of the SVC but conventional aspiration of the cystic fluid together with explorative open excision of the cyst is still regarded useful.A 32 years old male presented with urgency and frequency of micturition, constipation, post ejaculatory pain and USG, CT, MRI findings suggestive of right renal agenesis and bilateral seminal vesicle cyst.As other studies show, our patient is a sexually active male with characteristic symptoms of bladder and bowel obstruction. USG, CT, MRI were used for diagnosis co-relating other studies. Intervention was done by aspiration of the cystic fluid and open surgical excision of the cyst.Zinner's Syndrome is uncommon cause of symptoms of bowel and bladder obstruction in young men; whose diagnosis is mostly based on imaging techniques. •Seminal vesical cyst (SVC) together with ipsilateral renal agenesis known as Zinner’s syndrome is rare.•It is detected in second to fourth decade of life presenting with symptoms of bowel and bladder neck irritation/obstruction.•Diagnosis is based mainly on various imaging techniques with MRI being the confirmatory.•Conventional aspiration of the cystic fluid together with explorative excision of the cyst is still regarded useful. However, the symptoms increased over time and there was perianal pain for 2 months, pain after ejaculation for 1 month. The International Prostatic Symptom Score was 14. The patient's history was negative for fever, hematuria, hematospermia, per rectal bleeding. There were no any comorbidities and significant family history. The patient was not under any medications.Findings on his arrival were as follows: body height, 172 cm; body weight, 66 kg - BMI was 22.3 .; blood pressure, 120/70 mmHg; pulse, 80 beats/min; body temperature, 37.3 °C; no anemia and icterus in the palpebral conjunctiva; no edema in the legs, no cyanosis; no any palpable lymph nodes breathing sounds were clear/no secondary noises; no heart murmurs. No any other significant examination findings were present per abdomen. Per rectal examination revealed an anal fissure measuring 0.5 cm × 0.2 cm at 5 o'clock position.Hematological tests were sent and urinalysis was performed, the report of which were within normal limits. Urine culture also didn't show growth of any organism.Ultrasonography (USG) of Abdomen and Pelvis  couldn'tComputed Tomography (CT) of Abdomen and Pelvis A-D were i.Dilated lobular and tortuous cystic lesion in the Right side of pelvic cavity, the maximum diameter of which was 4 cm, extending along the right side pelvic wall up to the level of aortic bifurcation and opening into the prostatic urethra and showing wall enhancement in post contrast images. The lesion was seen to be abutting prostate inferiorly, urinary bladder and small bowel loops anteriorlyii.Another 4.6 × 3.1 × 2.5 cm sized similar dilated, tubular and tortuous cystic lesion in the left side of pelvic cavity, with diameter of 1.4 cm, opening in prostatic urethra. Prostate normal in size, outline and parenchymal signal intensity.iii.Non-visualization of Right kidney. Left kidney measuring 12.5 × 6.7 cm in size However, MRI did not reveal any rectal mass or wall thickening of the rectum.An MRI abdomen and pelvis A-C was aUrethrocystoscopy was done which showed no any lesions in urethra or bladder with a protruding mass at right lateral trigonal region which was partially obstructing the bladder neck. Imaging findings along with cystoscopic examination lead to the diagnosis of Zinner's Syndrome. Pelvic exploration with aspiration of cystic fluid accompanied by open surgical excision of cystic structure was then done by the consultant urologist. Operative finding include enlarged bilateral seminal vesicles, right sided about 5 cm in diameter left sided around 2 m in diameter; with 70 ml of cystic fluid in the right seminal vesicle. The aspirated cystic fluid was sent for microbiological examination which eventually came negative while the excised tissue was sent for histopathological assessment which revealed cyst wall lined by pseudostratified columnar epithelium. Few