It is not usually applied to LAPC involving both the CA and the gastroduodenal artery (GDA) because transection of the GDA cannot assure hepatic perfusion. Preserving the replaced hepatic artery might allow combined resection of the GDA without revascularization.Distal pancreatectomy with A 78-year-old woman who was diagnosed with LAPC of the pancreatic head and body that invaded the GDA and proper hepatic artery, as well as the CA. The left hepatic artery (LHA) was solitarily branched from the left gastric artery (LGA), which was branched from proximal to the confluence of the CHA and the SpA. The root of the LGA was intact. We successfully performed DP-CAR with combined resection of the GDA, without revascularization, by preserving the LGA.This is the first English literature case of extended DP-CAR with preservation of the replaced LHA (r-LHA). Aberrant right and left hepatic arteries are common variations. Checking the arterial variations is very important when deciding the treatment strategy for LAPC, especially in cases that appear unresectable.Our case indicated that the r-LHA alone can supply the entire liver in extended DP-CAR. The resectability must be decided with close evaluations of the vessel variations and the tumor status. •Locally advanced pancreatic cancer involving celiac axis and gastroduodenal artery•DP-CAR with combined resection of gastroduodenal artery without revascularization•First English literature case of extended DP-CAR with replaced LHA preserved•Significance of arterial variations when deciding the treatment strategy She was also taking oral prednisolone. The last CT chest detected a pancreatic tumor and dilatation of the main pancreatic duct by chance. She was asymptomatic. Contrast abdominal CT showed a low attenuated tumor at the pancreatic head and body invading the GDA and PHA. Furthermore, the tumor had extended along the CHA beyond the root of the SpA and the abutment with the CA was recognized . EUS-FNA2 and nab-paclitaxel 125 mg/m2 on days one, eight, and 15 monthly. After six months, the tumor size was stable and was still in contact with the CHA, SpA, GDA, and PHA. The tumor marker levels were still within the normal range. The arterial phase of the contrast abdominal CT revealed that the left hepatic artery was solitarily branched from the LGA, which was branched from proximal to the confluence of the CHA and the SpA. The root of the LGA was not invaded by the tumor  by preservation of the replaced left hepatic artery. Our experience highlights the efficacy of preserving the replaced left hepatic artery and the importance of preoperative evaluation of arterial variations.First, extended resection of the right surgical margin and combined resection of the GDA in DP-CAR was possible because of preservation of the replaced left hepatic artery. The existence probabilities of aberrant right and left hepatic arteries are 14 % and 13 %, respectively Surgeons often encounter the r-RHA in pancreaticoduodenectomy. Usually, the r-RHA from the SMA runs dorsal of the pancreatic head and sometimes through the pancreatic head. When the r-RHA is invaded by a tumor, combined resection of revascularization of RHA is performed. There is a risk of lethal bleeding after pancreaticoduodenectomy in arterial reconstructions. Therefore, the efficacy and safety of combination therapy of preoperative coil embolization for the r-RHA and pancreaticoduodenectomy with combined resection of r-RHA without reconstruction was reported These procedures are also based on the theory mentioned above. This includes intrahepatic arterial blood flow communications and rapid development of collateral blood flow. Although there is concern regarding whether the replaced left liver artery can supply sufficient blood flow to the right lobe (that is bigger than the left lobe), the existence of collateral blood flow from the right inferior phrenic artery to the right lobe, as well as intrahepatic communication, is possibly associated with the feasibility of these surgical procedures including our case.Second, it is important to perform a detailed preoperative evaluation for arterial variation. This sometimes allows for resection of unresectable pancreatic cancer, and can avoid arterial reconstruction that enhances mortality risk. Pancreatic cancer that has contact with the CA is classified as “locally advanced” and is often resected via DP-CAR As described above, replacement of the hepatic artery is not rare. When deciding the treatment strategy for locally advanced pancreatic cancer it is important to check the arterial variations. Surgeons must consider that one side of the hepatic artery can adequately supply the entire liver in almost all cases.4We successfully performed DP-CAR with combined resection of the GDA (extended DP-CAR) by preserving the r-LHA. Our case is the first English literature report of the r-LHA solely supplying the entire liver in extended DP-CAR. It is also important to note that although the resectability status for pancreatic cancer is decided according to the National Comprehensive Cancer Network guidelines, true resectability must be decided with close evaluations of both the tumor status and the vessel variations.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.No ethical approval was required for the present case report. The patient consented to the publication of this case report.Written informed consent was obtained from the patient's next of kin for publication of this case report and any accompanying images. 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.All relevant data are provided in the manuscript.Tetsunosuke Shimizu: Conceptualization, Methodology.Koji Komeda: Data curation.Atsushi Tomioka: Writing - Original draft preparation.Nao Kawaguchi: Visualization, Investigation.Mitsuhiro Asakuma: Writing - Reviewing and Editing.Sang-Woong Lee: Supervision.Not yet.Atsushi Tomioka MD.PhD.There are no conflicts of interest to declare.


Rosai Dorfman disease is a rare benign histiocytoproliferative disorder that occurs in the intracranial area, which occurrs typically in lymph nodes. Extrapnodal Rosai Dorfman disease rarely develops in the central nervous system and is often a focal lesion based on the dura. Based on imaging and clinical symptoms, RDD may be misdiagnosed as meningioma, and some lesions can also occur in the brain parenchyma. In the case of benign disease, the final diagnosis is made by pathological tissue diagnosis. For chronic diseases, progression may be chronic or remitting and relapsing.A 54-years-old man was hospitalized after experiencing paroxic convulsions and being unconsciousness. A head magnetic resonance imaging demonstrates a strip of lesions in the right parietal lobe. No obvious abnormality is found in the laboratory data.We diagnosed meningioma of right parietal lobe and secondary epilepsy, and prescribed oral sodium valproate to treat him.The lesion is located in the right parietal lobe on neuroimaging prior to surgery, which was taken for immunohistochemical examination.If it is found that immunohistochemistry reveals histiocytes are positive for CD68, S-100, but negative for CD1a, it is identified as RDD. For patients who are seizure-free following surgery, symptomatic management is used. Following parietal lesion resection, patients are seizure-free during the follow-up period (44 months).Basing on studying and summarizing relevant literatures, RDD is described in the report in terms of its diagnosis, pathology, treatment, and clinical outcome, in order to improve the diagnosis and identification of intracranial RDD by physicians. In accordance with the extent of lesion, types of RDD can be classified as lymph node, cross-domain, and mixed. The most commonly involved site is lymph node. Typically, RDD arises in nodal sites, but 43% of RDD arises extra-nodally, involving the head and neck, paranasal sinuses, bone, respiratory tract, endocrine glands and skin, and the painless and bilateral cervical lymphadenopathy includes all characteristics of RDD. Systemic disease is characterized by fever, anemia, leukopenia, lymphocytopenia, enhanced ESR and polyclonal hypergammaglobulinemia . An estimated 5% of RDD is primary central nervous system without lymph node disease (5%). Central nervous system RDD, occurring in the brain or spine alonely, or simultaneously, is an isolated disorder that does not involve other systems. RDD remains controversial when it gets optimal treatment, based on the numerous case reports.Rosai Dorfman disease (RDD), also called Sinus histiocytosis with massive lymphadenopathy, is a rare, non-neoplastic benign histiocytosis of unknown cause. It was described as a specific clinicopathological entity and a benign and self-limiting condition by Rosai and Dorfman in 1969.A 54-years-old man was hospitalized after experiencing paroxic convulsions and being unconsciousness for 9 days. Past medical history includes history of hypertension and gastric bleeding. And there are no special personal history and similar family history. Physical examination: T 36.5ºC P 78/minutes R 19/minutes BP 140/96 mm Hg, no abnormalities were detected in the nerve examination, neck resistance was negative, and there is no apparent abnormality with the heart, lung, or abdomen; Muscle volume was normal in all limbs without any tremor in the muscle bundles. On the physical examination of the nervous system, the patient had normal tendon reflexes in his biceps, triceps, knees, and ankles, Babinski sign was negative on both sides, and Kernig sign was negative.A head magnetic resonance imaging (MRI) demonstrates: a strip of lesions in the right parietal lobe Fig. A–C.