Salivary gland (SG) tissue and derived neoplasms may occur in the sellar region. As the current literature is mostly limited to case reports, the puzzling case of an inflammatory SG removed by transsphenoidal surgery (TS) and mimicking a prolactinoma prompted us to perform the first systematic review of these unusual conditions.n = 15), primary benign (n = 7) and malignant (n = 8) ectopic salivary tumours (ST) and sellar metastasis from eutopic primary ST (n = 14)—were suitable for the analysis of clinical, radiological and pathological characteristics. Therapeutic outcome was reviewed as a secondary endpoint.A systematic literature search was conducted according to the PRISMA guidelines. Forty-four individual cases—non-neoplastic enlarged salivary glands (NNESG, All cases were diagnosed after surgery. NNESG commonly affected young and/or female patients, typically leading to headaches and hyperprolactinemia and originating close to the neurohypophysis. Submucosal SG should be excluded before concluding to an intrasellar NNESG after TS. No gender or age predominance was found for primary ectopic ST, which present as large tumors, with histological phenotypes similar to common ST. Hypopituitarism and diabetes insipidus were more frequent in ST than in NNESG. NNESG and benign ectopic ST rarely recur. Malignant ectopic ST should be distinguished from secondary localizations of eutopic ST reaching the sella by contiguity or metastatic spread; both share a frequent unfavorable outcome.Sellar neoplasms derived from SG are rare but misleading conditions and pituitary dysfunction is likely to be more common than currently reported. Appropriate pathological evaluation and multidisciplinary approach are required.The online version contains supplementary material available at 10.1007/s40618-021-01577-6. Onl’s cleft , 12–20. ’s cleft –23, an e’s cleft . Sellar ’s cleft  and otheA recent puzzling observation  first author, year of publication; (2) case demographics , (3) symptoms, (4) endocrine abnormalities, in particular, PRL values, (5) neuro-radiological findings at MRI and/or computed tomography (CT): localization, size, invasion, signal intensity/density, contrast enhancement, (6) pre-operative and final pathological diagnosis, (7) treatment and, (8) where available, status at last follow-up .A systematic review of case reports and case series was performed according to the Cochrane Collaboration and PRISMA statements , 27. A lOverall, 1024 potentially relevant studies were found, 978 were excluded at first screening and 46 were selected for full-text assessment . Pre-operative diagnosis was: PA , Rathke’s cleft cyst (RCC) , craniopharyngioma , exceptionally chordoma (the largest one) [n = 10), but no recurrence or progression was reported, except a cystic relapse after 2 years, without pathological evidence of SG tissue [Fifteen cases of NNESG were found Table  8, 12–2, 28. Mosest one) . Two patest one) . All patG tissue . AdjacenThe individual characteristics of sellar ST according to their pathological classification are shown in Table n = 5), but craniopharyngioma, chordoma and benign teratoma were also considered. All patients were operated on—TS  or transcranially (TC) . Based on a variable follow-up duration  recurrences were rarely reported after complete surgical removal, but occurred 4 and 14 years after partial removal [Seven cases of benign sellar eST have been reported , 29–32,  removal . Four pa removal . Notewor removal –32.n = 2), the tumour was isointense on T1 and slightly hyper- or hypointense on T2 [n = 3) [n = 2) [Primary malignant eST were reported in 8 cases , 33–37 ase on T2 , 36. Pre [n = 3) , 34, 37, [n = 2) , 36, but [n = 2) , 35, wit [n = 2) .n = 6), nasopharynx (n = 2), palate (n = 1) and paranasal sinus (n = 1)—but also from the parotid gland  [n = 3) [n = 7), TC (n = 4) or undetermined (n = 2) surgery, and frequent post-operative radiotherapy (n = 8). Follow-up was available in 8 cases, 6 patients died within 4 years, in one case from early post-operative meningitis [Secondary ST were reported in 14 patients, deriving in most cases from minor salivary glands situated in the sphenoid sinus  , 38–46. , 28.6%) , 40, 45. [n = 3) , 29, 43— [n = 3) . One patThis is the first systematic review on salivary diseases and neoplasia localized to the sellar region. The puzzling case of an apparently intrasellar NNESG removed during TS surgery prompted us to further analyse these conditions, which are not mentioned in exhaustive reviews on sellar/parasellar lesions , 48 or sSalivary rests in the pituitary are relatively common incidental findings at autopsy (3.4–8.8%) , 11. ThiThe mechanisms leading to NNESG are not fully elucidated but the development of mucinous cysts , 18, 19 ST involving the sellar region have been reported more frequently than NNESG. Patients were adults of any age, mass effects were almost invariably present and amenorrhea–galactorrhea or hyperprolactinemia were occasionally reported. Malignant forms were characterized by a mild female predominance and a major frequency of ocular palsy and symptoms suggestive of hypopituitarism or DI. Similar to primary eutopic ST, they include a variety of histotypes , 58, andPrimary benign sellar eST were mostly represented by pleomorphic adenomas. Where specified, they presented as medium/large-sized heterogeneous sellar/suprasellar masses, sometimes with intratumoural hemorrhage or calcifications, potentially mimicking PA, craniopharyngioma, teratoma or chordoma. Hypopituitarism and DI were frequently documented in this group. Post-operative radiotherapy was often proposed due to the risk of recurrence after incomplete surgical removal, although but delayed regrowth could occur . Long-teMalignant ST usually presented as large, heterogeneous, typically invasive sellar/parasellar masses, and rapid progression could suggest pituitary metastasis or other malignancies. They included a variety of histotypes. Adenoid cystic carcinomas (ACC) accounted for nearly 80% of secondary forms versus 25% of primary malignant eST. With a few exceptions, both were diagnosed earlier (4th–5th decade) than common eutopic ACC (5th–7th decade), which are usually slowly growing . This suSellar/parasellar lesions derived from SG tissues are rare but challenging conditions. An appropriate pathological characterization is essential for a correct multidisciplinary approach, which should consider and treat their frequent endocrine complications. Where required, hormone replacement therapy is essential to improve patient’s quality of life and prevent the risk of acute adrenal insufficiency. In addition to surveillance for the early recognition of ST recurrences or metastasis, life-long endocrinological follow-up is necessary for the presence of permanent dysfunction or after radiotherapy, which may induce delayed hypopituitarism. Multicenter collection and long-term follow-up would be useful to better define disease evolution and optimal clinical management of these unusual conditions.Supplementary file 1 (PDF 335 KB)Below is the link to the electronic supplementary material.


Pilomatrixoma is a benign adnexal skin tumor involving the hair follicle matrix. It is found in children, predominantly involving the face. We report here an interesting and rare case of a 52-year-old male presenting with a large, firm, and painless mass over the scrotum considered to be a sebaceous cyst. The mass was completely excised and a biopsy report revealed it to be a pilomatrixoma of the scrotum. The patient recovered well postoperatively with no recurrence over two years. First described by Malherbe in 1880, pilomatrixoma is a rare, benign, slow-growing, cutaneous tumor of the hair follicle matrix. It is also called calcifying epithelioma of Malherbe . Few retThe adnexal tumor is often misdiagnosed clinically due to its resemblance with other common skin masses like sebaceous, epidermoid, or dermoid cysts. The diagnostic modality of choice is tissue biopsy, which shows the presence of characteristic basaloid cells and mummified shadow cells with areas of calcification amidst shadow cells . S100 prHere, we present a case of scrotal mass that was initially considered to be a sebaceous cyst but turned out to be a pilomatrixoma of the scrotum. Only one such case report has been published before.A 52-year-old male presented to the surgery outpatient department with a chief complaint of large scrotal mass over the scrotum for one year. The onset was insidious and gradually progressive in size over the duration causing increasing discomfort. There was no complaint of associated fever or pain. Bowel habits were regular. The patient was also diagnosed with urethral stricture one week ago for which a urethral catheterization was done elsewhere. There was no history of systemic illness. On examination, a large, firm, non-tender, pear-shaped, sessile mass was noted on the anterior aspect of the scrotum with irregular margins and lobulated appearance Figure .Bilateral testes were normal and could be felt separately. No regional lymphadenopathy was noted. A diagnosis of a scrotal sebaceous cyst was considered. The patient was posted for surgery under spinal anesthesia. Mass was excised in toto and sent for histopathological examination. The scrotum was closed in layers with absorbable sutures. The patient was discharged in clinically stable condition on the next day. The histopathological report, to our surprise, was suggestive of a pilomatrixoma of the scrotum Figure .Pilomatrixoma commonly is a single, nodular, painless mass, adhered to the underlying skin but not extending into the deeper planes . Based oThe beta-catenin gene (CTNNB1), which plays a vital role in the development of hair follicles, is mutated in up to 75% of cases. The presence of proto-oncogene B-cell lymphoma antigen 2 (BCL2) has also been associated with pilomatrixoma. Multiple forms have been observed to be associated with familial conditions such as Gardner syndrome, myotonic dystrophy, sarcoidosis, Steinert’s disease, or Turner syndrome . The risImaging modalities like ultrasound (USG), CT, and MRI scans have all been used to support the diagnosis. USG is acceptable enough in the majority of the cases with a positive predictive value of 95.5% since it is quick, cheap, and easily available. The definitive diagnosis of pilomatrixoma is, however, made by histopathological examination .The treatment of pilomatrixoma is essentially complete surgical resection, with 5 to 10 mm of safety margins. With a well-performed surgical procedure, the rate of recurrence is low at around 1.5% . Mohs miPilomatrixoma of the scrotum is a very rare entity. It is often misdiagnosed due to high clinical polymorphism. An ultrasound examination of a suspicious scrotal mass should be done to support the preoperative diagnosis. Histopathological evidence is confirmatory and the treatment is complete surgical excision with extremely low chances of recurrence.