of the epithelial cells show reddish brown lipofuscin granules in the cytoplasm. Wall of the cyst comprises of fibromuscular tissue with chronic inflammatory cell infiltrates. These findings are consistent with Seminal Vesicle Cyst.The post-operative period was uneventful and the patient did not experience any further genitourinary discomfort. The patient was then discharged on 3rd post-operative day and was symptomatically better and hemodynamically stable at time of discharge.3Unilateral renal agenesis is found to be present in 0.1 % of newly born babies SVC with size smaller than 5 cm in diameter remains asymptomatic and usually are discovered incidentally Imaging is key to diagnosis. Transabdominal Sonography Widely accepted treatment methods include open exploration with vesiculectomy, transperitoneal or transrectal aspiration of the cyst, or transurethral deroofing of the cyst Recent techniques include laparoscopy , as reported by Seo et al. which is minimally invasive as compared to the conventional open surgery which in very invasive due to deep location of seminal vesicles in retrovesical area USG can be the imaging of choice for follow up in patients with asymptomatic SVC as it is cheap, available, noninvasive and can be easily done by the urologist alone 4Zinner's Syndrome is uncommon cause of symptoms of bowel and bladder obstruction in young men; whose diagnosis is mostly based on imaging techniques. USG is valuable in initial steps as well as follow up, CT scan defines the origin of cyst and MRI is important for diagnosis and surgical planning. Aspiration alone is not the treatment of choice, but being added with open surgical excision can be proven reliable. However, newer laparoscopies techniques can be used.The patient was not aware of his condition before he visited our Centre. The patient was glad to be diagnosed and was satisfied by the treatment.Ethical approval was not needed for this study according to local/national guidelines.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.This work has been completed in line with the SCARE criteria No any grant was received for the preparation and publication of this manuscript from funding agencies in the public, commercial, or not-for-profit sectors.Aavishkar Raj Regmi, Sarmendra Mishra conceptualized the study and reviewed the topic. Aavishkar Raj Regmi, Adarsh Gurung and Archana Acharya wrote the original draft. Aavishkar Raj Regmi and Adarsh Gurung edited the manuscript. Sarmendra Mishra and Ajnish Ghimire reviewed the manuscript. Aavishkar Raj Regmi and Laxman Dutta Paneru worked up with publication.Not applicable.Aavishkar Raj Regmi accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.Not commissioned, externally peer-reviewed.The authors have no any conflicts of interest to declare.


Arthrobacter russicus presenting with abdominal pain and fever that was initially diagnosed as a presumptive urinary tract infection and treated with empiric antimicrobial therapy. However, persistent abdominal pain with increased serological inflammation necessitated further evaluation. Unenhanced multimodality imaging considering the renal dysfunction revealed infectious aortitis of the infrarenal abdominal aorta, together with the initial culture results, leading to the tentative diagnosis of Klebsiella pneumoniae aortitis. Thereafter, serial monitoring with unenhanced magnetic resonance angiography (MRA) using thin-slab maximum intensity projection (TS-MIP) revealed acute aortic expansion strongly suggestive of a pseudoaneurysm that was successfully treated with early surgical repair under adequate infection control. Despite negative Gram staining and tissue culture results for the excised aortic wall, a definitive diagnosis of IAA secondary to A. russicus rather than K. pneumoniae was finally made by confirming the histologic findings consistent with IAA and the identification of A. russicus 16S rRNA on the resected aortic wall. The patient also developed a vascular graft infection during the postoperative course that required