μmol/L ; Alkaline phosphatase: 126.0 U/L , Total bile acid 14.8μmol/L , Creatinine 56.0 μmol/L , Carbon dioxide 29.8 mmol/L ; Human immunodeficiency virus negative.Laboratory data: Blood routine: Platelet distribution width 9.70 fL ; Coagulation routine: Fibrinogen 2.02g/L ; Biochemical results: Indirect bilirubin 13.14 Preoperative examination shows no abnormalities and undergoes surgical resection. During the operation, it is found that the tumor originates from the dura of the right parietal lobe that is located near the superior sagittal sinus, and the lamina dura is significantly thickened, with tumor size being about 5.5cm × 5.0 cm × 1.5 cm. Tumors are firmer in texture, have moderate blood supply, and sections of excised tumors are gray-yellow, with no clear border between tumor edge and normal tissue. The tumor and the involved dura are completely resected. The pathological diagnosis is RDD through the pathological phenotypes and immunophenotype. The immunohistochemistry shows: CD1a (-), CD20 (+), CD3 (+), CD34 (-), CD38 (+), CD68 (+), EMA (-), GFAP (-), Ki-67 (5%), Nestin (-), NeuN (-), Syn (-), Vimentin (+), S-100 (+)  pathway activation are detected frequently in RDD specimens, with mutations in KRAS and MAP2K1 being mutually exclusive in about 1-third of Rosai Dorfman patients. Next generation sequencing reveals that the BRAF gene exhibites a single somatic mutation in exon 12, and cell proliferation in most central nervous system tumors is associated with BRAF V600E mutations, suggesting that RDD may be a tumor lesion.,8,9 Therefore, we speculate that BRAF-mutant patients with targeted therapy for RDD improve their survival significantly by using inhibitors of BRAF in the future. It has also been reported that a mutation in the nucleoside transporter gene SLC29A3 is the molecular basis of familial RDD and has a certain genetic predisposition.An unclear mechanism causes RDD, which might be caused by immune disorders triggered by specific infections. Scheel et al, reported skin RDD detected DNA of human herpetic virus 6 variant B, causing a biological reaction in histiocytes, or immune deficiency induced cell aggregation. In this case, patients admit that they are experiencing paroxic convulsions and unconsciousness. Laboratory data are basically normal, and further examination is required to diagnose RDD.Clinically, the bilateral cervical lymphadenopathy, which causes no pain, is the most common type. Symptoms of systemic disease include fever, anemia, leukocytosis, lymphocytopenia, elevated erythrocyte sedimentation rate, and polyclonal hypergammaglobulinemia , but none of the above symptoms are specific. When some patients are diagnosed as RDD, they have already suffered from auto-immunodeficiency diseases such as rheumatoid arthritis and systemic lupus erythematosus. In this case, epileptic seizures are the main symptoms, and it is found that there are intracranial lesions through imaging examination.According to the literatures, approximately 75% of central nervous system (CNS) RDD is intracranial and rarely involves the spine, approximately twice the incidence of spine, and more rarely involves the brain and spinal cord. Intracranial lesions often occur in suprasellar region, convexity, parasagittal area, cavernous sinus, petroclival region, and the dura mater and brain parenchymal tissue are involved individually or simultaneously. Recent statistics show that: depending on the location of the tumor, clinical symptoms are headache (45.1%), focal neurologic dysfunction (32.6%), visual symptoms (32.1%), epilepsy (24.6%), cerebral neuropathy (11.6%), cerebellar dysfunction (11.2%), and cognitive decline (5.8%), and spinal lesions may follow with hemiplegia or paraplegia. Neuroimaging in some patients shows that the intracranial lesion is unsurrounded by edema. Some scholars believe that RDD may follow with inflammation rather than tumor on neuroimaging, which has been suspected to be caused by infections, particularly virus infections, such as inflammatory pseudo-tumor, sarcoidosis, tuberculosis and Langerhans cell histiocytosis.As seen on imaging, CNS RDD usually appear as multiple or solitary dura-based masses, while CT scans are characterized by homogeneous, lobulated isodense or hyperdense mass to brain tissue, which may cause erosion of the skull. MRI usually shows that T1WI represents isointence in tumor, while T2WI represents hypointense or isointence in tumor, and an uneven or uniform enhancement and a clear boundary are visible after contrast-enhanced scanning. There is an obvious dural tail sign on enhanced MRI in almost all cases, which is easily diagnosed as meningioma.,2 CNS RDD lesions present as gray or gray-brown, or yellow-brown masses with an intracranial location attaching to the dura mater. There is a positive immunohistochemistry for the S-100 protein and CD68 marker in RDD, and a negative immunohistochemistry for CD1a, which should be distinguished from lymphoplasmacytic meningioma, plasma cell granuloma, Langerhans cell histiocytosis and Hodgkin lymphoma.In order to make a definite diagnosis of RDD, a histopathologic and immunohistochemical examination is required, which is characterized by phagocytosis or “protrusion” of lymphocytes. The condition exhibits mature lymphocytes, plasma cells and neutrophils with fiber hyperplasia, and tissue cells often contain autologous lymphocytes as a diagnostic basis. For some patients with subtotal resection, adjuvant therapy, such as radiotherapy, chemotherapy and steroid hormones, is alone or in combination to reduce postoperative recurrences. There is also no clear explanation of the mechanism and the efficacy shows individual differences, so this disease cannot be treated according to a standard protocol.It is possible to evaluate treatment protocols of RDD in different ranges of lesion sizes and locations for the adjacent brain tissue, clinical manifestations. Tumor biopsies may have some risk, while some tumor patients maynot be inoperable, such as the cavernous sinus invasion. This case is diagnosised as a meningioma, and surgical resection is the first therapy to relieve neurological symptoms and make a pathological diagnosis. Reoperation goes well for the patient, and epileptic seizures completely disappear.Due to the rare cases of intracranial RDD, clinicians have insufficient understanding and limited experience cannot guide clinical therapy. If multicenter collaborative works are recommended, the exact molecular mechanisms would be clarified from the molecular research level. Therefore, the best way to avoid overtreating is to make long-term clinical studies and follow-up summaries.Conceptualization: Zhanzhan Zhang, Zongmao Zhao.Data curation: Aobo Zhang.Formal analysis: Zhanzhan Zhang, Tao Zhang, Zongmao Zhao.Funding acquisition: Zongmao Zhao.Project administration: Zongmao Zhao.Resources: Tao Zhang.Supervision: Zongmao Zhao.Validation: Zongmao Zhao.Writing – original draft: Zhanzhan Zhang.Writing – review & editing: Zongmao Zhao.


Pituitary adenomas are benign, single, monoclonal slow-growing neoplasms usually related to chemical overproduction. A pituitary adenoma is the third most common intracranial tumor, with the first two being glioma and meningioma. Double pituitary adenoma is an infrequently occurring case and is characterized as occurrence of two adenomas in the single pituitary gland, both having typical immunohistochemical and histopathological highlights. In most of the cases, pituitary adenomas occurring as double adenomas are associated with Cushing's disease. It is further categorized into contiguous and clearly distinct types. Clearly distinct tumors are recognized on neuroradiological imaging. We present imaging findings of a rare case of a double pituitary microadenoma. Early diagnosis of such a rare condition is important and prevents further consequences. Pituitary adenomas are benign, single, monoclonal slow-growing neoplasms usually related to chemical overproduction . Double A 21-year-old female presented to our hospital with complaints of amenorrhea for the last four months and weight loss. On examination, the patient's general condition was fair, and vitals were normal. On systemic examination, cardiovascular, respiratory, and abdominal systems were normal. Neurologically, the patient was conscious and well oriented, and had no neurological deficit. On cranial nerve examination, there was normal visual acuity and normal visual field, and other cranial nerves were normal. On ultrasound, the patient was diagnosed with polycystic ovary disease, and on further hormonal investigations, the thyroid-stimulating hormone (TSH) level was 0.01 µIU/mL, which was below normal, and adrenocorticotropic hormone (ACTH) level was raised. For further evaluation, a brain MRI with gadolinium contrast was performed, which revealed two tiny altered signal intensity lesions in the anterior lobe of the pituitary gland. Both the lesion appeared isointense on T2- and T1-weighted images Figures . Both thDouble pituitary adenoma is an infrequently occurring tumor, with an incidence rate of 0.9% in random pituitary autopsy samples . Their pPituitary adenomas are segregated on the basis of size: if measuring ≤ 10 mm, it is considered as microadenoma, and if > 10 mm, it is considered as macroadenoma . Sumida In our case, findings on MRI imaging are similar to those described by Sumida et al., suggesting that both the lesions are pituitary microadenomas. In comparison with the study by Oner et al. and Zieliński et al., we can confirm the presence of double pituitary microadenoma.Double pituitary microadenoma is a rare tumor, and the majority of the patients are asymptomatic at an early age. Hence, they are very difficult to diagnose clinically. Any hormonal imbalance related symptoms must be further evaluated for their cause. It is important to diagnose early as it can present with vision disorder due to compression over optic chiasma or severe headache due to compression over cavernous sinus. MRI imaging provides its early diagnosis with a correlation with hormonal levels.