Extracorporeal shock wave lithotripsy (ESWL) is a relatively safe and convenient mode of treatment for ureteral and renal stones, despite its relative safety; ESWL is not without its complications. We present a case of a patient we managed for small bowel obstruction and strangulation due to an adhesive internal hernia after ESWL was done because of right ureteral calculi.We report a case of a 59-year-old patient who presented with severe abdominal pain a few hours after ESWL because of a right upper ureteric calculus. The abdominal pain increased in severity in time and became more generalized. The patient had one episode of gross hematochezia as she was being prepped for emergency laparotomy. Intra-op, she had a strangulated internal hernia because of an omental-mesenteric adhesion.This case report hopes to highlight the potential of complications like acquired IH due to adhesions in patients with a history of ureteral calculi, and also the complications that may come about post-ESWL. Patients who present with signs of persistent abdominal pain post-ESWL should be vigilantly observed. If symptoms persist, increase in intensity or there is a general deterioration of the patients’ hemodynamic status, even in light of negative MDCT findings, prompt surgical intervention is crucial for definitive diagnosis as well as management. Extracorporeal shock wave lithotripsy has advanced from its invention in the 1980s to becoming a relatively safe and non-invasive method used in treating renal, ureteral, and biliary stones. ESWL applies focused shock waves to the stones; the force applied by the shock waves brings about disintegration and destruction of calculi within the urinary and biliary system . DespiteA 59-year-old female presented at our emergency department with complaints of severe abdominal pain several hours after undergoing ESWL in another hospital. She presented at the peripheral hospital with her chief complaint being an acute onset abdominal pain that started 4 h before arriving at the hospital. At the time the abdominal pain was intermittent, localized , and radiated to the right flank. She also complained of nausea and had one episode of vomiting. After evaluation, an abdominal CT-Scan and abdominal ultrasound both revealed a right ureteral calculus and right renal hydronephrosis. They then scheduled her for ESWL. Unfortunately, in the patient's discharge summary, they did not disclose the specifics of the ESWL in terms of the shock waves delivered and the power range. The procedure was uneventful, and they discharged the patient.After some hours, the patient started complaining of diffuse abdominal pain. She was then referred to our hospital for further management. At our facility, she presented with complaints of diffuse abdominal pain with associated nausea and vomiting. She did not report any dysuria, change in bowel movements, or hematochezia prior to the ESWL. Before this admission, her past medical history was uneventful; she had no history of any chronic illnesses, significant abdominal trauma, or abdominal surgery.On physical examination, she was tachycardic but normotensive. Her abdomen was distended with generalized abdominal tenderness and mild rebound tenderness, but with no guarding present. Murphy's sign was negative. There was tenderness on percussion of the right kidney. Bowel sounds were increased at around 5/min and positive shifting dullness was present. Her other systems were normal.9/L and absolute neutrophilia of 76.5%, HB at 128 g/L, and hematocrit of 36.8%. CRP was elevated at 36.2 mg/L, revealing an inflammatory picture. LFT's showed a decrease in albumin at 26.8 g/L. Urea and creatinine were elevated at 9.2 mmol/L and 98.7 mmol/L respectively. Her coagulation profile was deranged, with prothrombin time and d-dimers at 12.6 s and 1302 μg/L, respectively. Urinalysis, urinary occult blood of 3 + , urinary protein 2 + , RBC 459.32/HP, WBC 45.83/HP.Routine blood tests found that she had raised WBC at 26.9 ↑ 10After surgical consultation, we immediately scheduled her for an emergency exploratory laparotomy. As the patient was being prepared for surgery, she had one episode of hematochezia of approximately 300mls of fresh blood. Because of this, she received a transfusion of four units of packed red blood cells.The laparotomy revealed that there was a large hematocele, with partial necrosis of the small intestine. The small intestine was entrapped by omental and mesenteric adhesions approximately 2 m from the ligament of Treitz. The bowel segments entrapped within the adhesions were released. Unfortunately, assessment of the bowel segment revealed that it was necrotic. The 2.6 m of the necrotic intestinal segment was resected and the continuity of the remaining 40 cm of the ileocecum and jejunum was maintained by end-to-end anastomosis.The patient’s postoperative course was uneventful. She was discharged after four days and was to be followed up at the urology and surgical outpatient clinic.Adhesions are a form of vascularized scar tissue that brings about a connection or adherence between surfaces and organs within the peritoneal cavity. They result from a pathological healing process in response to a peritoneal insult or injury. The main causes of abdominal adhesions are inflammation, surgeries, intraperitoneal infections, radiation, and also significant abdominal trauma , 16. AnyAdhesions have been linked to being a major cause of acquired internal hernias, and an increased risk of mechanical small bowel obstruction , 18. TheSince the clinical diagnosis of internal hernias still proves to be difficult, the mainstay modality of choice for the diagnosis of IH to date is the multi-detector CT-scan (MDCT). The most specific MDCT findings or key features in relation to adhesive IH include; clustering or crowding of intestinal segments, crowding of mesenteric blood vessels, kinking or angulation of bowel loops, bowel wall thickening, presence of a hernia orifice, and the fat notch sign. Mesenteric infiltrates, localized mesenteric fluid and asymmetric bowel wall thickening are indicators of intestinal strangulation , 21. DesSince its inception of ESWL in the 1980s, it has developed into a relatively safe and non-invasive treatment for nephrolithiasis and has an overall stone-free rate of 75%. ESWL delivers focused high-energy pressure pulses consisting of a short duration initial phase of positive pressure pulse (P +) and a relatively prolonged negative pressure phase (P-) through the aid of a lithotripter. The difference in pressure gradient between P + and P- plays different roles in the fragmentation process of calculi through four fundamental mechanisms; shear force, cavitation, quasi-static squeezing, and dynamic fatigue –26, 28. For our patient, in relation to the course of events and the appearance of abdominal symptoms, she probably had a self-reducible adhesive internal hernia that came about from a localized inflammatory process i.e. the ureteral calculi, since all the other causes of adhesive intestinal hernias were ruled out. The intestinal loop entrapped by the adhesion was along the pathway of the energy pulses, therefore causing an alteration in the acoustic impedance during the transmission of the shock wave. This change caused the dissipation of part of the high-energy pulses and initiation of the cavitation process on the surrounding tissue . This exIn conclusion, despite ESWL being a relatively safe and effective method of treatment for nephrolithiasis, as clinicians, we should be aware of the possibility of acquired IH in patients with a history of ureteral calculi and the complications associated with it. Patients who present with persistent abdominal pain post-ESWL should be vigilantly observed. If symptoms persist, increase in intensity or there is a general deterioration of the patients’ hemodynamic status, even in light of negative or inconclusive MDCT findings, prompt surgical intervention is imperative for definitive diagnosis as well as management in order to avoid further morbidity and also reduce any chances of mortality Fig. .Fig. 1Ab


Angiomatous polyp is a benign, nonneoplastic nasal polyp that accounts for 4-5% of all inflammatory nasal polyps but is rarely reported in the literature. It can grow rapidly and exhibit an aggressive clinical behavior that can simulate malignant sinonasal tumor. We herein report a case of a 13-year-old boy with a rapidly growing angiomatous polyp in the nasal cavity. We had followed up the patient without significant changes for two years, but the tumor had rapidly grown in the last six months. At first, the rapid growth of the tumor and the bone erosion of the maxilla were suggestive of a malignant tumor. However, with preoperative magnetic resonance imaging (MRI) and [18F]-2-fluoro-2-deoxy-D-glucose positron emission tomography imaging findings, we established the corrective diagnosis of an angiomatous polyp. After the diagnostic imaging, we performed an endoscopic endonasal surgery and totally resected the tumor without unnecessary excessive surgery. Recognition of this disease that can mimic malignancy is important to avoid excessive surgery such as en bloc resection by craniofacial approach, and we believe that MRI findings can be helpful for the imaging diagnosis. Angiomatous polyp is a benign, nonneoplastic nasal polyp that accounts for 4-5% of all inflammatory nasal polyps . It is cThis study was approved by the Ethics Committee of Kyoto University Hospital (R-2805).A 10-year-old male patient without serious medical history was referred to our hospital for an incidentally found nasal tumor on the right side in 2018. The tumor was relatively small and localized to the middle to the common nasal meatus, and the biopsy showed that it was a polyp. Therefore, the patient was followed up in the outpatient clinic for two years, and the size of the tumor did not change. However, the follow-up stopped in January 2020 due to the coronavirus disease 2019 pandemic. In December 2020, he came to the outpatient clinic again because of bilateral nasal obstruction that had worsened over the past six months. No bleeding was observed during the periods the follow-up was interrupted. An endoscopic examination showed that the right nasal tumor was dark reddish in color and enlarged with surrounding necrotic tissue, completely occupying the right nasal cavity and extending into the choana -positron emission tomography/MRI revealed low FDG accumulation throughout the lesion  revealed an expansive lesion with a confluent lobular to dendritic-shaped enhancement, occupying from the right maxillary sinus to the right nasal cavity and extending into the right ethmoid sinus and nasopharynx Figure . The lesBased on imaging findings, we suspected a benign angiomatous polyp, and a surgical resection was planned. Preoperative biopsy was not performed due to the risk of bleeding.Before surgery, preoperative angiography was performed. Right external carotid angiography showed a slight and partial tumor staining. Sphenopalatine artery was found to be the main feeder; thus, preoperative embolization of both the medial and lateral branches of the artery using coils  and an 8-fold dilution of Embosphere Microspheres (300-500um) was performed.Three days after the embolization, surgery was performed under general anesthesia in March 2021. The surgery was usual endoscopic endonasal surgery using the one-nostril/one-surgeon/two-handed technique. The tumor was significantly big to perform en bloc resection. Instead, we performed multilayer resection .First, lesions presenting in the nasal cavity and nasopharynx were removed piecemeal. A sample was obtained for frozen section, which confirmed a diagnosis of nonmalignant polyp with immunocyte infiltration. There was no active bleeding during the surgery. Second, right endoscopic modified medial maxillectomy was performed to access the maxillary sinus while preserving the nasolacrimal duct and inferior turbinate . Tumors The total blood loss during surgery was 170 ml. We did not insert gauze, but packed absorbable hemostat into the nose. Nasal irrigation with saline solution was started two days after the surgery, and the patient was discharged from the hospital five days after the surgery. The patient’s postoperative course was uneventful, with no bleeding or infection. No symptoms of nasolacrimal duct obstruction were observed.On histological examination, the tumor was covered with nonneoplastic respiratory epithelium. There were abundant dilated blood vessels, hemorrhage, fibrin deposition, and inflammatory cells in the stroma. Some “stromal” cells showed nuclear enlargement and atypia, which lacked nuclear immunopositivity for androgen receptor and beta-catenin. Accordingly, we finally diagnosed the tumor as an angiomatous polyp. Macroscopic and microscopic findings are shown in Figure Postoperative CT performed four months after the surgery showed no apparent tumor recurrence Figure .In literature, angiomatous polyp has been most commonly observed in the maxillary sinus with frequent extension into the nasal cavity, choana, and nasopharynx ,10. ApprIn the present case, based on these imaging findings, we could establish a correct preoperative diagnosis of the disease without histopathological findings and avoiding excessive surgery, although the tumor had rapidly grown, indicating the possibility of malignancy at first. The low FDG accumulation in the entire tumor reduced the probability of a high-grade carcinoma or sarcoma. Although the patient’s age, sex, and location also suggested the possibility of a juvenile angiofibroma, the anatomical site of origin and direction of extension, morphology of the contrast effect, and MRI findings suggested that this was also unlikely.−3 mm2/s) than that of a malignant tumor ([1.18 +/- 0.31] × 10−3 mm2/s) [In addition, MRI findings were consistent with those of previous reports ,11,13, sThe trigger of rapid tumor growth in this case was uncertain; however, minor trauma might cause damage to the feeder vessels and minor bleeding in the polyp, followed by accelerated reactive and reparative changes with neovascularization .The tumor in this case was similar to a vascular-rich juvenile angiofibroma, which is found in the nasal cavity in adolescent boys and could not be ruled out in appearance. However, the contrast effects on CT and MRI were not significantly high that it was considered unlikely that the tumor was juvenile angiofibroma.In fact, the angiography before surgery showed only a slight and partial tumor staining.Dai et al. have reported that 31 patients with angiomatous polyp were treated by surgery alone with no significant blood loss . In contIn conclusion, we report a case of large angiomatous polyp that could have been diagnosed with preoperative imaging findings and could be successfully resected by endoscopic endonasal surgery. Since angiomatous polyps are benign tumors usually with little blood supply, it is important not to mistake it for angiofibroma or malignancy, to consider biopsy after evaluation of blood flow, and to avoid excessive surgery such as en bloc resection by craniofacial approach when angiomatous polyps are suspected on imaging and/or histological findings.