long-term systemic antimicrobial therapy. This case highlights the value of unenhanced MRA in the early detection of IAA in patients with renal dysfunction and the importance of a molecular diagnosis for identifying the causative microorganism in cases of culture- or tissue-negative IAA.Infectious aortic aneurysm (IAA) can be a rare but potentially fatal sequela of infectious inflammatory disease of the aortic wall with a high incidence of rupture. The definitive diagnosis is based on vascular imaging of the aneurysm using contrast-enhanced computed tomography (CE-CT) and identification of the causative microorganism from positive blood cultures (BCs). However, IAA remains extremely difficult to diagnose and treat in patients with prior antimicrobial treatment or with renal dysfunction. Here we describe a case of an 85-year-old woman with IAA caused by  Infectious aortic aneurysm (IAA) is a rare but serious infectious inflammatory disease of the aortic wall that often requires prompt surgical intervention because of a high associated mortality rate with antimicrobial therapy alone . HoweverAn 85-year-old woman was admitted to our hospital with a 3-day history of abdominal pain and fever. Her medical history included a cerebral infarction, Parkinson’s disease, dementia, and diabetes. Her vital signs were as follows: blood pressure, 186/86 mmHg; heart rate, 90 beats/min; blood temperature, 38.4°C; respiratory rate, 18 breaths/min; oxygen saturation, 99% on ambient air; height, 150 cm; and weight, 43.5 kg. An abdominal examination revealed no significant pulsatile mass, rebound tenderness, audible vascular murmur, or costovertebral angle tenderness except for mild tenderness in the periumbilical region. Chest X-ray findings were unremarkable. An initial laboratory workup revealed an elevated leukocyte count of 10,200/μL , elevated levels of C-reactive protein , fasting blood glucose , and glycated hemoglobin . Severe renal dysfunction with a calculated creatinine clearance of 19.6 mL/min was observed. A urine dipstick test revealed glucose 4 +, blood 1 +, protein 1 +, and bacteria 2 +. We initially suspected gastroenteritis, pyelonephritis, or a liver abscess.Contrast-enhanced computed tomography (CE-CT) was omitted due to the patient’s severe renal dysfunction. Abdominal ultrasonography revealed multiple gallstones and obvious intestinal gas but no intrahepatic mass, hydronephrosis, or flap in the abdominal aorta. After the collection of a urine culture and two sets of blood cultures (BCs), the patient was intravenously administered ceftriaxone 1 g daily for a presumptive urinary tract infection. Persistent abdominal pain with increased serological inflammation prompted further abdominal evaluation on day 4. Unenhanced CT revealed a non-aneurysmal dilation of the infrarenal abdominal aorta with increased soft tissue mass around the aorta , 2A. UneKlebsiella pneumoniae susceptible to conventional antimicrobials but naturally resistant to ampicillin. Accordingly, a tentative diagnosis of K. pneumoniae abdominal aortitis was made. The dose of ceftriaxone was increased to 2 g twice daily, and oral levofloxacin (250 mg/day) was added. Insulin therapy was initiated to manage the hyperglycemia. The echocardiographic and endoscopic examination findings were unremarkable. Thereafter, the patient’s symptoms disappeared, the serological inflammation decreased, and all the subsequent repeated BCs remained sterile. The periaortic soft tissue lesion appeared stable on serial CT imaging . However, serum immunological examination results were within normal ranges, suggesting less likelihood of inflammatory diseases. Urine culture and BCs conducted on admission revealed the presence of  imaging . Neverth imaging . Additio imaging . She wasin situ graft (GORE-TEX Vascular Graft)  . Patholor Graft) –3H. The quencing –4, leadiquencing . TherefoAfter follow-up blood examination and MRA confirmed the resolution of an inflammatory response to the infection , the antA. russicus, successfully treated using an early