Marginal zone B-cell lymphoma (MZBCL) of mucosa-associated lymphoid tissue (MALT) type, which is primary to the central nervous system (CNS), is a rare lesion, with those originating within the parenchyma even more so. We present the case of a 64-year-old male with weakness in the left hand and focal motor seizures of his arm, who was found to have a right frontal intraparenchymal lesion. Following resection, histopathological and immunohistochemical evaluations were completed, leading to a diagnosis of a primary CNS MZBCL of MALT type in the context of a negative workup of systemic disease. Neuroimaging, histopathological, and immunohistochemical findings, as well as a comprehensive literature review of similar cases, are discussed. Primary central nervous system lymphoma (PCNSL) is an aggressive yet rare variant of extranodal non-Hodgkin lymphomas, accounting for roughly 4% of primary and malignant tumors of the CNS . They maUnder the category of small B-cell lymphomas, marginal zone lymphomas (MZL) represent the majority of neoplasms that are primary to the CNS . Mucosa-Tu et al. reported 15 primary CNS MZL cases, of which 93% were dural-based lesions mimicking meningiomas, arising from sites including the convexity of the brain, falx, tentorium, middle skull base, ventricles, and spinal dura mater . PrimaryWe present a case of a patient with primary CNS intraparenchymal MALT lymphoma with an immunohistochemical profile. Furthermore, a review of the literature on similar cases, including treatment options and outcomes, is discussed. To our knowledge, the present case represents the first reported instance of a patient with such a lesion to be managed solely with surgical resection.A 64-year male with a history of rheumatoid arthritis and anti-phospholipid syndrome presented with mild left-hand weakness and a focal motor seizure involving his arm. The patient was receiving hydroxychloroquine for his rheumatoid arthritis and no biologic agents were used to our knowledge. He was found to have an extra-axial mass overlying the posterior right frontal lobe at the convexity, measuring approximately 2.3 x 2.7 x 2.3 cm (anteroposterior (AP) x transverse (TR) x craniocaudal (CC)), and an intra-parenchymal lesion within the subcortical white matter of the right frontal lobe spanning approximately 0.8 x 1.1 cm with radiologic features consistent with a low-grade glial tumor  with kappa light chain restriction. Ki-67 demonstrated a very modest proliferative index. The tumor was uniformly positive for BCL2 and negative for CD5, CD21, CD10, and cyclin-D1 (Figure H. pylori-negative. To date, the patient has elected not to proceed with adjuvant therapies, and the nine-month follow-up MR and positron emission tomography imaging has confirmed no recurrent mass or adverse interval change within the parenchyma.With the diagnosis of low-grade B-cell lymphoma, the patient subsequently had a bone marrow biopsy, CSF analysis, and lymph node biopsy, which did not show systemic disease. He was also found to be HIV and Only a few cases of intracranial primary low-grade lymphomas of the MALT subtype have been reported in the literature, with the vast majority located in the dura mater. As the CNS does not contain any mucosal or MALT tissue, it has been hypothesized that the meningothelial cells in the brain are analogous to epithelial cells at other sites where MALT lymphoma typically arises . HoweverA review of the literature using the EMBASE and MEDLINE databases using the keywords of “MALT lymphoma” or “mucosa-associated lymphoid tissue lymphoma” and “brain tumors” primarily yielded previous cases of dural MALT lymphomas. In total, 13 cases were found in the literature of cases who were diagnosed with primary MZBCL of MALT type involving the brain parenchyma (Table In addition to presenting a novel and interesting radiologic diagnosis, this case poses questions regarding the oncologic management of intraparenchymal MALT lymphomas. Currently, surgery, chemotherapy, radiation, or a combination of these modalities are used to treat CNS lymphomas. To our knowledge, our case represents the first reported instance of a patient with intraparenchymal MZBCL of MALT type to be managed solely with surgical resection. Our patient has remained disease-free at nine months postoperatively suggesting that adjuvant treatment may not be required in the initial management of intracranial MALT lymphoma in certain cases. Radiation and chemotherapy may cause significant neurotoxicity. Hence, cases need to be carefully evaluated on an individual basis to minimize iatrogenic sequelae from exposure to these therapies. Furthermore, given the propensity of MALT lymphomas to recur, this patient and others similarly affected, ought to be closely followed with serial MR imaging .In conclusion, the results presented here indicate that primary MZBCL may not be isolated to the meninges and can develop in brain parenchyma. Thus, MZBCL should be considered in the differential diagnosis of intra-axial CNS masses. This case suggests that localized MZBCL may be managed with local excision without the need for early radiation or chemotherapy. However, more evidence is required to draw conclusions regarding the optimal management of this disease.


The treatment of hepatocellular carcinoma (HCC) requires diverse and multidisciplinary approaches. In recent years, new agents with good antitumor effects have emerged for systemic chemotherapy, and conversion surgery (CS) after systemic chemotherapy is expected to be an effective treatment strategy for unresectable HCC. We herein report a case of unresectable HCC with portal vein tumor thrombus (PVTT) in which atezolizumab plus bevacizumab therapy induced PVTT regression, followed by CS with R0 resection.The patient was a 79-year-old man with S2/S3 HCC who was referred to our department due to tumor re-growth and PVTT after two rounds of transcatheter arterial chemoembolization. The PVTT extended from the left portal vein to the main trunk, and it was determined that the resection of the left portal vein would be difficult to perform with R0 status. Based on the diagnosis of unresectable HCC, treatment with atezolizumab plus bevacizumab was initiated. After two courses of treatment, contrast-enhanced computed tomography showed that the PVTT had regressed to the peripheral side of the left portal vein, and R0 resection became possible. The patient developed grade 3 skin lesions as an immune-related adverse event, and it was determined that the continuation of chemotherapy would be difficult. Four weeks after the second course of atezolizumab plus bevacizumab administration, left lobectomy was performed. Intraoperative ultrasonography was used to confirm the location of the tumor thrombus in the left portal vein during the resection, and a sufficient surgical margin was obtained. The histopathological findings showed that primary tumor and PVTT were mostly necrotic with residues of viable tumor cells observed in some areas. The liver background was determined as A1/F4 (new Inuyama classification). The resection margins were negative, and R0 resection was confirmed. There were no postoperative complications. No recurrence was observed as of five months after surgery.CS with atezolizumab plus bevacizumab therapy has potential utility for the treatment of unresectable HCC with PVTT. The treatments for hepatocellular carcinoma (HCC), including hepatectomy, radiofrequency ablation, transcatheter arterial chemoembolization (TACE), and systemic chemotherapy are diverse and multidisciplinary. The portal vein tumor thrombus (PVTT) is a strong postoperative prognostic factor for hepatectomy, and PVTT at or near the main trunk or contralateral branch is generally considered to be inoperable or difficult for hepatectomy. In contrast, if the PVTT is reduced and R0 resection becomes feasible after prior systemic chemotherapy, conversion surgery (CS) may become possible.Sorafenib has been used for standard systemic chemotherapy; however, its antitumor effect is limited . In receWe herein report a case of unresectable HCC with PVTT in which atezolizumab plus bevacizumab therapy induced PVTT regression, followed by CS with R0 resection.A 79-year-old man was referred to our department for TACE-refractory HCC in the S2/3 area after two TACE treatments failed to control the disease. In August 2021, the contrast-enhanced computed tomography (CT) showed re-enlargement of the TACE-treated area of the S2/3  (median OS of 10.7 months in the sorafenib group vs. 7.9 months in the placebo group) . LenvatiWhen R0 hepatectomy can be performed in CS, a good therapeutic prognosis can be expected. Shindou et al. performed a prospective analysis of patients with unresectable HCC who received lenvatinib therapy . Twelve Good responses to immune checkpoint inhibitors are known to be associated with immune-related adverse events . In the Bevacizumab has a suppressive effect on wound healing. The appropriate interval between the cessation of administration and surgery is unknown. The estimated half-life of bevacizumab is 20 days. Periods of 4 weeks  and 6–8 There is no consensus by experts on the appropriate timing of CS. The decision is made by the surgeon based on a combination of factors, including a reduction in AFP/DCP levels on blood tests, imaging findings that suggest R0 resection, general condition, liver function, and side effects of chemotherapy, as in the present case.Here, we describe a case of unresectable HCC with PVTT, which was successfully treated with CS after atezolizumab plus bevacizumab therapy. This therapeutic approach may enhance outcomes for patients with unresectable HCC.