These genetic alterations and protein expression profiles of ascitic fluid cells were consistent with those of DEL transformed from FL. Given that a significant population of patients with indolent FL of the gastrointestinal tract developed into aggressive DLBCL, it is likely that primary FL of the jejunum transformed into the abdominal aggressive DEL in this case. This case is unique in that concurrent occurrence of FL and DEL was confirmed by immunohistochemical and FISH analyses and that abdominal DEL transformed from jejunal FL was highly suspected.Double expressor lymphoma (DEL), defined as overexpression of BCL2 and MYC, is an aggressive subtype of diffuse large B cell lymphoma (DLBCL). Here we report a case of a 64-year-old female diagnosed with abdominal DEL transformed from jejunum follicular lymphoma (FL). 18F-fluorodeoxyglucose (FDG)-positron emission tomography showed diffuse accumulation of FDG into the peritoneum and small bowel wall. Double balloon-assisted enteroscopy revealed whitish submucosal tumors in the proximal jejunum. Aggregation of atypical lymphocytes positive for CD20, CD79a, and BCL2 was seen in the jejunal biopsy samples. These atypical lymphocytes were monoclonal since cell surface expression of Ig light chains was limited to κ chain by flow-cytometry. Thus, immunohistochemical and flowcytometric analyses data were consistent with FL of the jejunum. Neoplastic lymphocytes obtained from ascites were positive for CD10, CD20, CD79a, BCL2, and BCL6. Fluorescence  MYC and BCL2 and/or BCL6 whereas DEL is defined as overexpression of MYC and BCL2  is a heterogeneous disease entity including a wide variety of pathologic findings and gene expression profiles , 2. Stanand BCL2 –6. Thus,and BCL2 .Although DLBCL and FL frequently occur in the abdominal organs including the gastrointestinal (GI) tract, clinical manifestations of DHL or DEL arising from the abdomen have been poorly understood. Here we report a case with aggressive abdominal DEL, which was likely to be transformed from FL of the jejunum.4/μL) were seen in the context of complete blood cell counts. Biochemical analyses showed hypoproteinemia  and hypoalbuminemia . Although her serum concentrations of transaminases, blood urea nitrogen, and creatinine were normal, marked elevations of serum lactate dehydrogenase  and C-reactive protein  were noted. Tumor markers including carcinoembryonic antigen, carbohydrate antigen 19-9, alpha fetoprotein, and cancer antigen 125 were within normal range except for soluble IL-2 receptor .A 64-year-old female was admitted to our hospital due to abdominal distention. She had been treated for hyperlipidemia. On admission, she developed a low-grade fever and her superficial lymph nodes were not palpable. Physical examinations revealed abdominal distention caused by ascites. Leukocytosis  and thrombocytosis  was performed. FISH showed BCL2/IgH fusion signal in 99 cells among total 100 cells examined  staining and IHC analyses as previously described . H&E starognosis –6. In adrognosis . To ascened (MYC Figure 4es in FL , 9, thesAlthough DEL is resistant to R-CHOP, she was initially treated with R-CHOP due to very bad performance status . After oBCL2/IgH fusion signal, one of the most characteristic chromosomal abnormalities in FL, was detected in 99% of analyzed cells (MYC signals and overexpression of MYC protein, respectively. Therefore, neoplastic lymphocytes in this case were characterized by overexpression of BCL2 and MYC as well as formation of BCL2/IgH fusion gene. These FISH and IHC data fully support the diagnosis of abdominal DEL transformed from FL (Here we report a case with abdominal DEL, which was likely to be transformed from FL. FDG-PET showed massive accumulation of FDG into the peritoneum and small bowel wall, which findings together with elevated levels of serum LDH and sIL-2R were consistent with the diagnosis of aggressive type malignant lymphoma. The final diagnosis of DEL transformed from FL was done based on the results of IHC and FISH data. Neoplastic lymphocytes obtained from ascites were negative for CD5 and MUM1 and positive for CD10, CD20, CD79a, BCL2, and BCL6 in IHC analyses. Moreover, ed cells , 9. Althed cells , 9, aggred cells . FISH anMYC and BCL2 and/or BCL6, is considered a clinically aggressive neoplasma with a poor prognosis (MYC as compared with DLBCLs of other sites including cervico-cephalic region, central nervous system, testes, and skin (DEL and DHL are subtypes of DLBCL with poor outcomes and aggressive clinical manifestations , 6, 10. rognosis , 6, 10. rognosis , 6, 10. and skin . TherefoExtranodal FL preferentially occurs in the GI tract . The GI + lymphocytes positive for CD20, CD79a and BCL2 into the jejunum mucosa was seen. Given that CD20, CD79a and BCL2 are the prototypical markers for FL, these data on IHC and flow-cytometric analyses strongly support the diagnosis of FL of the jejunum. Therefore, we speculate that FL arising from the jejunum might have transformed into DEL. However, we could not perform IGHV sequencing to demonstrate that DEL and FL arose from the same clone due to limited amount of jejunal biopsy samples. Moreover, we could not confirm the presence of BCL2/IgH fusion gene by FISH to verify the diagnosis of FL. Therefore, further molecular evidence obtained by IGHV sequencing and FISH is required to verify that jejunum FL transformed into abdominal DEL in this case. Although less likely, we could not completely exclude the possibility that nodal FL arising from abdominal lymph nodes transformed into DEL in this case.One question arising from this case is where FL transformed into DEL. In this regards, capsule endoscopy and DBE detected a whitish submucosal tumor in the proximal jejunum, which finding was consistent with those of malignant lymphoma of the GI tract . AccumulMYC and BCL2 and/or BCL6 and overexpression of these proteins.We report a case with abdominal DEL transformed from FL of the jejunum. Our case was unique in that concurrent occurrence of FL and DEL was confirmed by IHC and FISH analyses and that abdominal DEL transformed from jejunal FL was highly suspected. We need to bear in mind a possibility of DHL or DEL upon encounter with a case highly suggestive of aggressive malignant lymphoma even in the presence of an indolent type of GI FL. In such cases, FISH and IHC analyses might be very useful to confirm a dual rearrangement of The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.All procedures followed have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from the patient for publication of this report.RT, IS, KYo, AH, YO, and YK took care of the patient. RT and TW wrote the manuscript draft. TY, KK, KM and MK edited and revised the manuscript. YA and KYa analyzed chromosome and pathological data. TC performed pathological analyses. All authors contributed to the article and approved the submitted version.This work was supported in part by a Grant from Yakult BioScience Foundation.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.