surgical intervention concurrent with long-term antimicrobial therapy. Our case report offers three clinical implications. First, unenhanced MRI/MRA was feasible for diagnosing IAA in our patient with renal dysfunction. An IAA refers to an arterial dilation secondary to destruction of the infected aortic wall. IAA  accounts for 0.7–4.5% of all aortic aneurysms (Staphylococcus spp. (50–60%) and Salmonella spp. (30–40%) remain the most common causative species underlying IAA owing to their high affinity for the arterial wall  an neurysms ; and (4)neurysms . Althougial wall , 11, 12.Untreated IAA can cause rupture, aortofistulous communication, mural thrombosis, distal ischemia, sepsis, or multiorgan failure. Of these, rupture, the most fatal sequela, occurs in 50–80% of all cases, with a significantly higher mortality rate of 42% in cases of IAA with free or contained rupture vs. without rupture , 13. TheHelicobacter cinaedi is a low virulence bacterium that contributes to the promotion of atherosclerosis via macrophage-driven proinflammatory response and hence slowly progressive over months to years   characteristics of IAA: while most pathogens are associated with the rapid aneurysmal expansion, to years , 15; (2)as on CT . Specifiph nodes ; and (3)ctively) , 19. HowThe first diagnostic challenge was the presence of significant renal dysfunction in our patient, which required us to preclude iodinated contrast media exposure. The other diagnostic challenge was that CT findings observed in our case were similar between IAA and IgG4-RD. IgG4-RD is a life-threatening inflammatory vasculopathy that frequently affects individuals of middle to advanced ages by involving large and medium-sized vessels simultaneously, which often occurs in the infrarenal segment of the abdominal aorta , 21. Var18F-flourodeoxyglucose positron emission tomography/computed tomography (PET/CT) is a potential alternative for evaluating IAA. Although PET/CT is very sensitive for detecting metabolic activity, its diagnostic accuracy is limited due to difficulty distinguishing IAA from inflammatory aortic aneurysm and false positive results including malignancy and non-specific findings. However, a recent retrospective study analyzing 29 patients with abdominal aneurysms who underwent both PET/CT and CE-CT reported that a combination of specific imaging features  and metabolic activity (intensity and site) can identify the etiology of each aneurysm with high accuracy among abdominal aortic aneurysms   , 28. TheA. russicus 16S rRNA on the resected aortic wall. Advanced age, poorly controlled diabetes, and renal dysfunction, which are closely associated with atherosclerosis, might have provided a rich nidus for aortic infection. Therefore, this case report emphasizes the importance of considering IAA as a possible source of unexplained abdominal pain and fever among elderly patients with severe atherosclerosis and the use of unenhanced MRI/MRA to evaluate and monitor aortic diseases in patients with renal dysfunction wherein iodinated contrast media exposure is undesirable.In our case, IAA was confirmed based on histologic findings and the identification of A. russicus. The 16S rRNA sequencing was also helpful to identify this microorganism. Arthrobacter spp.  are widely distributed in the environment, especially the soil  was reported in 1996  within 2 years  resolved the clinical symptoms, imaging findings, and blood laboratory data of inflammatory responses. Choosing optimal antimicrobial therapies for Arthrobacter infections remains challenging because of the difficulty isolating and identifying the phenotype  can be found below: NCBI GenBank; HY contributed to the clinical design and study concept. HY, TS, TH, and HO acquired the clinical data. YF and MG performed the microbiological analyses. YI performed the pathological analyses. JI performed the radiological analyses. HY, JI, and TT interpreted the data and drafted the manuscript. All authors discussed, read, and approved the manuscript and its submission for publication.