Intrathymic bronchogenic cysts are extremely rare lesions, and the differential diagnosis with a banal thymic cyst or a solid tumor can be problematic. Thymic carcinomas arising within thymic cysts have also been reported. We report a case of radical thymectomy for a slowly growing small thymic cyst. The pathological finding revealed a bronchogenic cyst rather than a thymic neoplasm. Intrathymic bronchogenic cysts are extremely rare lesions of the anterior mediastinum. The overlapping radiological characteristics with solid tumors, especially on the computed tomography (CT) scan, make the preoperative radiological diagnosis quite difficult , 2. SoftWe present a case of a slowly growing small intrathymic cyst, which was incidentally discovered on the CT scan of the chest while evaluating a sub-centimetric pulmonary nodule. Because of its growing evolution, we strongly suspected a thymoma, and thus, a radical thymectomy was performed. The pathological finding revealed a bronchogenic cyst rather than a thymic neoplasm. In the light of this rare situation, we discuss the preoperative diagnostic issues and the therapeutic options.2). The patient has no symptoms related to myasthenia gravis and the neurological examination was normal. Routine blood test and specific blood test for thymic tumor investigation  were normal except for a slight hypo-gamma-globulinemia of 7.4 g/L (N: 8–13.5) without any clinical consequences.A 65-year-old male patient was referred to our hospital in July 2021, for a slow-growing intrathymic lesion, incidentally discovered in July 2015 on a routine chest CT scan for lung cancer screening. The patient was an active smoker (40 pack-years). His comorbidities were hypercholesterolemia, hypertension, and overweight  of 42], without mural enhancement or calcification. A slight growth was noticed on a 2018 control CT scan with a 1.7 × 1.1 × 1.7 cm (HU of 42 to 80) lesion. A further increase in size was noted on a 2021 CT scan examination. Indeed, the lesion was 1.9 × 1.2 × 1.7 cm and the patient was referred to thoracic surgery. Thoracic MRI in July 2021  was performed. After exploration of the whole chest cavity, complete thymectomy, including the lesion as well as the mediastinal fat between the two phrenic nerves, was performed.A radical thymothymectomy by a robotic extrathoracic approach  was performed under general anesthesia with double-lung ventilation. The patient was placed in supine position. Three-port access with COThe specimen was retrieved through the subxiphoid incision and a 24-Fr non-aspirative chest tube was placed at the level of one of the subcostal trocar incision. The operative time was 163 min and there were no intraoperative complications. The postoperative course was uneventful. The chest tube was removed on the first postoperative day and the patient was discharged home the day after. Histologic examination showed an 18 × 14 × 8 mm cyst lesion, filled with yellow viscid fluid. The cystic wall was thin and slightly fibrous, formed by a bistratified ciliated columnar coating epithelium, with large oval nuclei, sometimes angular with flat chromatin and sometimes with a small eosinophilic nucleolus. The rest of the thymic parenchyma was in adipose involution, it did not present any anomaly Figure 2Intrathymic bronchogenic cysts are extremely rare, making them difficult to suspect when they are incidentally discovered on a radiologic examination. In our case, because of a growing cyst, we strongly suspected a cystic thymoma and, thus, decided to do a radical thymectomy. In the light of this case, the question arises whether we could avoid an “unnecessary thymectomy” or whether we could propose a limited resection of the thymus in case of a cystic lesions and, if so, what could be the criteria for selecting patients for a limited thymic resection.Most of the bronchogenic cysts are located in the posterior mediastinum or intrapulmonary since they derived from abnormal germination of the embryonic foregut . The firn = 124) were the most common lesion.Nevertheless, surgery exposes the patient to risks and there is a concern regarding the so-called “non-therapeutic thymectomy” or “unnecessary thymectomy”, if the thymic lesion is not a cancer or the patient does not have myasthenia, since its incidence in the literature ranges from 22% to 68% . MoreoveHowever, it is not very clear if a thymectomy for thymic cyst is an “un-necessary thymectomy”. Some surgeons advocate early surgical resection for thymic cysts in order to avoid complications, such as rupture of the cysts, malignant transformation, or compression of the surrounding organs in the mediastinum , 10, wheIn conclusion, patients diagnosed with thymic cysts fall under “unnecessary thymectomy”, especially a young patient with a unilocular cyst, containing a clear fluid within the thin wall, with a DCT value of less than 6 HU. However, in case of multilocular thymic cysts or thymic cysts presenting with symptoms, bleeding, inflammation, or growing tendency, surgical resection is indicated and partial resection should be considered. A robotic approach allows safe surgery in a limited area such as the anterior mediastinum, with reduced postoperative complications.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by CEPAR-Comite d’Evaluation des Protocoles et d’Aide à la Recherche. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


Paragangliomas are tumors that originate from microscopic structures associated with the Central Nervous System (CNS) in the para-axial regions of the trunk, neighboring the branchiometric arches and CNS periphery, the paragangliaN.F.S., 76, black, complained of dizziness that did not improve with medication, pulsatile tinnitus and progressive hearing loss for the past 3 years in his right ear, as well as left side neck bulging for 30 years, of slow growth, painless, of fibroelastic material, non-pulsatile.On CT scan we noticed an extensive solid mass with ill-defined lobulated contours, occupying the carotid space in both sides, with right side temporal bone destruction by a tumor radiologically equal to the one previously described, and the patient was allergic to iodine. MRI showed hypervascularized lesions , in the aforementioned regions, thus corroborating CT findings. Angiography confirmed the diagnosis.Neck paragangliomas, because of their rare occurrence, are a difficult to diagnose and treat pathology. Among other causes of neck bulging we have: branchyal cysts, carotid aneurisms, neurofibromas, parotid tumors, tumor metastasis, inflammatory lymphadenopathy, amongst others.They are mostly benign; paragangliomas can have malignant transformation in 2 to 10% of cases, accounting for 0.012% of head and neck tumors. The most frequent site is the carotid body; the less common sites are the middle ear, jugular, vagus nerve, larynx and aortic archCT scan is the most adequate diagnostic method for obtaining data on the tumor’s extension and location. MRI is considered superior to CT in documenting soft tissue details and tumor characterizationSurgery is the treatment of choice; radiotherapy is questionable. Expectation approach and embolization with routine assessments are treatment options for those who do not fit the surgery profileSurgery is the major therapeutic approach. Radiotherapy, controversial, did not prove to help in these tumors. To wait and use embolization also seems to be an option, and this was the approach preferred by our patient because of his cardiac condition, and it was an excellent outcome.


Up to one month prior to presentation, the patient was injecting herself repeatedly in the abdominal wall with subcutaneous liraglutide for about two years. Except for abdominal liposuction years before, past medical history was irrelevant. The patient had a body mass index of 47. Upon presentation, her vital signs were normal with no history of fever. Physical examination revealed a 20-cm circumscribed mass on the right side of the abdominal wall. It was movable and distinguishable from the muscles of the abdomen. The overlying and surrounding skin showed ecchymoses and “peau d'orange”, but no evidence of cellulitis or wounds.A CT scan showed a 9-cm oblong lesion within soft tissues of the abdominal wall. Its structure was complex and composed of isodense and mildly hypodense areas . There wSeven weeks later, the patient presented again at the emergency room complaining that a mass reappeared in the same location. On physical examination, cellulitis of the surrounding skin was evident. The CT scan showed a recurring mass in the same area. However, it was more extensive and had a multi-lobulated, nodular appearance with enhancing walls and vascularized areas . There wSixteen days later, the patient was seen again. Recurrence of the mass was evident. A skin infection was observed once again. New subcutaneous nodules in proximity of the mass were identified. The working diagnosis was now evident as an underlying neoplastic process. The patient was admitted, and antibiotics were prescribed. A third resection was attempted. The specimen revealed again large hemorrhagic abdominal masses. However, upon careful examination, ulcerated subcutaneous hemorrhagic poorly formed tumors could be identified. Microscopic examination revealed high grade epithelioid and pleomorphic cells organized in solid sheets, papillae and anastomotic sinusoid spaces occasionally forming large bloody lakes. The cells were composed of abundant eosinophilic cytoplasm, large vesicular and hyperchromatic nuclei with numerous mitoses. On immunohistochemistry studies, cells expressed CD31 and ERG. The findings were compatible with a diagnosis of high grade epithelioid angiosarcoma , Fig. 4.Following the diagnosis of cutaneous angiosarcoma, the patient was transferred to a sarcoma referral center. Upon admission, rapid progression of the tumor was documented; the upper thigh now being involved in addition to the abdominal wall . A syste3Soft tissue sarcomas represent respectively 0.72 % and 0.49 % of all expected cancers in United States In addition to the previously described risk factors for angiosarcoma, obesity is recurrent finding among reports. Angiosarcomas are often misdiagnosed owing to their rarity and their subtle and varied clinical presentation. In this case, the abdominal wall angiosarcoma was initially presumed to be a large, abscessed hematoma because of the history of repeated liraglutide subcutaneous injections. Despite multiple but because of so rapid recurrences, the working diagnosis of acute hemorrhages remained unchanged. Histological examination of the first specimen was not prioritized and furthermore failed to identify foci of angiosarcoma within the large hematoma partly because of the low clinical suspicion of cancer. Identifying angiosarcoma at the first surgical intervention would have however probably not affected the prognosis, considering the early bulky presentation and the aggressive biology of the disease. Despite adequate surgical resection, angiosarcoma are associated with high recurrence rates The most probable risk factor for this patient with primary angiosarcoma of the abdominal wall remains her morbid obesity, and subsequent chronic lymphedema of the abdominal panniculus. The association with liraglutide injection is probably coincidental. It remains probable that the injection itself precipitated the occurrence of a large hematoma within the angiosarcoma. However, considering the rarity of abdominal wall angiosarcomas, a causal relationship between the subcutaneous injections of GLP-1 receptor agonist, must be considered and cannot be excluded.4Angiosarcoma is a rare and highly aggressive cancer that occasionally originates in the abdominal wall. The majority of cases are reported in patients with morbid obesity. In this described patient's case, in addition to the underlying obesity, a possible association of her liraglutide subcutaneous injections cannot be excluded. In the future, if other cases of abdominal walls angiosarcomas associated with liraglutide subcutaneous injections were to be reported, a possible causality should be further investigated.No funding to declare.Not requested by the Ethic Committee.There is no possibility to identify the patient in the text or in the study material.EB, and JN reviewed the case. MD reviewed histopathologic material. XVD was involved in the provision of study material and reviewed imaging. CV provided medical expertise. EB wrote the manuscript. JN reviewed the English syntax. All authors critically reviewed and approved the final version of the article.Not applicable.EB accepts the responsibility for the work.No conflict of interest to declare.