Fishbone ingestion is quite common. Most of the time, patients are asymptomatic and the fish bone exits the gastrointestinal tract spontaneously. However, in some rare cases, it can drop in the appendix and induce appendicitis or even appendicitis with perforation. Herein, we report the unusual case of an 18-year-old woman, who presented with acute right lower abdominal pain. Computed tomography suggested the presence of acute appendicitis with a linear foreign body of 3 cm in length. The patient underwent an open appendectomy and removal of the fish bone without stigmata of perforation. The postoperative course was uneventful. Acute appendicitis is one of the major causes of acute abdominal pain in the lower right quadrant. Rarely, appendicitis can be induced by ingested foreign bodies that drop in the appendix . The fisAn 18-year-old female patient presented to the emergency room with acute abdominal pain in the lower right quadrant associated with nausea and vomiting. The physical examination showed local tenderness in the right lower quadrant.Laboratory tests showed elevation C-reactive protein with normal white cell count. The Alvarado score was 6/10. Abdominal ultrasound showed a dilated appendix associated with appendiceal wall thickening measuring 6.5 mm alongside the presence of a linear foreign body. Thus, a contrast-enhanced CT scan was performed and it revealed evidence of acute appendicitis, as well as the presence of a spontaneously hyperdense, linear image measuring 3 cm in length .No stigmata of gastrointestinal perforation were found. The patient made an uneventful recovery and was discharged from the hospital on postoperative day 2.The fish bone is one of the most ingested foreign objects. Mostly, fishbone ingestion can be asymptomatic; however, it can get impacted in any part of the digestive tract and cause serious complications, such as perforation, abscess, and tract obstruction . TerminaThe incidence of fishbone-induced appendicitis is still unknown; nonetheless, foreign objects in the appendix have been reported in 0.005% to 0.113% of cases .When the foreign object drops in the appendix, its poor peristaltic movement is unable to expel the object back to the cecum, leading progressively to inflammation with a high risk of perforation . In our The diagnosis of acute appendicitis can be easily made in 80% of cases based on symptoms and physical examination, but in the other 20% of cases the diagnosis may be difficult and different means of imaging will be needed .Laboratory assessments show classically elevated inflammatory markers. Abdominal radiography is not reliable in finding the fish bone. The plain radiography has a sensitivity of only 32% of detecting fish bones according to several studies ,9. CT scSurgical treatment is the gold standard in the case of fishbone-induced appendicitis . In our Generally, patients do not recall ingesting fish bones. Due to their small size, they tend to pass through the gastrointestinal tract without incidence or may cause nonspecific symptoms, which decreases the chances of preoperative diagnosis of fishbone-induced appendicitis. A meticulous investigation should always be done with the patient whenever a foreign body is suspected on a CT scan.This paper illustrates an unusual case of fishbone-induced appendicitis without any stigmata of perforation. The fish bone is one of the most ingested foreign bodies. However, in some rare cases, it can drop in the appendix and induce appendicitis or even appendicitis perforation. CT scan remains the means of choice in finding ingested foreign objects. Surgical treatment is the gold standard in case of fishbone-induced appendicitis.


Bilateral giant inguinoscrotal hernia (GIH) is rare and creates significant challenge in surgical management. The main concern of hernia reduction to abdominal cavity is development of abdominal compartment syndrome (ACS). Different approaches for prevention of ACS after surgery have been suggested.We report a case of 68-year-old male with bilateral inguinoscrotal hernia for 20 years reaching just below midpoint of thigh. He presented with difficulty in micturition and mobility. Preoperative investigations were normal. He underwent bilateral mesh repair without any preoperative or intraoperative adjunct measures. No significant complication occurred in postoperative period.Bilateral GIH is rare and the patients usually present late. GIH has been classified into three types on the basis of extension. Type I GIH can be managed with simple hernioplasty, in both unilateral and bilateral cases. Measures like resection of hernia contents and measures to enlarge intraabdominal space are warranted in type II and III GIH. Abdominal volume can be increased by utilising techniques like Pre-operative Progressive Pneumoperitoneum (PPP), injection of Botulinum toxin A (BTA) in the anterior abdominal wall, and rotation of viable tissue. The measures can be used either alone or in combination.Type I GIH can be treated with simple hernioplasty with safety with monitoring for features of ACS and respiratory complications postoperatively. However, additional measures like resection of hernia contents or procedures to enlarge intra-abdominal space are warranted for type II and III GIH. •Surgical management of bilateral giant inguinoscrotal hernia is challenging as reduction of hernia contents to abdominal cavity may lead to development of abdominal compartment syndrome (ACS) and cardiorespiratory complications.•We report a case of bilateral GIH managed with bilateral mesh repair with postoperative monitoring for features of ACS and cardiorespiratory complications.•There was no significant complication in the postoperative period and no recurrence in six month follow-up period. This case report has been reported in line with the SCARE Criteria 2A 68-year-old male, known case of bilateral inguinoscrotal hernia for 20 years presented to our center with complaint of increasing difficulty in micturition for past two years. He had multiple episodes of acute urinary retention that required catheterization. The patient couldn't walk and sit properly. The swelling had become irreducible with time. He didn't have abdominal pain, distension, and vomiting. He didn't have any co-morbidities.Physical examination revealed bilateral massive inguinoscrotal swelling that descended to just below midpoint of inner thigh in the standing position . There wPatient underwent elective exploration via inguinoscrotal approach in tertiary care hospital by a team of general and gastrointestinal surgeons and mesh hernioplasty performed on bilateral inguinal region. Intra-operatively, large hernia sac was present containing omentum and small bowel with only the proximal ileum A and B. A double-layered closure by prolene surgical mesh was done followed by reconstruction of the wall. This was followed by exploration of contralateral left inguinoscrotal hernia. Intraoperatively, we found hernia sac containing omentum and small bowel with only the proximal jejunum lying within the sac. Adhesiolysis was done and manual reduction of hernia content was done through the deep inguinal similar to left inguinal hernia. Closure was done with Prolene Mesh followed by reconstruction of wall and bilateral inguinal drain was placed .Fig. 3ClPostoperatively, there was early return of bowel movement and mobilization. His intraabdominal pressure was monitored routinely to avoid abdominal compartment syndrome. No respiratory complication was seen during his stay in hospital. On the seventh postoperative day, the drain was removed before discharge. Small postoperative inguinal seroma developed which resolved within few weeks without surgical intervention. There was no evidence of recurrence at six months during follow up.3Giant inguinoscrotal hernia (GIH) is defined as hernia extending below the midpoint of inner thigh of a patient in erect position In 2013, Akpo conducted a study focusing on psychosocial aspects of bilateral GIH. The patients visited medical facility either due to inability of penetration or denial of sexual intercourse by partners. They presented late because of financial constraint or neglect of the disease despite understanding that surgery is necessary for treatment. These patients also experience difficulty in movement like our patient and at times face acute complications like bowel obstruction and acute retention of urine. These consequences significantly impair their quality of life. Our patient also experienced multiple episodes of acute retention of urine which can possibly be due to constrictive effect of enlarged scrotum on buried penis. In the same study, Akpo also gave classification of bilateral GIH for the first time Considering the rarity of the disease and unavailability of standard approach, dilemma exists among healthcare providers for management of GIH Trakarnsagna A et al. classified GIH into three types on the basis of extent of hernia sac, based on which management principles differ. In type I GIH (hernia that extends between midpoint of inner thigh and the midpoint of the mid-inner thigh and suprapatellar margin), hernioplasty with forced reduction with post-operative intra-abdominal and intra-thoracic pressure monitoring is considered enough. However, in other types, resection of contents or increased intra-abdominal volume procedures is warranted to prevent intra-abdominal hypertension One study conducted among 32 patients with type I GIH including a case of bilateral GIH showed that laparoscopic surgery using Transabdominal Pre-peritoneal (TAPP) approach with negative pressure drain can be performed with safety and low post-operative complications In type II and type III GIH with loss of domain, additional procedures to prevent ACS should be considered. Various approaches used for prevention are resection of hernia contents and procedures to enlarge intra-abdominal volume The techniques mentioned earlier are either used alone or in combination for GIH  as mentioned in some recent studies Despite emergency surgical intervention, a rare case of fatality in bilateral GIH has been reported in an obese patient presenting with respiratory distress 4Type I GIH, including bilateral GIH, can be treated safely with simple hernioplasty. However, patient should be monitored vigilantly for features of ACS and respiratory complications during the postoperative period. In type II and type III GIH, additional measures like resection of hernia contents or procedures to enlarge intra-abdominal space are required.The case report is exempt from ethical approval in our institution.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Sunil Basukala (SB), Sabina Rijal (SR), Narayan Thapa (NT), Rakesh Kumar Gupta (RKG) = Study concept, Data collection, and surgical therapy for the patientSB, SR, Bishnu Deep Pathak (BDP) = Writing - original draft preparationRM, SR, BDP = Editing and writingNT and RKG = senior author and manuscript reviewer.All the authors read and approved the final manuscript.Sunil Basukala.Not applicable.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.None.