Herein, we present a case of cryptomenorrhea due to imperforate hymen where approximately 3400 ml of retained menstrual blood was drained in a 16-year-old girl who presented with primary amenorrhea, cyclical abdominal pain, mass abdomen and acute pain abdomen for 15 days. Magnetic resonance imaging revealed hematocolpos due to imperforate hymen with grossly distended vagina measuring 28.6 × 9.9 × 11.3 cm. Surgical drainage of hematocolpos was done by performing hymenotomy with a cruciate-shaped incision. The post-operative period was uneventful and patient was discharged the next day in stable condition. To our knowledge, this is the first case of hematocolpos reported in literature where more than 3 liters of retained menstrual blood was drained. Imperforate hymen is one of the obstructive congenital anomalies of the female genital tract which is rare with a prevalence of 0.05-0.1% . AlthougWe present here a case of a 16-year-old girl who presented in the outpatient department of Obstetrics and Gynaecology in All India Institute of Medical Sciences, Patna, with chief complaints of not attaining menses yet, cyclical pain abdomen lasting for four to five days coming at an interval of around one month and acute pain abdomen for 15 days. The pain abdomen was not associated with nausea, vomiting or diarrhoea. There was no history of altered bowel habits or urinary complaints. There was no significant past medical or surgical history. On examination patient was alert, conscious, oriented and co-operative. She was of average built and fairly nourished. Her vitals were normal and she was afebrile to touch. Systemic examination was normal. Her secondary sexual characters were well developed with breast and pubic hair tanner stage 4. Abdominal examination revealed a lower mid-abdominal mass about the size of a 32-week pregnancy. The mass was slightly tender, dull to percussion, and transmitted a fluid thrill.Examination of the external genitalia revealed bulging of the entire perineum. The hymen was intact. There was a 6×6 cm bulging membrane posterior to the urethra, which was non-tender, but was exaggerated on doing Valsalva manoeuvre. Labia majora was normal whereas the labia minora was fused with the bulging membrane. Figure A provisional diagnosis of imperforate hymen with hematocolpos was made. Magnetic resonance imaging (MRI) was done to confirm hematocolpos and to look for associated hematometra, hematosalpinx and any other associated congenital anomalies of the genito-urinary tract which revealed a grossly distended vagina measuring 28.6 ×9.9 × 11.3 cm  till the level of hymen, filled with T1 hyperintense and T2 hypointense fluid collections suggestive of hemorrhagic collection in vagina consistent with hematocolpos. The uterus measured 5.8 × 5.2 × 3.2 cm, was displaced superiorly and was normal. Superiorly it was reaching up to L3-L4 inter-vertebral disc level. Anteriorly it was abutting the anterior abdominal wall, compressing the urinary bladder and posteriorly it was compressing the rectum and recto-sigmoid. Bilateral ovaries appeared normal and were displaced supero-laterally. A diagnosis of massive hematocolpos with imperforate hymen was confirmed. Figure Patient was taken up for surgery after taking written informed consent. Hymenotomy was performed under general anaesthesia after catheterization of the urethra. A stab incision was first made in the centre of the imperforate hymen which was then extended in a cruciate manner. The hymen was thick and tough. Around 3400 ml of thick tarry coloured old menstrual blood were drained. Redundant flaps were cut and the edges of the margins were everted by suturing the inner vaginal mucosa to the exterior vestibular mucosa. The abdominal mass disappeared and the enlargement of the abdomen subsided as the vagina emptied. Culture of the vaginal fluid showed no growth. Antibiotics were prescribed and perineal hygiene was maintained. Catheter was removed as soon as the patient could ambulate. She had an uneventful post-operative period and was discharged the next day in stable and satisfactory condition. On follow-up after six weeks, patient started having normal flow of her menses.Imperforate hymen with hematocolpos or hematometra is a slightly rare and well-known congenital anomaly of the female genital tract by most pediatric and gynecologic surgeons, which usually occurs isolated but can vary rarely be associated with other female genitourinary tract anomalies or genetic disorders . Hence, Although numerous cases of imperforate hymen with hematocolpos drainage have been reported in literature, the total volume of tarry-colored menstrual blood drained is usually more or less around one liter. After a thorough review of literature, we found one such case wherein Cecutti (1964) reported a case of imperforate hymen with hematocolpos where 3000 ml of blood was drained . The chaAlthough a rare condition, imperforate hymen is easily diagnosed. The most common presenting symptom is painful cryptomenorrhea. Young teenage girls presenting with amenorrhea and cyclical abdominal pain should arouse suspicion of this condition. Surgical hymenotomy should be performed to treat the condition. Drainage of large volumes of hematocolpos should be done only after taking into account all the possible complications.