This case report describes the efficacy and advantages of using a high-power diode laser in non-contact mode to remove racial melanin pigmentation from the oral mucosa in an aesthetically sensible area to reduce thermal damage and promote better postoperative results. In the presented case, the lesion was removed under local anesthesia in a single session using high-power diode equipment with circular movements over the lesion , maintaining an average distance of 2-3 mm from the target tissue without fiber activation . The patient did not report immediate postoperative pain; however, analgesic use was recorded during the first day after the surgical procedure. The biological response and cosmetic results were satisfactory, with proper lesion removal and adequate cicatrization observed during a two-year follow-up period, without complications or compromise of periodontal tissue esthetics. Gingival pigmentation is a benign condition that can affect the oral mucosa and can be expressed in different areas of the oral cavity. This condition has different etiologies, and various clinical approaches to treatment are based on the diagnosis. Clinically visualized as the accumulation of dark or brown pigments in the oral mucosa, located in free or attached mucosa, these melanotic macules are derived from melanin production by melanocytes in the basal layer of the epithelium, which are then absorbed by surrounding epithelial cells and connective tissue. The role of melanocytes in the oral mucosa is not yet well understood. Melanin production can be considered physiological or related to neoplastic conditions .Lesions can cause inconvenience to patients, especially in patients with esthetic conditions such as high smile lines, leading to self-image discomfort. Different options to remove oral melanotic macules have been described in the literature, including scalpel surgery, abrasion, electrocautery, cryosurgery, radiosurgery, chemical cauterization, and laser .Diode lasers are a safe and well-described alternative to manage melanotic lesions. Diode lasers (808 nm) target melanin and melanosomes, without causing major damage to the epithelium, connective tissue, and teeth in the area surrounding the site of energy delivery , althougIn the present case report, the authors opted to use a high-power diode laser  in non-contact mode, without fiber activation, due to lesion characteristics and the localization of the lesion. The combination of pigmentation location and characteristics, along with the surgical technique proposed, contributed as an innovative alternative to manage buccal melanotic pigmentation in esthetically sensitive areas in attached gingiva.A 27-year-old woman was referred for the evaluation and treatment of melanotic pigmentation. The patient did not report the presence of previous pathologies or continuous medication use. Furthermore, no substance use, diet, smoking, and other conditions that could lead to extrinsic pigmentation were reported by the patient. The patient reported that the lesion began developing two years prior and had been stable in size and color since then.The lesion was black/brown in color, located in the attached gingiva, and was limited to the region extending from the anterior to the posterior interdental papilla of tooth 13 (right superior canine). The patient presented a Peeran Pigmentation Index of 1  and clasInformed consent was obtained from the patient before intervention. Surgical removal was indicated due to the lesion compromising the patient’s esthetic appearance.A high-power diode laser  was used in non-contact mode (defocused), without fiber activation, under local anesthesia. Irradiation was delivered using a 300 µ quartz fiber and kept 2-3 mm away from the lesion surface, in continuous wave mode, and proceeding with quick circular movements in an area for 10 seconds. The endpoint of laser delivery was a sign of blanching on the lesion surface, following which the laser fiber was moved to another area. This procedure allowed gradual irradiation of the entire lesion surface, with two irradiations , with an interval of 30 seconds between each irradiation to prevent heat damage. The immediate postoperative aspect can be visualized in Figure There was no bleeding or any postoperative complications. Immediately after the first laser session, the patient developed slight swelling of the treated area that lasted for three days. No analgesic or anti-inflammatory medication was used. The clinical aspect at seven days postoperatively is shown in Figure The total follow-up period was two years, with no recurrence of lesion or esthetic damage during this period, as observed in Figure Our case report demonstrates the benefits of non-contact, continuous wave, diode laser (808 nm) depigmentation in aesthetically sensible areas in patients with high smile lines. It is also important to observe periodontal stability and overall positive aesthetical outcomes after two years of follow-up.2, erbium, and diode [There are reports of different approaches using different lasers for managing melanic pigmentation, such as COnd diode . Diode lnd diode . The majnd diode . On the nd diode ,10.Another described option for melanotic pigmentation management is the use of diode lasers in non-contact mode. The “non-contact” technique with diode lasers without fiber activation is not described in the majority of randomized clinical trials and lacks standardization and evidence with prolonged follow-ups . Our stuThe reduced energy density is the major factor behind adequate depigmentation in the case described, caused by the increased spot size generated by the 2-3 mm distance between the fiber tip and target tissue. The lack of fiber tip activation also plays an important role, allowing direct energy-pigment interaction. This is achievable due to near-infrared wavelength and its affinity for melanin and other pigments, which leads to pigment removal without major damage to surrounding tissues .Regarding pain management, diode laser surgery is one of the less invasive and predictable procedures performed on soft tissues in the oral cavity, facilitating visualization during the surgery with minimal bleeding within the intervention site, as well as promoting better immediate esthetic results and patient comfort . This caThis technique is a safe, quick, previsible, and replicable option to manage racial melanotic pigmentation. More studies evaluating the results obtained with different techniques in aesthetically sensible areas using diode lasers and different populations are needed.The use of a high-power diode laser in non-contact mode (defocused) is an effective, bloodless, and safe alternative for removing melanin pigmentation from the oral mucosa. No postoperative complications and pain were reported. This technique generated predictable outcomes when considering periodontal stability and did not cause gingival recession, scars, and recurrence of the lesion during the two-year period of follow-up.


Local control of intramuscular sarcomas of the limbs may include limb amputation or marginal excision plus radiotherapy. In human medicine, compartmental excision for local control of muscular sarcomas has been widely reported. This procedure is effective when a specific tissue, such as the fascia, acts as a barrier to the neoplastic invasion. The barriers define a compartment, i.e., an anatomo-functional region having the same origin. The aim of this study was to describe this surgical procedure in three dogs affected by intramuscular sarcomas with no signs of fascial invasion at imaging. No major complications were observed in any of the patients, and all experienced a rapid recovery. Tumours treated via compartmental surgery were: chondrosarcoma, a perivascular wall tumour and a hemangiosarcoma. Accurate preoperative tumour staging, including advanced imaging techniques, are necessary in order to perform this procedure successfully.Compartmental excision consists of the complete resection of an anatomic district in which specific structures act as a barrier to local tumour invasion. It is a well-established procedure in human medicine, while only a few reports are available in veterinary medicine. The aim of this study was to describe complete muscle resection in 3 dogs affected by different intramuscular sarcomas. The clinical outcome was also reported. Medical records were searched, including preoperative diagnostic findings, compartmental excision, histologic diagnosis, and outcome. Three dogs fit the inclusion criteria, which had a sarcoma confined to a single muscular belly . Complete excision of the affected muscle was performed in all cases. One dog showed moderate lameness in the immediate postoperative period, resulting from the dorsal lifting of the scapula due to serratus ventralis tenotomy performed to remove the caudal insertion of the splenius capitis muscle. All the dogs recovered fully within one month, experiencing good clinical function. Histopathology showed complete tumour removal with no neoplastic fascial disruption in all cases. Compartmental excision provides effective local tumour control, representing an alternative to limb amputation or more radical excision if adjuvant radiotherapy is not an option for owners. No evidence of distant metastases and definition of the anatomical extent and relationship with surrounding tissues of a tumour is the first step addressed to correct surgical planning finalized to local tumour control.In human medicine, sarcomas have been classified as intracompartmental or extracompartmental based on their relationship with the fascia (the connective tissue layer tightly connected to the muscle); singular or groups of skeletal muscles covered by a deep fascia can be assimilated into a compartment .More specifically, a compartment is an anatomo-functional unit with the same ontogenic origin and well-defined connective tissue boundaries  . CompartMore recently, the same concept has also been applied to both the tumours of the tongue, in which tissue preservation is mandatory to conserve speech and swallowing functions ,5 and ofCompartmental surgery has also been applied in veterinary medicine for solid tumours, considering that surgery may often be the only treatment option accepted by pet owners .In the early 1980s, Enneking’s anatomical studies of the compartments of the thigh completely modified the surgical approach to soft tissue sarcomas, underscoring that low-grade, intracompartmental sarcomas could be conservatively removed, thus minimising morbidity and simultaneously obtaining effective local tumour control .Enneking divided the body into distinct anatomical sections called compartments and proposed a classification for planning the resection of musculoskeletal tumours based on tumour extension ,3. It waThe local control obtained may not be enough for high-grade soft tissue and/or infiltrative sarcomas in which the fascial layer may be penetrated through perforating vascular channels .Kawaguchi translated anatomical barriers into centimetres of the surgical margin. He divided tissues into thin and thick barriers . A thin Local control is more difficult for lesions in the extracompartmental fascial planes or areas with less distinct fascial boundaries, such as the groin and the popliteal fossa .Additional human studies have validated Enneking’s concepts, even showing an increase in survival times and a lower local recurrence rate compared to patients treated with a more traditional wide-margin excision .Compartmental surgery is not always feasible; in a publication dealing with 143 soft tissue sarcomas , only onIn more recent decades, Enneking’s model has been criticised in favour of less invasive approaches, supported by the inclusion of radiotherapy in a multimodal treatment approach, which allows for reducing the surgical dose and, at the same time, lowering the risk of local recurrence .The concept of compartmental surgery in humans has often been overcome thanks to the advent of radiotherapy; this may not be true in veterinary medicine due to the high cost of radiotherapy, thus rendering an aggressive malignant tumour excision the unique therapeutic option possible.Few veterinary studies regarding compartmental tumour excision have been published. The increasing use of computed tomography (CT), which allows a better characterisation of the tumour and its relationship with the surrounding structures, opens up new perspectives for this procedure, thus reducing both the surgical dose and the postoperative morbidity.At present, the trend in veterinary surgical oncological surgery is to abandon the concept of an “en bloc” resection, always in favour of a more reasoned and planned excision, taking into account the presence and extent of tissue barriers between the tumour and the surrounding tissues.In 2014, Bray described an anatomically-based surgical technique for a hemipelvectomy that enabled the compartmental resection of tumours in the pelvic region . Better Despite all the limitations and possible confounding factors, Bray’s paper paved the way for the applicability of compartmental surgery, including in veterinary medicine .Nevertheless, compartmental surgery is less frequently applicable in veterinary medicine than in human medicine due to the fact that many mesenchymal neoplasms arise from the subcutis and not from the muscle itself . HoweverAn anatomic classification of the relationship between the fascia and the superficial muscles of the neck, trunk , and forCompartmental surgery has also been applied to tumours of the peripheral nerves, following the human medicine standard of care, where surgical excision consists of the removal of the affected nerve with a proximal and distal margin; limb amputation is performed only in rare cases . This teIn this case series, the authors reported on the feasibility, technique and outcome of muscular compartmental resection in three dogs bearing an intramuscular soft tissue sarcoma.The medical records of dogs referred to the Veterinary Teaching Hospital (VTH) of the Department of Veterinary Sciences of the University of Turin  for intramuscular sarcomas from January 2018 to June 2022 were identified and reviewed.The inclusion criteria were: (a) the presence of a muscular sarcoma, (b) complete tumour staging to exclude distant tumour spread and confirm the integrity of the muscular fasciae (intramuscular sarcoma); (c) complete muscular compartmental excision; (d) complete histological report; (e) a minimum of a 30-days follow-up.Written consent was obtained from the owners for all the procedures  before proceeding. Perioperative standard-of-care management, including analgesia, was assured for all the dogs. This study did not fall within the application areas of Italian Legislative Decree 26/2014, which governs the protection of animals used for scientific or educational purposes. Therefore, ethical approval was waived for this study. The animals were not treated as part of an experimental study; only the data were later selected and included in this study. No specific informed consent statement was signed for inclusion in this retrospective study.