For magnetic resonance imaging (MRI) of non-traumatic brachial plexus (BP) lesions, sequences with contrast injection should be considered in the differentiation between tumors, infection, postoperative conditions, and post-radiation changes. The most common non-traumatic inflammatory BP neuropathy is radiation neuropathy. T2-weighted images may help to distinguish neoplastic infiltration showing a high signal from radiation-induced neuropathy with fibrosis presenting a low signal.MRI findings in inflammatory BP neuropathy are usually absent or discrete. Diffuse edema of the BP localized mainly in the supraclavicular part of BP, with side-to-side differences, and shoulder muscle denervation may be found on MRI.BP infection is caused by direct infiltration from septic arthritis of the shoulder joint, spondylodiscitis, or lung empyema.MRI may help to narrow down the list of differential diagnoses of tumors. The most common tumor of BP is metastasis. The most common primary tumor of BP is neurofibroma, which is visible as fusiform thickening of a nerve. In its solitary state, it may be challenging to differentiate from a schwannoma.The most common MRI finding is a neurogenic variant of thoracic outlet syndrome with an asymmetry of signal and thickness of the BP with edema. In abduction, a loss of fat directly related to the BP may be seen.Diffusion tensor imaging is a promising novel MRI sequences; however, the small diameter of the nerves contributing to the BP and susceptibility to artifacts may be challenging in obtaining sufficiently high-quality images. •MRI allows narrowing the list of differential diagnoses of brachial plexus lesions.•MRI helps to distinguish neoplastic infiltration from radiation neuropathy in T2-weighted images.•Differentiation between tumors, infection, postoperative conditions and post-radiation changes is possible with contrast.•MRI helps to determine the extent of the infection.•Diffusion tensor MRI is a promising method for brachial plexus assessment. Traumatic lesions are covered in Part 2 .1.1In 75% of cases, the BP is composed of the anterior branches of the spinal nerves C5—Th1 Pre- or postfixed BP is a term concerning the BP position in relation to the craniocaudal axis of the spinal cord. The contribution of fibers from C4 is called prefixed, while the contribution from Th2 plexus is called postfixed. Significant discrepancies can be observed in determining the frequency of these variants from 15% 1.2Anatomical assessment of the BP starts with evaluating the spine, spinal cord, and roots of the spinal nerves. It should be noted that the roots of the spinal nerves are located in the intradural space in the subarachnoid space of the vertebral canal . The venFurthermore, the C5 and C6 roots fuse to form the upper trunk, the C7 root extends as the middle trunk, and the C8 and Th1 roots unite to form the lower trunk. Each trunk is divided into anterior and posterior divisions, which form the cords of the BP when joined. The medial cord is formed as a prolongation of the lower trunk. The lateral cord is formed by anterior divisions of the middle and upper trunk , Fig. 7.1.3Identifying BP components might be difficult, but helpful tricks can make the process easier and more effective. The tortuosity of BP increases from C5 to T1 1.3.1The first step is determining whether the spinal nerves C5 - Th1 form the BP . The spi1.3.2At the level of the scalenus muscles, the trunks of the BP descend inferolateral and slightly anteriorly and divide into anterior and posterior divisions. All trunks run parallel and then converge and become closer , Fig. 7.1.3.3The radial nerve is the largest and the most posteriorly located nerve running toward the humerus . The axi1.4In the adult, a proper anatomical approach is crucial for imaging of the BP disorders, and several MRI protocols have been proposed It is still unclear which method is more reliable in assessing a complex injury or pathology of the BP. The intradural part of the spinal nerves can be evaluated by CT myelography and MR myelography 1.5This group includes primary or secondary malignant or benign tumors, infections, inflammatory neuritis or neuropathy, compression of the BP, and thoracic outlet syndrome (TOS) 1.5.1Radiation neuropathy is the most common non-traumatic inflammatory cause of BP neuropathy and is seen when the cumulative dose of radiation exceeds 60 Gy 1.5.2Inflammatory BP neuropathy manifests as an acute onset of burning pain in the shoulder, subsequent sensory disturbances, muscle weakness, and atrophy Parsonage-Turner syndrome is the classic presentation of a BP inflammatory neuropathy and starts with a unilateral onset of continuous pain in the shoulder and arm. As it causes muscle denervation, it may be confused with rotator cuff pathology. Usually, the diagnosis is based on medical history, clinical examination, and electromyography. MRI is usually applied in atypical cases or if there is an unclear history of trauma. MRI may reveal nerve edema and higher signals on T2-weighted sequences  [26], . AbAnother rare tumor is the plexiform neurofibroma Tumor or tumor-like lesions close to the BP may compress or displace it , Fig. 121.5.4.3The neurovascular bundle to the upper limb comes from the thoracic outlet and the neck. Anatomically, the thoracic outlet is limited by the Th1 posteriorly, the first rib laterally, and the manubrium sterni anteriorly. The thoracic outlet's central part contains structures passing between the neck and mediastinum, among other subclavian vessels, while the lateral part contains the apex of the lung covered by the pleura. The thoracic outlet space is related to other compartments like the scalene triangle containing the BP and subclavian artery, the costoclavicular space, and subcoracoid space with the entire neurovascular bundle MRI findings, which can be suggestive for neurogenic TOS, are sometimes discreet. The most common, however non-specific, is asymmetry and edema in the BP , Fig. 161.5.4.4Water diffusion imaging of the brachial plexus may contribute to evaluating nerve tissue arrangements on the molecular level However, with the progress of surgical treatment, this method will probably become more applicable in clinical practice 1.5.4.5The identification and description of non-traumatic pathologies involving the brachial plexus need to be systematic and detailed based on anatomical localization because it includes diverse lesions. Imaging findings need to be correlated with clinical data to achieve a correct diagnosis. MRI may help narrow down the list of differential diagnoses and plan further invasive diagnostics such as biopsy or to plan radiotherapy.Not applicable. No ethics approval is required for this educational review.Not applicable. The manuscript does not contain the data of individuals in any form.This project received no funding.PS conceived the idea of the pictorial review to publish in this study. PS selected appropriate MRI figures. PS, MG, BC, AMG analyzed and annotated the chosen images. BC prepared anatomical specimens. PS, AMG, and MG wrote the first draft of the manuscript. All authors read and approved the final manuscript.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Congenital nasal dorsum cysts are very rare lesions. Its differential diagnosis lies between gliomas, dermoid cysts and encephaloceles. We present a case of solitary congenital external nasal cyst with no intranasal fistulous tract connection in a newborn. Histopathologic analysis of the mass demonstrated findings consistent with an external mucocele. Total excision with external open approach provided the cure with good cosmetic outcome. This is the first report presenting an external mucocele in a newborn in the literature. External mucoceles should be kept in mind in the differential diagnosis of congenital nasal dorsum masses. Congenital nasal dorsal masses are rare, but mostly well-known pathologies. Differential diagnosis of these nasal lesions includes nasal dermoid cysts, gliomas and encephaloceles .In this article we report the case of a newborn with a congenital external mucocele located on the tip of the nose. To the best of our knowledge, such a malformation in a newborn has not been described in the literature to date.A one-month-old male baby was observed to have a lesion on his nose at birth. The 2x2 cm, cystic and round shaped mass was located on the tip of the nose . Magnetic resonance imaging (MRI) showed a well-circumscribed, T2 hyperintense, homogeneous cystic mass on the tip of the nose with no evidence of any fistulous tract into the cranial or nasal cavity .Direct open approach with an alar rim incision was used to remove the cyst. The cyst was just under the skin without any connection to the cartilages of the nasal dorsum . We did Histopathologic examination revealed an external mucocele composed mainly of ciliated epithelium and regions of focal pseudostratified columnar epithelium without lymphoid tissue, seromucous gland, goblet cell, or crypt. Pressure atrophy caused by fluid accumulation was observed in the epithelial lining of the cyst .The tip of the nose was packed for two days after the operation. There was no complication during or after the operation. The patient’s appearance one month after the operation is shown in Informed consent was taken from the father of the patient for publication.Mucus retention cysts, benign skin adnexal tumors, cholesterol granulomas, dermoid and epidermoid cysts and encephalocele are included  in the differential diagnosis of a nasal mucocele , 3, 4.After detailed histopathological examination, presented case was diagnosed as an external mucocele. Histopathologically, the most similar lesions to our case are the cyst formations following rhinoplasty. The sites of these cysts vary from the glabellar region to the tip of the nose and the paranasal sinuses. Herniation of the mucosa, interposition or inoculation of the nasal mucosa are supposed to be the most accepted explanations of this entity , 5.Similarly, in our case, proliferation of the cells in an ectopic mucous membrane island seems to be an acceptable theory of etiology. Occlusion of sebaceous glands, as reported by Rettinger and Steininger , can alsComprehensive physical examination is important for diagnosis. Also, preoperative imaging of nasal congenital lesions is an essential tool to confirm the diagnosis. It is important to bear in mind intracranial extension of intranasal masses. Understanding the extent of the lesion with MRI will help to tailor the surgical approach, hence completely excise the lesion and prevent recurrences. In this type of lesions, it is also important to remove the cyst and the fistulous pathway in the same session to avoid possible infectious complications , 7.Given the risks of exposure to radiation, computed tomography scanning is not always necessary for diagnosis in young children, as in our case, when MRI findings provide adequate preoperative information. In patients with uncertain MRI findings or when further bone anatomy evaluation is needed, computed tomography scan can also be performed . MRI finThe treatment of choice is complete excision with intact capsule. For similar nasal masses, open or closed rhinoplasty approach, endoscopic excision or direct excision with external skin incision can be preferred , 7. ConsMain Points• Nasal dorsum cyst in a newborn is a rare lesion.• Nasal dermoid and epidermoid cysts, gliomas, encephaloceles, benign skin adnexal tumor and cholesterol granulomas are well-known lesions in differential diagnosis.• In patients with congenital nasal masses preoperative radiologic examination is crucial for differential diagnosis and for determining the extension of the lesion and the appropriate surgical planning.• External mucoceles of the nasal dorsum are cyst formations that have been reported following rhinoplasty. However, external mucocele formations in the nasal dorsum can also occur as congenital lesions.


Renal cell carcinoma (RCC) is the most common neoplasm that arises from renal parenchyma. About one-third of patients with RCC develop metastatic spread, with common sites including the lung, liver, bone, adrenal gland, and brain. Distant metastases can be difficult to detect unless symptoms appear. We report a case of a 56-year-old female who presented to the emergency department with the unresponsiveness of unknown duration. She underwent a thorough laboratory workup, and the computed tomography (CT) scan revealed a retroperitoneal mass originating from the right kidney and a large hemorrhagic brain mass in the left frontal lobe. The patient underwent emergent full craniotomy for tumor removal, and histology confirmed metastatic RCC. Since several patients with RCC are asymptomatic, the slow growth of tumors leading to distant metastasis can be overlooked. Thus, this case demonstrates the importance of early detection of RCC to help prevent or delay further disease progression. Renal cell carcinoma (RCC) accounts for about 5% of cancer in adult men and 3% in adult women; it is the most common primary renal neoplasm accounting for about 90% -2. Risk A 56-year-old previously healthy woman without an established primary care physician (PCP) was brought to the emergency department by paramedics for unresponsiveness of unknown duration. In the emergency department, initial vital signs were within normal limits, besides a Glasgow Coma Scale score of six. Physical examination revealed abdominal distension with a large firm mass located in the right upper and lower quadrants. Myoclonic jerks, tongue injury, drooling and evidence of urinary or fecal incontinence were not observed. Laboratory data, including complete blood count, comprehensive metabolic panel, and urine toxicology, were unremarkable. Computed tomography (CT) scan of the brain without contrast showed a large left frontal lobe mass measuring 4.5 x 5.2 cm with acute intraparenchymal hemorrhage, edema, and mass effect Figure . FurtherThe patient was started on dexamethasone to reduce tumor-associated vasogenic cerebral edema and levetiracetam for seizure prophylaxis. The following day, she was alert, awake, oriented, and following commands. The patient later commented that she felt fine before passing out and denied fever, unintentional weight loss, fatigue, headache, dizziness, visual disturbance, abdominal pain, nausea, vomiting, change in bowel habits, hematuria, or seizure activities. Past medical history was significant for fatty liver disease and leiomyoma of the uterus. She denied personal history or known family history of malignancy. She was not taking any medications at home and denied using tobacco, alcohol, or recreational drugs. The patient’s mental status significantly improved over the hospital course, and she was discharged on dexamethasone for 10 days along with levetiracetam. She was cleared by neurosurgery and urology for discharge. She elected to follow-up with urology as an outpatient for cytoreductive nephrectomy evaluation and with oncology for bone scan for completion of staging.RCC accounts for approximately 2%-3% of all adult malignant neoplasms and 80%-85% of primary renal tumors . RCC canIn regards to diagnostic imaging, a contrast-enhanced, triple-phase helical CT scan is the preferred imaging study to evaluate renal masses as it can identify pathological features . ImagingThis case highlights the importance of annual physical exams, general health screening, and evaluation by PCPs. It is noted that more than 50% of patients with RCC are asymptomatic and, therefore, diagnosed incidentally . A retroThis case demonstrates the importance of early detection of RCC in preventing distant metastasis. Our patient lacked obvious risk factors for RCC and was asymptomatic until the day she presented with syncope. With the slow growth of renal cell cancer, distant metastasis can occur for an extended time without notice. A delay in diagnosis can lead to catastrophic consequences, as seen in our patient. Although periodic screening for RCC in asymptomatic individuals is not recommended unless they have high-risk factors, annual physical exams and proper use of routine labs at PCP’s office may enable prompt diagnosis of RCC and prevention of further complications.