Teaching Point: Although magnetic resonance imaging (MRI) plays a considerable role in the detection and differentiation of chondrosarcoma , it is important to be aware of atypical features of common bone tumors. A 60-year-old woman presented with chronic pain in the left hip. For assumed osteo-arthritis, X-rays were ordered. The pelvic radiograph showed a blurry outlined osteolucent lesion in the left femoral neck, with focal broadening of bone , arrow.Computed tomography (CT) revealed moth-eaten osteolysis in the femoral head with extension to the intertrochanteric region , arrows,Magnetic resonance imaging (MRI) confirmed a lesion in the proximal femur with remarkably limited extra-osseous extension and limited edema in the surrounding soft tissues . On STIRRegarding differential diagnosis, our first consideration was primary bone lymphoma, because of the typical location in the proximal femur and the presence of cortical breakthrough. Low-grade chondrosarcoma was also included in the differential, due to the hyperintense appearance on T2-WI and the nodular contrast enhancement. We considered a high-grade chondrosarcoma or osteomyelitis to be less likely, because of the limited soft tissue extension and edema. However, on histopathology the final diagnosis turned out to be a high-grade chondrosarcoma.Chondrosarcoma is the second most common malignant bone tumor after osteosarcoma, with an incidence of 1/200,000 per year [The other two grades of chondrosarcoma are more likely to metastasize, with reported incidences of 30% (intermediate-form) up to 70% (high-grade form). The therapeutic approaches for these tumors are amputation or endoprosthetic reconstruction combined with limb salvage techniques. MRI plays an important role in the detection and differentiation of these tumors because of the accurate detection of cortical destruction, peritumoral soft tissue edema, and soft tissue tumor extension. However, it has been reported that the combined use of MRI and radiography results in higher accuracy, because radiographs are more sensitive in the detection of calcification, scalloping, and cortical penetration . Althoug


A rare case of oncocytic Schneiderian papilloma originating from the sphenoid sinus characterised, for 3 years, by non-specific symptoms of severe headache, a block of nasal breathing, and deprecating sense of smell was presented by an elderly female patient. Sphenoid sinus functional endoscopic sinus surgery (FESS), with a one-block tumour excision, through an endonasal approach, with a histological study of removed tumour masses, were performed on the patient. Long observation in the post-operative period was necessary, considering the risk of recurrence and malignancy of oncocytic Schneiderian papilloma (OSP). Although the oncocytic papilloma of the sphenoid sinus is rare, non-specific symptoms make this pathology easily misdiagnosed. Thus, any isolated unilateral process in the paranasal sinuses with long-existing symptoms must be given careful attention due to the chance of this process being an inverted papilloma with malignization. CT scan indicating a unilateral opacification of paranasal sinuses with local calcifications is a typical manifestation, and endoscopic sphenoidotomy can be recommended as a treatment of choice. Oncocytic Schneiderian papilloma, also known as cylindrical cell papilloma, is a rather uncommon type of epithelial tumour that develops from the Schneider's membrane. The Schneiderian membrane comprises a few layers, including the epithelial lining, the lamina propria, and the bone interface. This membrane includes a richly vascularized lamina propria; osteoprogenitor cells which may be associated with cells, pericytes, within the microvascular walls  or in thUnilateral lesions of the sphenoid sinus should be differentiated from other inflammatory pathologies in the sphenoid sinus or tumours. Lawson et al., in their analysis of isolated sphenoid sinus disease, found 10 benign and 18 malignant tumours out of 132 cases . AccordiThe most common clinical presentation of IP is unilateral nasal obstruction and epistaxis, such symptoms that arise as a result of lateral nasal wall involvement –17. HoweEthiology of Schneiderian Papillomas is still unclear. To date, the roles of the mucosal membrane allergic reactions, chronic sinusitis, air pollution, and viral infections are unclear. The etiopathogenetic factors of either inverted or fungiform Papillomas development include human Papillomavirus (HPV), mainly of the types 6, 11, 16, and 18. However, there is no official supporting data that HPV is a provocative factor in OSP development . OSP appA patient who is a 85-year-old woman of Caucasian descent complained of a severe headache, a