®, Orion Pharma, Turku, Finland) and methadone (0.2 mg/kg) . General anaesthesia was induced with propofol   and maintained with isoflurane in oxygen . After being clipped and aseptically prepared, the patients were moved to the surgical room and positioned with the affected muscles entirely included within the surgical field. Muscular excision was performed in order to remove the complete muscular belly with both tendons. The intravenous administration of cefazolin (20 mg/kg)  was performed 20 min before skin incision and repeated every 60 min until extubation.The dogs were premedicated with an intra-muscular combination of dexmedetomidine (2 mcg/kg)  or buprenorphine , and meloxicam . The dogs were all discharged with an Elizabethan collar and meloxicam  within 1–5 days and were then re-evaluated on days 7, 14 and 21 after discharge.The postoperative management included intravenous fluid (lactated Ringer’s 2 mL/kg/h), analgesia with methadone (SemfortanComplications have been classified accordingly to the guidelines of “Veterinary Cooperative Oncology Group—Common Terminology Criteria for Adverse Events” (VCOG-CTCAE) . Follow-Three dogs bearing intramuscular sarcoma met the inclusion criteria and are described in this study.An 11.5-year-old, 28 kg, castrated male Labrador retriever was referred for a 4 cm painless, firm mass in the caudal region of the thigh. The mass had been present for several months but had recently grown. The dog showed no lameness or discomfort. Physical examination and the laboratory profile  were unremarkable. An incisional punch biopsy was performed during the total body CT exam . The hisFor the surgical excision, the dog was positioned in the left lateral recumbency. A skin incision was made from the ischiatic tuberosity to the popliteal region, with an elliptical deviation of 3 cm around the biopsy site. The subcutis underwent blunt dissection, and Farabeuf retractors were used to retract the skin edges laterally and medially in order to visualise the underlying muscle bellies. The semitendinosus muscle, with its medio-distally located mass, was isolated from the biceps muscle laterally and the semimembranosus muscle medially. Its attachment on the ischiatic tuberosity was resected using a number 11 surgical blade. The proximal and distal vascular pedicles  were electrocoagulated. Passing the popliteal fossa, a periosteal elevator was used to transect the semitendinosus attachment on the medial surface of the tibia. Walking sutures were placed before wound closure using 2-0 absorbable monofilament to limit the dead space before skin closure. A modified Robert Jones bandage was applied for 48 h.The dog was able to walk with the aid of a rear suspensor 12 h after surgery. No seroma formation or other complications were recorded during the hospitalisation period, and the dog was discharged 24 h postoperatively. At the 1-week postoperative check-up, the dog presented VCOG-CTCAE grade 1 lameness . NeitherFive months postoperatively, the dog was examined for VCOG-CTCAE grade 3 lameness  affectinAn 11-year-old, 19 kg, spayed female Bloodhound was admitted for a perivascular wall tumour (PWT) recurrence localised at the level of the caudal aspect of the thigh. The tumour had been removed three years earlier by the referring veterinarian. The recurrence appeared as a thickening of the scar of the first surgery, which deepened into the underlying muscular tissue. The remaining clinical examination was unremarkable, with the exception of a slightly decreased body condition score (2/5), and a CBC showing mild neutrophilia.Cytology of the lesion via fine needle aspiration (FNA) was not diagnostic; therefore, an incisional biopsy was performed at the time of the total body CT. This revealed a 5.8 cm × 5.5 cm, poorly defined mass confined within the biceps femoris muscle, with heterogeneous enhancement after the administration of an intravenous contrast medium . No lesiThe dog was positioned in left lateral recumbency, and an elliptical skin incision was performed with 3 cm margins around the biopsy site on the lateral surface of the thigh. The incision was then extended proximally to the ischiatic tuberosity and distally to the tibial crest. The subcutaneous fat and the superficial fascia were incised under the skin incision. After dissecting the fascia lata, the biceps muscle was isolated from the vastus lateralis muscle. The craniodistal insertion of the biceps was isolated and resected from the craniolateral aspect of the tibial crest. Finally, the biceps muscle was freed from the mid-proximal femur, dissecting the fibres adherent to the bone A.A tenotomy was performed at the level of the lateral border of the ischiatic tuberosity to definitively remove the muscle. The deep wound was sutured in a continuous pattern, as previously described. A modified Robert Jones bandage was applied for 48 hThe dog was able to walk 24 h after the procedure. The modified Robert-Jones bandage was removed 48 h after surgery at the time of discharge. The patient was evaluated seven days postoperatively. At this check-up, the dog showed VCOG-CTCAE grade 1 lameness  and a miAn 8-year-old 35 kg spayed female mixed breed was referred for a 10 cm mass localised between the dorsal neck and the left scapular region, which had been noted a week earlier and had grown rapidly. At clinical examination, the mass appeared as a painful, firm, subcutaneous lesion adhering to the underlying tissues. No regional lymphadenopathy was detected. The cytology performed by the referring veterinarian was indicative of a malignant mesenchymal sarcoma. Total body CT confirmed the anatomic confinement of the tumour to the dorsal surface of the splenius capitis . No otheWith the patient in sternal recumbency but with a mild rotation to the right side, a skin incision from the external occipital protuberance to the spinous process of the fifth thoracic vertebra was performed A.The splenius capitis was isolated dorsally from the rhomboideus and distally from the serratus ventralis muscles. Caudally, a partial tenotomy of the aponeurosis of the serratus dorsalis cranialis muscle was performed in order to visualise and remove the caudal insertion of the splenius from the third thoracic vertebra. Cranially, the splenius muscle was dissected from the occipital protuberance. The muscle was completely isolated and excised by dissecting its belly from the dorsolateral aspect of the cervical and thoracic vertebrae B. The paThe patient was able to stand and walk 12 h after surgery, but a VCOG-CTCAE grade 2 lameness was present due to the dorsal lifting of the scapula during movement. The active drain was removed five days after surgery when the dog was discharged with a soft thoracic bandage.At the 7-day check-up, the thoracic bandage was removed. The wound appeared normal, and no seroma was observed. Fourteen days after surgery, the patient appeared painless during walking; however, the mechanical lameness on the left thoracic limb persisted (VCOG-CTCAE grade 1 lameness). The left scapula tended to rise dorsally with each step due to the lack of attachment of the splenius on the cervical and thoracic vertebrae. This anomalous motion decreased over time and was almost imperceptible after two months.2]) given by slow intravenous infusion every three weeks; after four cycles of doxorubicin, metronomic therapy was instituted . The dog was euthanized 183 days after surgery for seizures unresponsive to therapy due to brain metastases.The histological report was consistent with a subcutaneous intramuscular hemangiosarcoma. The excisional margins were free of neoplastic cells. Chemotherapy was started 20 days after surgery  is mandatory .Magnetic Resonance (MR) imaging is a more reliable tool than a CT scan for the characterization of soft tissue sarcoma, even though CT displays some limitations on the soft tissue evaluation. In human medicine, MR features are relevant for the assessment of treatment strategies, surgical planning and definition of borders/signs of fascial infiltration . DespiteLocal control of low to intermediate-grade malignant tumours can be achieved with surgery alone or with surgery and adjuvant radiotherapy. When histopathology is consistent with a high-grade tumour, adjuvant chemotherapy is needed despite negative tumour clinical staging at presentation and completeness of excision margins. Muscular hemangiosarcoma is a high-grade sarcoma due to its high metastatic rate, and adjuvant chemotherapy is considered essential in an attempt to prolong survival time . In thisEven if the compartmental excision can be classified, when applied to tumours of the limbs, as less invasive than amputation, nevertheless it should be considered a major elective procedure, which requires good anatomical knowledge of the region of interest; the goal is to avoid any vascular or neurological damage. Additionally, the complete excision of a muscle may result in large dead spaces and, consequently, in seroma formation. In this limited cases series, only in dog number 3 an active draining system was applied, while in the remaining two dogs, only a soft padded bandage was applied for 48 h, but no seroma formation occurred even though a draining system was not applied. Despite this, it is reasonable to state that it would be prudential to apply it in all cases.Postoperative complications observed were few. All dogs experienced a transient and self-limiting lameness. In two dogs, the lameness was caused by the pain secondary to soft tissue surgical trauma. On the contrary, the cause of the persistent lameness in case number 3 was mechanical due to the tenotomy of the serratus ventralis tenotomy. Dorsal scapular luxation is a common consequence of the traumatic rupture of the serratus ventralis muscle . This coThe main limitations of this report are the low number and the heterogeneity of the cases included and its retrospective nature. The first condition is influenced by the rarity of the disease in dogs, i.e., patients with soft tissue sarcoma limited to a single muscle belly. Nevertheless, this report provides some guidelines regarding the selection of patients who could potentially be candidates for a compartmental excision. When this selection is correct, it is possible to reach a local tumour control by performing a less aggressive surgery, often resulting in a desirable preservation of function.Overall, it can be concluded that dogs with mid-belly intramuscular sarcomas still confined within the muscular fascia are potential candidates for a compartmental excision. Attention should be addressed to the resulting function; this requires in-depth knowledge of both anatomy and physiology of the region.The main advantages of a compartmental excision are the possibility of obtaining local tumour control and function preservation. While in humans, these goals may also be reached with marginal excision plus radiotherapy or radiotherapy only, in veterinary medicine, radiotherapy, despite being a well-known therapeutic option, is not always used due to its high cost and/or equipment availability. With this in mind, in case of an intramuscular soft tissue sarcoma still confined to a single and not functionally essential muscle, a compartmental excision may be a valuable option.