Mediastinal schwannomas are sometimes confused with other neoplasms during initial radiological studies, especially when there is a history of cancer in another area. In these cases, a more accurate analysis using computed tomography (CT) or even magnetic resonance (MRI) is required. Our study aimed to perform a retrospective analysis of the clinical and imaging features for a series of patients with mediastinal schwannomas that were confirmed by histology and immunohistochemistry.We found eight patients, five men and three women, with an average age of 51 years for this study. The main signs and symptoms at diagnosis were chest pain, dyspnea, cough, and dysphagia. CT showed that the tumor was located in the posterior compartment of the chest in 7/8 cases. Tumors > 10 cm were more heterogeneous and showed cystic changes. All patients underwent posterolateral thoracotomy, and radiological follow-up showed no evidence of recurrence. Histological analysis was considered the gold standard to confirm diagnosis, along with at least one neurogenic IHC marker. In conclusion, mediastinal schwannomas are benign encapsulated tumors. According to CT, schwannomas > 10 cm show cystic degeneration more frequently. Posterolateral thoracotomy allows complete resection and is considered the surgical approach of choice.The online version contains supplementary material available at 10.1186/s13104-021-05694-6. Schwannomas are benign neoplasms that arise from Schwann cells, which surround peripheral nerve fibers , 2. LessA retrospective and descriptive study was performed for patients with a mediastinal schwannoma diagnosis at UMAE Hospital de Oncologia, from January 2013 to January 2015. Permission was requested to access the clinical file to review patient records. Age, gender, time of evolution, type of treatment, and follow-up data were obtained from medical records. In all cases, telephone calls were made to complement follow-ups. Association with neurofibromatosis type 2, schwannomatosis, and Gorlin–Koutlas syndrome was also investigated. Chest CT and MRI scans from each patient were obtained from the radiology files and re-revaluated by two experienced radiologists (ALRC and LMH) who investigated the location, shape, size, and features of each lesion. In addition, a comparative analysis was made between the preoperative imaging studies (CT and MRI) and those performed during the follow-up of each patient after surgery to rule out disease recurrence. All cases were reevaluated by three experienced pathologists  using the WHO criteria .All tissues were fixed in formaldehyde buffered at 10% and paraffin embedded. Histological sections were stained with hematoxylin and eosin. For immunohistochemistry (IHC) analysis, 5-μm sections of a representative block were obtained for each case. The following antibodies were used: S100 protein (Biosb), glial fibrillar acid protein , CD34 (Biocare), and Ki-67 (Biosb), which were used for detection on an automated immunostainer , and ran with appropriate simultaneous positive and negative controls.During the period analyzed, 163 primary soft tissue tumors of the mediastinum were resected, of which only eight corresponded to mediastinal schwannomas (5%). Five men (63%) and three women (37%) with average age of 51 years range 32–78 years). The average age for women was 43 years versus 56 years for men. Seventy-five percent of the patients had symptoms. The clinical manifestations were chest pain in four patients (64%), dyspnea (17%), cough (17%) and dysphagia (17%), in one patient respectively. Two patients were asymptomatic (25%). No weight loss was found for any of the patients. The average clinical evolution time was 4 months (ranging from 1 to 6 months). No associations with neurofibromatosis type 2, schwannomatosis, or Gorlin–Koutlas syndrome were found for any of these cases  according to CT, and in one case the mass was located in the posterior upper para-esophageal compartment. No patient showed evidence of tumoral activity elsewhere. In all cases, the mass was ovoid and well-defined. In four cases, the lesion was homogeneous, and in the other four cases it showed heterogeneous reinforcement with hypo and hyperintense areas after the application of contrast material Fig. a, b. DurMacroscopically, all cases were solitary tumors, with ovoid growth, encapsulated and with a gray-yellow outer surface. The average size of the tumors was 8 cm (range 3.5–14.0 cm). The average size of the tumors for the group of women was 8.6 cm (range 4.0–14.0 cm) versus 7.16 cm in the case of men (range 3.5–11.0 cm). Fifty percent of the tumors showed cystic degeneration. These tumors had an average size of 10.0 cm (ranged between 7.0 and 14.0 cm), in contrast to tumors without cystic changes, which had an average size of 5.4 cm (ranges between 3.5 and 8.0 cm) , Fig. a. Four cBy IHC, all cases were intensely positive for the S100 protein in nucleus and cytoplasm, and showed a focal expression of GFAP, mainly in Antoni A areas. None of the cases showed CD34 expression. The proliferation index according to Ki-67 was less than 1% in all cases. One case (case #5) showed hypercellularity with a storiform pattern in approximately 50% of the tumor, mimicking a solitary fibrous tumor. However, the neoplastic cells were positive for two neurogenic markers (S100 protein and GFAP) and negative for CD34  post-surgery. Four patients were found alive without clinical or radiological recurrence of the disease at their last visit. One patient died from diabetes mellitus (DM) complications, with no mediastinal tumor activity during the 72-month follow-up. There was no malignant transformation of the disease diagnosed for any of the patients.Less than 9% of all schwannomas occur in the mediastinum , 4, 11. Mediastinal schwannomas can originate from spinal, paravertebral sympathetic branches of vagus, phrenic and intercostal nerves, respectively –3, 12. ICT and MRI can help to accurately determine the exact location of the mediastinal tumor and its relationship to adjacent structures. On CT scanning, schwannomas appear a as well-defined rounded mass with smooth margins, low densities and mild enhancement in the paravertebral region, and long along the courses of intercostal nerves –8, 14. TTypically, mediastinal schwannomas measure less than 10 cm. However, there are a few case reports of giant mediastinal schwannomas that have measured between 13 and 23 cm –8. These18F-fluorodeoxyglucose positron emission tomography and computed tomography (18F-FDG PET/CT), mediastinal schwannomas can simulate metastases of breast cancer lymph nodes, as shown by Martinez-Esteve et al. [Mediastinal schwannomas can be misdiagnosed as lymph node metastasis . The clie et al. . SimilarIn 1981, Woodruff et al.  describeSchwannomas are slow-growing tumors with a proliferation rate of 2% to 3% , 22. HowMediastinal schwannomas are benign encapsulated tumors, and are more frequently located in the posterior compartment when using CT. Tumors > 10 cm are usually heterogeneous with cystic degeneration. Histological analysis remains the gold standard to confirm the diagnosis along with IHC markers that include at least one neurogenic marker.This is a retrospective study with a small sample.Additional file 1: Table S1. Summarizes the clinical and image characteristics of all patients.Additional file 2: Table S2. Morphological characteristics of eight cases of benign schwannomas of the mediastinum.Additional file 3: Fig S1. Mediastinal schwannoma (Case 7): a) Preoperative MRI for T2 sequence shows a right paravertebral mediastinal mass, which was ovoid with smooth edges, solid, and measuring 89 × 70 × 55 mm; b) Heterogeneous reinforcement after the application of intravenous contrast, without pleural infiltration, to either vertebral bodies or vascular structures; c) Follow-up CT three years after surgery only shows focal pleural thickening, with a homogeneous oval appearance in the upper right lobe posterior segment, measuring 3.4 × 1.6 cm, and a mean density of 10 HU (red asterisk), compatible with scar, and without evidence of tumor activity.