block of nasal breathing, and a decreased sense of smell for 3 years. The patient reported hypertension in the medical history, without additional related hereditary diseases, also in the family history. No previous surgical interventions of the nasal cavity or paranasal sinuses have been reported.First, she was observed by an ear, nose, and throat (ENT) specialist and then diagnosed with chronic isolated sphenoid sinusitis. Since topical corticosteroid therapy and oral antibiotics (2 g of Amoxicillin/Clavulanic Acid 875 mg/125 mg every 12 h for 7 days) were not effective, the patient then was submitted to a CT scan examination .Considering the suspicion of a tumour and the absence of bone destruction of the sphenoid sinus, it was decided on a wide endoscopic resection of the lesion in one block. Intraoperative biopsy confirmed the diagnosis of OSP, and the bone drilling at the attachment site was performed .Radiation therapy was not recommended for this patient due to tumour location .The observation period for such patients should be at least 5 years since inverted papilloma is characterised by a high recurrence rate , 28.In the follow-up period, an otolaryngologist observed the patient in her city. After 5 years, she was re-invited for an endoscopic control examination and provided a CT scan conclusion. All symptoms, including the headache and block of nasal breathing, were reduced.The most important point is drilling out of the tumour matrix from the bone and subsequent careful observation of the intervention area.A lesion was found to be an opacification that was expanding into the right sphenoid sinus, extending to the nasal cavity on the unilateral side. The radiologist described this tumour as a lobulated homogeneous mass. The sinus wall was thinned, but there were no signs of intracranial invasion or defects of bony borders of the sinus. The anterior sphenoid sinus wall was detected to be the tumour matrix.Following the CT scan, endonasal endoscopic imaging was performed. Sinus CT   demonstrNext, the patient was subjected to a sphenoidotomy by 0- or 30-degree rigid endoscope under general anaesthesia . The maiClinical manifestations, diagnostic procedures, and treatment of a rare case of OSP originating from the sphenoid sinus are reported.Analysis of symptoms, localisation, pre-operative OT scans, and surgery performed on the patient with OSP originating from sphenoid sinus, followed by a follow-up period.Non-specific symptoms of severe headache, a block of nasal breathing, and deprecating sense of smell, over a period of 3 years, were presented by an elderly female patient. Sphenoid sinus functional endoscopic sinus surgery (FESS), with a block tumour excision, through an endonasal approach, with a histological study of removed tumour masses, was performed on the patient. Long observation in the post-operative period was necessary, considering the risk of recurrence and malignancy of OSP.The oncocytic Papilloma (OP), also identified as columnal cell papilloma, is an uncommon benign neoplasm growing from the Schneiderian membrane which occurs only in 3 to 5% out of the three types mentioned above of Papillomas cases. The ectodermal-derived mucosa of the nose and paranasal sinuses, the so-called Schneiderian membrane, may give rise to three morphologically distinct papillomas, excluding the keratinizing squamous papilloma of the nasal vestibule. These are referred to individually as the fungiform , inverted, and cylindrical cell papillomas (CCPs) or, collectively, as Schneiderian papillomas . It usuaA feature of this article is a rare case of Schneiderian papilloma in geriatric patients. The patient's main complaint was the block of nasal breathing without any headache, ophthalmological complications, or postnasal drip, which are typical for sphenoid sinus opacification. It is very important to identify the pathology in the early stages. Clinical manifestations are largely reminiscent of the primary acute sinusitis, while often exhibiting unilateral character and resembling polyposis masses in the endoscopic view. Clinical manifestations of nasal cavity diseases are reduced in geriatric patients.The latest research into the diagnosis of inverted papilloma with the Storz Professional Image Enhancement System (SPIES) and White Light Endoscopy (WLE) showed a high sensitivity of the former, confirmed by histological data . Such a Another additional factor in the diagnosis of inverted papillomas is the titer of antibodies to human papillomavirus. Studies note that high levels of human papillomavirus are directly correlated with inverted papilloma of the nasal cavity and sinuses. As noted in the study, cell proliferation was found much more frequently on histopathological