The optimal management for peritoneal dissemination in patients with hepatocellular carcinoma remains unclear. Although several reports have described the usefulness of surgical resection, the indications should be carefully considered. Herein, we report the case of a patient with hepatocellular carcinoma with peritoneal recurrence who underwent surgical resection using an indocyanine green fluorescence navigation system and achieved favorable disease control.A 45-year-old Asian woman underwent left hemihepatectomy for a ruptured hepatocellular carcinoma. Seventeen months after the initial surgery, a single nodule near the cut surface of the liver was detected on computed tomography, along with elevation of tumor markers. The patient was diagnosed with peritoneal metastasis and underwent a surgical resection. Twelve months later, a single nodule on the dorsal side of the right hepatic lobe was detected on computed tomography, and we performed surgical resection. Indocyanine green (0.5 mg/kg) was intravenously administered 3 days before surgery, and the indocyanine green fluorescence imaging system revealed clear green fluorescence in the tumor, which helped us perform complete resection. Indocyanine green fluorescence enabled the detection of additional lesions that could not be identified by preoperative imaging, especially in the second metastasectomy. There was no further recurrence at 3 months postoperatively.When considering surgical intervention for peritoneal recurrence in patients with hepatocellular carcinoma, complete resection is mandatory. Given that disseminated nodules are sometimes too small to be detected by preoperative imaging studies, intraoperative indocyanine green fluorescence may be an essential tool for determining the indications for surgical resection. Peritoneal dissemination is a rare form of recurrence in hepatocellular carcinoma (HCC), and it has been reported that implantation of tumor cells by rupture of the primary tumor , needle A 45-year-old Asian woman with history of diabetes mellitus visited her family doctor with a chief complaint of epigastric pain. Contrast computed tomography (CT) revealed a 45-mm-diameter tumor with extravasation in liver segment S3/4, indicating HCC rupture Fig. a. TranscSeventeen months after the initial surgery, CT revealed a 10-mm nodule near the cut surface of the liver Fig. a, togethTwelve months after resection of the peritoneal dissemination, a CT scan revealed a 12-mm nodule on the dorsal side of the lower part of the right liver lobe Fig. a with elPeritoneal recurrence is a rare form of HCC. According to the report of the 22nd Nationwide Follow-Up Survey of Primary Liver Cancer in Japan 2012–2013) , of 74942–2013 , et al. [ICG is used not only for evaluation of liver function but also for surgical navigation, such as detection of tumors or blood flow assessment. ICG fluorescence can be used to detect both primary and extrahepatic lesions in HCC. Sato et al.  reportedTo assess the efficacy of ICG fluorescence for resection of peritoneal dissemination in patients with HCC, we conducted a literature search using the PubMed database and found seven cases of surgical resection for peritoneal dissemination of HCC using ICG fluorescence imaging, including our case , 10, 14 In conclusion, we report the case of a patient with HCC who underwent surgical resection for peritoneal dissemination. ICG fluorescence imaging may be useful for determining the indications for surgical resection of peritoneal dissemination.


Absence of an internal jugular vein at birth is infrequent. These developmental anomalies affect approximately 0.05 percent to 0.25 percent of the population in the general community. Avascular abnormalities emerging from the internal jugular vein were detected during radiographic studies of chronic headache in an adult male patient. A dull headache troubled a 32‐year‐old man for more than 20 years. After taking most of NSAIDs and other medications for the condition, which persisted, a diagnosis of left internal jugular vein agenesis was made, which was most likely the cause of the headaches. When treating recurrent, persistent headaches in the emergency room and outdoor medical services, keep in mind that agenesis of the jugular venous system can play a role—one of the uncommon causes of headaches we have observed in our cases. Persistent headaches sometimes concern incidental findings: A rare case of internal jugular vein agenesis. The absence of an internal jugular vein (IJV) is an asymptomatic, relatively unusual vascular abnormality.One of the most common bodily complaints in people is a headache. Despite the fact that headaches are mostly benign, neuroimaging tests are regularly carried out in clinical settings because of concern that they may fail to detect a serious underlying condition. So, we report a 32‐year‐old man with left internal jugular vein agenesis who has experienced a dull headache for more than 20 years and who has no family history of the condition. There was not yet a remarkable intervention for this situation. We hypothesis this persistent headache may be an uncommon cause of internal vein agenesis.2A 32‐year‐old man with a 20‐year history of chronic headaches was referred to the National Institute of Neurosciences & Hospital on November 25th, 2021. Apart from that, the physical checkup was normal. Since 2002, he has had constant and recurring headaches, occurring 2–3 times each week. The headaches were reported as forehead pain that did not extend to his eye or any other body part. The attacks lasted 30 to 45 min on average. These headaches frequently occurred in the afternoon and were not characterized by eye redness or weeping. The headaches were so bad that he could not stand it any longer. Except for NSAIDs, which only eased the pain to a minor degree, no therapies were helpful before consulting with a physician. He was previously diagnosed with tension headaches and also treated as migraine for dull on–off headaches. He had previously been prescribed paracetamol, NSAIDs, propranolol, methysergide, antihistamines, anti‐anxiety and sedative medication and naproxen sodium were among the earlier ineffectual treatments. A clinical interview, the Minnesota Multiphasic Personality Inventory‐2 (MMPI‐2), the State–Trait Anxiety Inventory (STAI), and the Beck Depression Inventory (BDI) were all used in a comprehensive psychiatric assessment. The psychological perception was the situational anxiety resulting from his disease, with no underlying psycho‐emotional dysfunction. On numerous occasions, physicians have recommended that he undergo contrast‐enhanced computed tomography (CT scan) and magnetic resonance imaging (MRI), but he has always planned to do it later. He experienced acute watery diarrhea recently on November 10, 2021, and laboratory tests are done . The most common headache symptom is usually caused by that benign, and it can generally be detected after a comprehensive history and targeted neurologic and overall physical tests. Headache caused by cerebral venous abnormalities is a new issue that all health care workers should be aware. Future research into these unsolved riddles and the exploration of surgical or nonsurgical methods to optimize the treatment for IJV outflow disturbance will give us a profound understanding of this headache and other similar IJV agenesis‐related issues.Mohammad Ashraful Amin involved in conceptualization. Mohammad Delwer Hossain Hawlader involved in supervision. Mohammad Ashraful Amin and Sabrina Nahin involved in writing—original draft. Mohammad Ashraful Amin, Sabrina Nahin, and Mohammad Delwer Hossain Hawlader involved in writing—review and editing.This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.The authors declare that they have no competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.The article is about a case study. As a result, our Ethics Committee's consent was not required.The patient's written informed consent for publishing of this case report, as well as images, was acquired.