Although primarily a respiratory virus, coronavirus-19 acts on the gastrointestinal tract to cause symptoms such as anorexia, nausea, vomiting and diarrhea. One possible mechanism involves the ACE2 receptor, which serves as the primary receptor for virus entry into the gastrointestinal epithelium. We describe the case of a 54-year-old-male with recent coronavirus disease 2019 (COVID-19) infection, who later presented with nausea, vomiting, diarrhea and progressively worsening diffuse abdominal pain for 1 week. He was diagnosed to have a small bowel obstruction; however, continued to have progressively worsening pain and failed conservative management. No cause for the obstruction was found in the operating room. Gastrointestinal involvement occurs in at least two-thirds of patients with coronavirus infection. Viral entry into the small bowel, triggering an inflammatory response, and virus-induced microthrombosis of the microcirculation have been postulated as a possible mechanism for paralytic ileus/small bowel obstruction. Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although primarily a respiratory virus, it acts on the gastrointestinal (GI) tract to cause symptoms such as anorexia, nausea, vomiting and diarrhea .Small bowel obstruction (SBO) refers to a partial or complete blockage that prevents progression of abdominal contents through the intestinal tract. The most frequent causes include postoperative adhesions, hernias and neoplasms. Less common causes include intussusception, volvulus, Crohn’s disease and appendicitis. The predominant symptoms are obstipation/constipation, abdominal distension and vomiting (often bilious). Diagnosis is made through physical examination and imaging. On computerized tomography (CT) scan, SBO is identified with dilated loops of bowel (>2.5 cm) proximally and collapsed loops distally . FindingWe describe the case of a patient who presented with a small bowel obstruction possibly due to a COVID-19-related ileus. In the operating room, a cause for the obstruction could not be found.This case is a 54-year-old-male with past medical history of obesity, laparoscopic cholecystectomy, recurrent small bowel obstructions in 1997 and 2006 resolved with supportive care and COVID-19 infection in December 2020 who presented to the Emergency Department with nausea, non-bilious vomiting, non-bloody diarrhea and progressively worsening, sharp, diffuse abdominal pain for 1 week. On physical examination, he had diffuse abdominal tenderness. His white blood cell count was 3.8, consistent with his recent COVID-19 infection. Abdominal CT showed partial small bowel obstruction with a transition point in the right lower quadrant as well as fluid in the colon and throughout the bowel . The patIn the operating room, a midline longitudinal incision was made. The small bowel was found to be dilated but there was no definite transition point of obstruction found. There were some adhesions in the right lower quadrant around the appendix and the cecum, but no obstruction was found.Postoperatively, the patient remained NPO with an NG tube for 8 days. On Day 9, his abdominal X-ray  was muchGastrointestinal involvement occurs in at least two-thirds of patients with SARS-CoV-2 infection . It enteAnother possible mechanism of paralytic ileus includes virus-induced microthrombosis of the microcirculation resulting in dilation within the large and small bowel . Viral iPreviously published cases include an 80-year-old female who presented with a 10-day course of fevers, chills and productive cough . On physAnother case involved a 53-year-old male patient who presented with abdominal discomfort and distension, progressively worsening obstipation and fever that had worsened over 2 days . AbdominPossible causes of COVID-19-related ileus include hypercoagulability causing microthromboses and inflammation mediated through ACE2 receptors. Patients present with abdominal pain and distention, nausea, vomiting, obstipation, guarding, rebound and/or peritonitis. Alter the management of patients with gastrointestinal predominant symptoms, starting them on a bowel regimen and anticoagulation early could prevent small bowel obstruction or ileus and prevent its complications.


Teaching point: Unexplained persistent perineal pain poses a differential diagnosis, including pelvic nerve lesions. The rare occurrence of pelvic schwannoma is easily shown by a MRI as a T2-hyperintense enhancing mass. A 60-year-old woman in good general condition complained of right-sided perineal pain in sitting position. The clinical examination found an ovoid mass to the right of the rectovaginal septum, palpation of which triggered very painful dysesthesia.Figure 1) in the sagittal (A–D) and axial  planes showed a well-defined 20 mm mass on the right postero-lateral side of the rectovaginal septum, making a protrusion in the pouch of Douglas. This anomaly is T1 isointense ; T2 hyperintense, with a well delimited hypointense periphery ; causes restriction on diffusion-weighted imaging , without apparent diffusion coefficient decrease ; and lastly, intensely enhances after injection of gadolinium .Subsequent magnetic resonance imaging (MRI)  and eccentric to the nerve.Perineal pain is a frequent complaint especially amongst women, and it can have different origins: ligament, muscular, nervous, hernia, prolapse, infectious, inflammatory or tumoral.In the case of a perineal mass, the most frequent benign nodule is endometriosis which typically has, unlike in the present case, a high T1 signal and/or a low T2 signal depending on its subtype.Schwannomas, though rare in the perineal region, are the most common benign tumors of the peripheral nerves, recognizable on MRI, as in the present case, with intensely high T2 signal and enhancement after injection of contrast .Malignant masses such as adenocarcinoma, GIST, and metastasis have less-intense T2 signal and heterogenous enhancement. Furthermore, other imaging findings  and patient history are suggestive.


Non-traumatic hemoperitoneum was a rare event with the risk of sudden death. Spontaneous rupture of hepatocellular carcinoma is the most intuitive diagnosis when hemoperitoneum occurs in cirrhotic patients who are not regularly followed up. However, other etiologies of hemoperitoneum, such as intra-abdominal varix rupture, should be kept in mind.A 44-year-old man with alcoholic liver cirrhosis, Child–Pugh B was sent to our emergency department (ED) because of recurrent abdominal pain and hypovolemic shock. He had similar symptoms one month ago and was diagnosed as hepatocellular carcinoma (HCC) rupture with hemoperitoneum, therefore he underwent trans-arterial embolization (TAE). However, the follow-up magnetic resonance imaging (MRI) showed less possibility of hepatocellular carcinoma. Contrast enhanced abdominal computed tomography (CT) showed possible umbilical vein contrast agent extravasation. Exploratory laparotomy confirmed the diagnosis of rupture umbilical varix with hemoperitoneum.Although umbilical varix rupture is a rare cause of hemoperitoneum, it should be kept in mind in cirrhotic patients with unexplained hemoperitoneum.The online version contains supplementary material available at 10.1186/s12876-022-02167-3. Hepatocellular carcinoma (HCC) is a late complication of chronic hepatitis B, chronic hepatitis C and alcoholic liver cirrhosis. The incidence of HCC in Taiwan is approximately 30/100,000 . MeanwhiA 44-year-old man with a history of alcoholism and hypertension without regular medication control, presented with a sudden abdominal pain, dizziness, and loss of consciousness twice in 2 h. This patient was brought to our ED. At ED, the temperature was 36.5 °C, the blood pressure 84/42 mm Hg, the pulse 92 beats per minute, the respiratory rate 32 breaths per minute, and the oxygen saturation 95% while he was breathing ambient air. The level of consciousness was E4V4M6 but lethargy. Physical examination revealed abdominal muscle guarding with whole area rebounding pain. The lab data at ED were white blood cell (WBC) 6360/ul; hemoglobulin (Hb) 5.9 gm/dl; prothrombin time (PT) 11.9 s; aspartate aminotransferase (AST) 77 IU/l; alanine aminotransferase (ALT) 28 IU/l; total bilirubin (T/B) 1.0 mg/dl; and albumin (ALB) 2.8 gm/dl. Contrast enhanced abdominal CT presented hemoperitoneum without definite active contrast extravasation, irregular liver contour and one atypical hepatic lesion was noticed at S4 segment (Additional file Sixty-six days after last discharge, the patient was brought to our ED again due to aggravated abdominal pain and malaise for 2 days. Vital sign showed as follow: the temperature was 36.9 °C, the blood pressure 77/44 mm Hg, the pulse 95 beats per minute, the respiratory rate 19 breaths per minute, and the oxygen saturation 97% while he was breathing ambient air. The level of consciousness was E4V4M6 but obtundation. The blood test at ED showed WBC 9140/ul; Hb of 6.9 gm/dl; PT 10.9 s; AST 27 IU/l; ALT 20 IU/l; T/B 1.1 mg/dl; and ALB 2.3 gm/dl. Sonography showed massive ascites, and bloody contents were observed during abdominal paracentesis. Abdominal CT demonstrated a dilated tubular structure originated from falciform ligament with contrast enhancement. In non-contrast phase, there was an adjacent high-density content beside umbilical area (Fig. Non-traumatic hemoperitoneum in patients with cirrhosis is fatal and emergent. When spontaneous hemoperitoneum occurs, we should evaluate the possibilities of hepatocellular carcinoma, ovarian carcinoma, hemorrhagic pancreatitis, and rupture of intra-abdominal varices , 3. If tThere is no meta-analysis or systemic review for the investigation of intra-abdominal varix rupture . HoweverBased on the surgical review, in 20% cases of varies rupture related hemoperitoneum caused by recanalized umbilical vein . To the Back to our case, there was no case report presented both liver nodular lesion and co-existed varix. Rupture of HCC with self-limited bleeding listed to the most possible diagnosis in this patient without records of previous esophageal or gastric varices bleeding. Nevertheless, we ought to consider the possibility of intra-abdominal varix rupture when the image of MRI revealed HCC less likely. This case informed us that we should keep in mind of the diagnosis of umbilical varix rupture in patient of spontaneous hemoperitoneum.Additional file 1. The result of contrast enhanced abdominal CT showed one atypical hepatic lesion at S4 segment.Additional file 2. This is a supplementary video demonstrating tortuous and engorged umbilical varix rupture with active oozing was ligated successfully through exploratory laparotomy.


Angioma serpiginosum is a rare benign nevoid disorder affecting the small vessels of the upper dermis. We are presenting a case of this rare disease in an 11‐year‐old girl who presented with this condition on abdomen in zosteriform pattern which is rare presentation and is the first of its type. Angioma serpiginosum is a rare benign nevoid disorder affecting the small vessels of the upper dermis. We are presenting a case of this rare disease in an 11‐year‐old girl who presented with this condition on abdomen in zosteriform pattern which is rare presentation and is the first of its type. We are presenting a case of this rare disease in an 11‐year‐old girl with multiple progressive asymptomatic scattered and confluent punctate erythematous to violaceous macules over the left side of the abdomen in T8‐T10 dermatomal distribution with normal surrounding and intervening skin since birth. Histopathological examination (HPE) revealed few ectatic congested thin‐walled blood vessels in papillary dermis with few areas of downward growth of the rete ridges between these blood vessels. Based on the clinical and the HPE, a diagnosis of angioma serpiginosum was made. This rare vascular anomaly and abdomen involvement with zosteriform distribution are rarely reported in the literature.Angioma serpiginosum is a rare benign primary telangiectatic disorder affecting the capillaries of the upper dermis characterized by asymptomatic pinpoint macules that group together in linear, serpiginous, or gyrate patterns.2An 11‐year‐old girl presented with multiple asymptomatic erythematous lesions on the left abdomen which was first noticed by her mother as multiple red pinhead‐sized lesions during birth. The lesions progressively extended with new satellite lesions appearing around the previous ones with the increasing age. There was no family history of similar skin lesions. There were no visual or neurological symptoms.Cutaneous examination revealed multiple discrete and confluent punctate erythematous to violaceous macules on the left abdomen in T8 to T10 dermatomal distribution with normal surrounding and intervening skin  is a rare vascular disorder described first by Hutchinson in 1889 as a “serpiginous or infective nevus” and then named by Crocker in 1894.15The condition usually starts in childhood or birth with a female predominance.In our case, the patient presented with localized telangiectasia without skin atrophy. The differentials for the condition include Angioma serpiginosum, capillary malformation, unilateral nevoid telangiectasia, and purpuric conditions.None.KA: concept, manuscript preparation, and literature search. PP: manuscript editing, guidance, and final approval. RS: histopathological reporting. MB: manuscript preparation and literature search. SS: manuscript editing and correspondence Author.Consent obtained from the parents of the patient for publication and use of the images.


Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal neoplasms of soft tissue or bone origin that can give rise to a challenge in diagnostic imaging. These tumors are frequently associated with tumor-induced osteomalacia, also called oncogenic osteomalacia, which is a rare paraneoplastic syndrome characterized by ectopic secretion of fibroblast growth factor 23, a hormone that regulates serum phosphate level. PMTs show polymorphic features on both radiological findings and histological examination, causing problems in diagnosis owing to their similarity with other mesenchymal tumors. Thus, this paper aims to describe radiological aspects of PMTs and suggest an imaging pathway for accurate diagnosis throughout the evidence from the literature review. Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal neoplasms of soft tissue or bone origin that can give rise to a challenge in diagnostic imaging. These tumors are frequently associated with tumor-induced osteomalacia (TIO), also called oncogenic osteomalacia, which is a rare paraneoplastic syndrome characterized by ectopic secretion of fibroblast growth factor 23 (FGF-23). FGF-23 regulates serum phosphate level reducing its renal reabsorption  and causThe vast majority of PMTs occur in middle-aged adults and are small and undetectable on physical examination . They afX-rays are often the first radiological technique performed in symptomatic patients. Common plain radiographic findings include coarse trabeculae, thinned-out cortex, and Looser’s zones, manifestations of generalized osteopenia in adults, and rickets in children . X-rays Ultrasonographic characteristics of PMTs were described by Busquet et al. in a mass located in the right thigh which presented a heterogeneous and hypoechoic structure with well-circumscribed edges . This leComputed tomography (CT) is another imaging technique often used to localize or characterize PMTs. They can easily mimic other pathologies; thus, a high index of suspicion, based on the pattern of fractures, osteomalacia, and characteristics of the mass, should help with diagnosis. PMTs are generally small in size with an average diameter reported as 3.4 cm (1.1–9.8 cm) . LesionsMagnetic resonance imaging (MRI) has been reported to aid in localizing lesions in cases not previously demonstrated on plain radiographs or CT , 26. PMTPMTs are small, slow-growing tumors that often develop in unorthodox locations such as the mandible, ribs, or sinuses; in these cases, CT and MRI can be non-contributory to their localization; thus, it is necessary to resort to functional diagnosis . In the PMTs remains a relatively rare entity, proving challenging to diagnose because of their heterogeneous morphological aspects on imaging. These can mimic other similar bone or soft tissue neoplasms leading to a delayed diagnosis or in the worst case, a missed diagnosis on imaging. Therefore, throughout the evidence from the literature review, this study aims to suggest an imaging pathway for accurate diagnosis. Firstly, correlation with clinical presentation and laboratory findings is mandatory. Once a lesion is identified clinically and is palpable, an initial radiograph or a CT can be used to localize and classify the lesion, into appendicular and axial skeleton-based neoplasms . Appendi


He subsequently reported spontaneous extrusion of the broken rod through the gluteal skin, without the need for surgical removal. This case is reported for its rarity and to raise awareness about the rare occurrence of rod migration after breakage that can lead to potential complications if left unattended.Instrumented fusion with rods and pedicle screws is often performed for the surgical treatment of adult spinal deformity (ASD). One of the complications of such long construct fusions is that of pseudoarthrosis, which can present with implant loosening, failure, and rod breakage. However, migration and spontaneous extrusion of the rod is relatively rare and has yet to be reported in the literature. We report a gentleman with previous long construct instrumented fusion done six years ago for ASD, who presented with gluteal pain. Radiographs revealed rod breakage and caudal Adult spinal deformity (ASD) is of increasing concern as our population ages and life expectancy increases, along with improved access to healthcare resources. ASD may result in significant physical disability, with adverse effects on one’s mental health, self-rated quality of life, and health status as a whole . In the A 73-year-old gentleman underwent staged lateral lumbar interbody fusion (LLIF) from L2 to L4, followed by posterior instrumentation from T10 to the ilium with L2-L5 posterolateral interbody fusion and L5/S1 transforaminal interbody fusion six years prior. He developed proximal junctional failure of the T10 pedicle screws 10 months later and underwent revision instrumentation from T5 to the ilium. Postoperative recovery was uneventful and subsequent radiographs showed good restoration of alignment.However, he returned to the outpatient department reporting acute left buttock pain for one month with pain on sitting, as well as implant prominence over the left gluteal region. On examination, there were no swelling or skin changes over the left gluteal region. However, there was prominence of the rod on deep palpation as well as tenderness over the left gluteal region. Lumbar spine radiographs showed broken rods bilaterally with caudal migration of the rod on the left Figure ,B.A CT scan was arranged which demonstrated pseudoarthrosis at L5/S1, and the absence of the rod on the left Figure ,B. At thImplant-related complications are widely recognized to be a leading cause for revision surgery in the treatment of ASD. Rod fracture has been reported to be the most common of implant-related complications , with anPrior authors have identified risk factors for rod fracture in ASD, such as a greater preoperative sagittal imbalance, a greater preoperative thoracolumbar kyphosis, and the use of smaller diameter rods . In our In the case presented, the rod fracture was accompanied by loss of fixation to the pedicle screwhead, resulting in distal migration of the rod. Rod migration, although extremely rare, has also been reported, with instances of rods migrating to regions ranging from the knee to the pelvis -6. This Although rod breakage may be a relatively common complication of ASD surgery, resultant sequelae such as rod migration remain relatively rare. However, it is important to be vigilant in the follow-up of patients undergoing ASD surgery, as rod breakage and migration due to pseudoarthrosis can lead to serious neurological, visceral, and vascular sequelae. We present the first known case of caudal rod migration with spontaneous extrusion from the skin in a patient with previous long-construct instrumented fusion.


Described is a case of diffuse large B cell lymphoma that presented within a typical fistula tract, possibly secondary to oxidative stress within the fistula tract itself and consequent malignant change rather than a fistula as a consequence of necrosis in a lymphoma. If so it would be unique in the world literature. A 42-year-old fitness instructor presented with a typical appearing left lateral anal fistula. Biopsy of the fistulous tract revealed B cell lymphoma, graded 1E. Although chemotherapy cured the lymphoma, surgical treatment by ligation of the inter-sphincteric fistula tract was required to heal the fistula. At 3-year follow-up, there has been no recurrence of the lymphoma or the fistula. Neoplasia arising secondary to oxidative stress within an anal fistula is a well-established phenomenon. Early diagnosis of rare conditions associated with anal fistula can only be accomplished by routine biopsy of every fistula tract. In contet al.  with moret al. . We repoA 42-year-old female was referred for the investigation of anal pain for which 4 weeks earlier she had undergone an incision and drainage of a perianal abscess at a teaching hospital. Pus for culture (but no tissue sample) was taken. On examination, there was an external opening evident in the 4 o’clock position about 2 cm from the anal verge. In the light of an altered bowel habit, she underwent colonoscopy with no additional findings. EUA confirmed a trans-sphincteric fistula involving the lower one-third of the external anal sphincter. The distal part of the tract was partially excised for histology and a loose seton inserted. Histopathology showed a sinus tract lined by inflammatory granulation tissue but which was infiltrated by sheets of lymphocytes and plasma cells with clusters of medium and large lymphocytes, centroblasts and immunoblasts. The cells showed no viral cytopathic effects. Adjacent mature fibrous tissue showed patchy mixed inflammatory cell infiltration  and 2. IImaging with MRI showed a trans-sphincteric fistula crossing the junction of the middle and lower third of the anal sphincters with a prominent left inguinal lymph node. A PET scan  showed aThe patient was commenced on R-CHOP , and after 3 cycles, there was a complete metabolic response on repeat PET scanning. Three months after surgery, the seton became dislodged. A repeat EUA was performed with reinsertion of the seton and an area of induration was noted between the 9 and 11 o’clock positions on the contralateral side, although without any evidence of an internal opening. The patient underwent a further 2 cycles of R-CHOP therapy. Repeat MRI confirmed the left-sided fistula with a new active tract on the right-hand side. This developed into a right perianal abscess which underwent incision and drainage. Biopsy of the right side showed no evidence of lymphoma. A left LIFT procedure was subsequently performed with ligation of the main tract in the inter-sphincteric space and a superficial secondary tract on the right side was divided and ligated. Histology showed no lymphoma. Infection in the inter-sphincteric space led to recurrence but repeat LIFT procedure plus a seton in the inter-sphincteric space resulted in closure . The fisin-situ hybridization [Primary lymphoma of the anal canal represents only about 0.1% of all anal malignancies . The majdization , 10.et al. [et al. [Similarly to our case, Yaprak et al.  have rep [et al.  proposedet al. [In perianal sepsis, the finding of a persistent pro-inflammatory cytokine profile in cryptoglandular fistulas  can precet al.  have demet al. .In summary, we have highlighted a rare case of B cell NHL of the anal region in an HIV-negative, non-immunocompromised patient. The course of this case raises the prospect that the lymphoma supervened on the fistula. In this patient, the lack of features in the initial presentation which suggested anything other than a simple fistula reinforces the importance of routine histopathology of perianal disease particularly where there is an underlying mass effect or in recurrent cases.