examination of inverted papilloma compared to the study of polyps. The principal hypothesis regarding the ability of HPV to induce cellular proliferation in various mucosa lesions is based on the fact that the virus uses the replication system of the host cell, as the virus itself does not code for replication enzymes .In some cases, inverted papillomas appear reminiscent of polyp-like masses in combination with chronic sinusitis in the CT scan images. Inverted papilloma of the sphenoid sinus is caused by the development of serious complications due to the location of the sinus. Therefore, it is doubly difficult to detect sinus masses in these patients. Thus, we recommend that all patients over 70 perform CT of the sinuses and endoscopy if they have complaints of nasal congestion. Papillomas always affect one side of the nasal cavity leading to the dilatation of the sinus walls, followed by bone erosion. An intracranial extension might happen; however, it is always an indicator of malignancy disorders of the mucosa. The treatment of choice is usually a complete removal of the lesion with wide resection, including the removal of the normal margins of the mucosa. It was identified that the removal of the mucosa from the affected sinus leads to a better outcome in the follow-up period, indicated by the fewer case of recurrence. The endoscopic approach appeared to be more effective, especially in the initial stages of the disease, with an opacification of one or two parts of the nasal cavity. The radiation therapy had been reserved in the cases of inverted Papilloma in association with squamous cell carcinoma. Other reports indicate that neither chemotherapy nor radiation therapy is effective.Any isolated unilateral process in the paranasal sinuses, with long-existing symptoms, must be given careful attention due to the chance of this process being an inverted papilloma with malignization, therefore a histological confirmation must be completed.Although the OP of the sphenoid sinus is rare, non-specific symptoms make this pathology easily misdiagnosed. The CT scan indicating a unilateral opacification of paranasal sinuses with local calcifications is a typical manifestation, and endoscopic sphenoidotomy can be recommended as a treatment of choice , 32.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.SK, OV, OS, PB, DK, MB, and AK contributed to the concept and design, acquisition, analysis and interpretation of the data, drafting and critical revision of the article, and giving final approval. All authors contributed to the article and approved the submitted version.The reported study was funded by the Russian Science Foundation, project number 21-79-20219.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.


Lipoma is a common benign soft-tissue tumor. Giant lipoma  is gener Giant lipomas are relatively rare. Surgical resection is the only curative option. Generally, a huge cavity will be left after surgical resection of a giant lipoma, and it is particularly important to prevent incision infection and fluid accumulation after surgery. Drainage tube can be placed after surgery, but it will affect the postoperative aesthetics and daily activities of the patient. In this case, a self-made rubber drainage strip is placed after the operation of the giant lipoma, which can not only drain the fluid in the surgical area but also make the patient feel comfortable afterwards.A 33-year-old man was admitted to our department with complaint of founding a mass in the left scapular region and gradually increased for 2 years, accompanied by discomfort in the supine position. The preoperative imaging examination showed a giant lipoma with a size of about 10.0 cm × 8.7 cm × 1.6 cm. Subsequently, surgical resection was performed. During the operation, we made a transverse fusiform incision on the mass surface and placed a self-made rubber drainage strip before the incision was closed. The rubber drainage strip took from a single-use sterile rubber surgical glove. We pulled out the rubber drainage strip on the second day after the operation. The sutures were removed 12 days postoperatively and the incision healed well .Surgical resection of giant lipoma is the most appropriate treatment  and not Q.C. wrote the manuscript. P.S. drafted the initial manuscript.


A 29-year-old man presented with tonic-clonic seizures. Initial MRI showed a lesion centered on the white matter of the left frontal lobe, with restricted diffusion and contrast enhancement on its margins and low rCBV and hypometabolismon PET-CT, suggestive of a tumefactive demyelination lesion . Patient,Demyelinating sentinel lesions preceding CNS lymphomas are a rare entity and its pathophysiology is not fully understood