Anal canal duplication (ACD) is an extremely rare congenital anomaly of the intestinal tract that presents as an extra opening of the anal canal without communication with the anorectum. We present the case of a five-year-old male presenting to the pediatrician without symptoms and upon physical examination, a duplicated anal canal along the midline was discovered. The patient was admitted for surgery and the canal was removed via mucosal stripping. Postoperatively, the patient recovered well. The present study aims to expand on our knowledge of a very rare pathological entity and emphasize the importance of a complete pediatric physical examination. Anal canal duplication (ACD) is an extremely rare congenital anomaly of the intestinal tract. ACD presents as an extra opening of the anal canal without communication with the anorectum and is usually tubular . It is mWe present the case of an asymptomatic child with anal canal duplication where we performed a complete excision of the ACD. This study aims to expand on our knowledge of a very rare pathological entity and emphasize the importance of a complete physical examination in this anatomical area.A five-year-old male presented to the pediatric ward with his mother for the first time. The main reason for the visit was, as the mother revealed, that she noticed an extra opening canal in the perineal area a few days prior. The patient was asymptomatic, and his medical history was unremarkable. During the physical examination, no associated pathologies were identified but upon inspection of the perineal area, it was found that the patient had a suspected extra anal canal Figure . The susThe patient was referred to a pediatric surgeon, who was responsible for the treatment of this infrequent pathology. Pre-surgery, an MRI was performed Figure . The MRIPostoperatively, the duplicated anal canal repair was removed Figure  and the Histological examination of the specimen revealed the presence of transitional-cell epithelium, glandular tissue, and smooth muscle cells. Figure . The aboPost-operative follow-up of the patient at one and two weeks showed no further complications, and the patient was pain-free. There was no evidence of recurrence until follow-up after nine months.Anal canal duplication is the rarest anomaly of the alimentary tract. The condition was first described by Dukes et al. in 1956 . It affeThe largest and most comprehensive literature review of ACD conducted by Trecartin et al. in 2019 found that only 38% of cases were asymptomatic, a novel finding since previous literature stated that most patients presented without symptoms . The mosA key aspect underemphasized in literature is the importance of a physical examination. Examining the patient is the primary way of identifying this condition. Diagnosis can be made by a simple perineal inspection revealing a small opening behind the anus. It was found that the lack of literature on anal canal duplication and their low frequency worldwide can lead to more missed diagnoses and, as a result, delay in treatment. Furthermore, two conditions that present with common symptoms and are found in similar locations are rectal duplication and anorectal fistulas . HoweverThe only curative measure for ACDs is surgery . Total rThe diagnosis of ACD relies on two factors: clinical and histopathological assessments. ACD frequently presents with the histological findings of the squamous epithelium at the caudal end, a transitional epithelium at the cranial end, and smooth muscle cells in the wall of the lesion . Thus, hFinally, the report of these cases in the literature is significant due to the lack of knowledge of this condition. The delay in diagnosis of children until the age of five, as in our case, reveals the need to raise awareness of this condition. This case report emphasizes the importance of the pediatric physical examination.In conclusion, ACD is the rarest congenital anomaly of the intestinal tract. The low prevalence of the disease and its asymptomatic presentation lead to missed diagnoses and delays in treatment. The gold standard for the management of this condition is the complete pediatric clinical examination, in all anatomic areas of the neonates, from birth until early adulthood, to identify and immediately treat this rare condition.


Question 1What is your diagnosis?A. Blue nevusB. MelanomaC. TrichoblastomaD. Pigmented apocrine hidrocystomaE. Pigmented basal cell carcinomaCorrect answer: D. Pigmented apocrine hidrocystoma. Apocrine hidrocystomas (AHs) are rare, benign, cystic lesions of apocrine glands. A pigmented variant has been described, characterized by a darker coloration related to lipofuscin pigments, hemosiderin, melanin deposits, or Tyndall effect.A 42-year-old woman (Fitzpatrick type IV) presented with a 4-year history of hyperpigmented growing asymptomatic lesion on her right inferior eyelid. Physical exam revealed a dark bluish 3 mm tumor and dermoscopy showed a blue-gray area with peripheral shiny white streaks and an arborizing central vessel Fig. . ExcisioQuestion 2What are you most likely to see on pathology?A. Excess mature apocrine glands in the reticular dermis, extending into the subcutaneous fat.B. A dermal cyst with a cavity partially replaced by a papillary or adenomatous proliferation.C. An intradermal cyst lined by a low cuboidal or flattened epithelium with paler cytoplasm and a watery secretion without cytoplasmic contributions.D. An intradermal cyst lined by an outer layer of flattened vacuolated cells and an inner layer of tall columnar cells with eosinophilic cytoplasm, vesicular nuclei with secretory decapitation and periodic acid-Schiff (PAS)-positive granules.E. Villi covered by a double-layered epithelium consisting of an inner zone of small cells and an outer zone of tall columnar cells, without cytologic atypia.Correct answer: D. An intradermal cyst lined by an outer layer of flattened vacuolated cells and an inner layer of tall columnar cells with eosinophilic cytoplasm, vesicular nuclei with secretory decapitation and PAS-positive granules. Decapitation secretion is usually present, and it is typical of apocrine glands. Pigmented variants contain lipofuscin, hemosiderin, or melanin deposits in a colloidal suspension that can be revealed by different stains including PAS with diastase, Sudan Black, or Fite acid-fast.Question 3Which is the most common dermoscopic feature of apocrine hidrocystomas?A. A homogeneous area that occupies the whole lesionB. Arborizing vesselsC. Multiple gray-blue globulesD. Shiny white streaksE. Blue-white veilCorrect answer: A. A homogeneous area that occupies the whole lesion. Most commonly, on dermoscopy, AHs show a skin-colored, yellow, or blue homogeneous area that occupies the whole lesion. The second most frequent feature is arborizing vessels, followed by shiny white streaks.1 AHs are usually found on the head and neck affecting the eyelids and cheeks most commonly.2Eccrine and AHs are the most common adnexal eyelid tumors. They are considered nonproliferative retention cysts.3 Classically, eccrine hidrocystomas are described as more frequent but recent studies have shown that apocrine cysts predominate.3Eyelid hidrocystomas typically affect older patients without gender distinction unless there are multiple cysts, where women outnumber men.1 The reasons for the more frequent involvement of the lower eyelid and the higher incidence of left side cysts remain unknown. AHs rarely cause madarosis as opposed to malignant tumors. The former do not affect vision unless they are multiple and/or develop a considerable size. On palpation, hidrocystomas are soft and compressible.3 The pigmented variants might be misdiagnosed as vascular, pigmented epithelial, or melanocytic proliferations such as angiokeratoma, seborrheic keratosis, blue nevus, and melanoma.1The clinical presentation is an asymptomatic, 1 to 4 mm, skin dome-shaped cystic papule or nodule on the lower eyelid with a predominance for the left eye. The lesions can be skin colored, translucent, milky white, blue, amber, brown, or black in coloration.3Chromhidrosis describes the excretion of colored secretions composed of lipofuscin pigments in apocrine gland-rich anatomic locations. The darker coloration is believed to be caused by the Tyndall phenomenon. Hemosiderin or melanin deposits are rarely identified in hidrocystomas. Nonetheless, the Tyndall effect rather than specific pigments is thought to be the source of the color we perceive in clinically pigmented hidrocystomas.2. Lipofuscins can be detected by fluorescent microscopy and histochemistry for PAS with diastase, Sudan Black or Fite acid-fast.1Histologically, they are large unilocular or multilocular dermal cysts typically lined by a bilayer of epithelial cells with an outer layer consisting of myoepithelial cells and an inner layer of tall columnar cells. Decapitation secretion is usually present and is the hallmark of apocrine glands.2A recent multicenter study analyzed the dermoscopic features of 22 cases of AHs with the most frequent findings being: a homogeneous area that occupies the whole lesion (100%), arborizing vessels (68.2%), and shiny white streaks (22.7%). The commonest detected colors were: skin colored, yellow, and less frequently blue.3There are multiple therapeutic modalities to remove these lesions such as excision, injection of trichloroacetic acid, botulinum toxin , topical application of atropine , electrodesiccation, and laser therapy. However, when hidrocystomas are pigmented or exhibit concerning features leading to suspicion of malignancy, histopathologic confirmation is recommended.Dermatologists must be aware of pigmented hidrocystomas because although being rare, they mimic cutaneous malignancies. In order to improve the diagnostic accuracy, we report the clinical and dermoscopic aspects of these benign palpebral tumors.None.None.MVR participated in drafting the article, data collection, conception or design of the work, critical revision of the article, and final approval of the version to be published. MVRK participated in data collection, conception or design of the work, critical revision of the article, and final approval of the version to be published. MMMP and LDM participated in conception or design of the work, critical revision of the article, and final approval of the version to be published.The author(s) confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies.Patient consent has been obtained to publish these photographs and case report.


Mycetoma, well known as “Madura foot,” is a long-standing granulomatous infection of the skin and subcutaneous tissue. Causative organisms are filamentous fungi (eumycetes) and bacteria (actinomycetes). It characteristically presents with firm woody swelling, discharging sinuses with grains (containing the causative organism). Diagnosis in suspected cases can be made by microbiological evaluation, histopathological, cytological and radio imaging techniques. To differentiate between eumycetoma and actinomycetes histopathology is an accurate diagnostic modality as seen in the present case. We report a case of 42 years male who presented with swelling on his back with discharging sinus. Histopathological specimen containing multiple, irregular, greyish, whitish tissue pieces with skin attached all together measuring around 12×9×4 cm from the paraspinal region. The section shows histopathological features suggestive of eumycetoma. Periodic acid -Schiff stain showed the presence of septate, branching fungal hyphae and black granules. Eumycetoma can be accurately diagnosed by histopathological evaluation using a special stain. It is confirmatory and provides a guide for treatment plans with a high index of suspicion. Madurella mycetomatis and the actinomycetes Nocardia brasiliensis, Actinomadura madurae, Streptomyces somaliensis and Actinomadura pelletieri [Mycetoma is a chronic granulomatous infection of the skin and subcutaneous tissue mainly involving extremities. It is a kind of implantation mycosis, which presents as large tumor-like swelling . It can lletieri .World Health Organization has recently declared it a “neglected tropical disease” . The cauThe accurate occurrence of mycetoma is not well known, but the maximum cases fall between the latitude of 15°S and 30°N, which is known as the “mycetoma belt.” The endemic countries consist of Sudan, Somalia, Senegal, India, Yemen, Mexico, and Venezuela . The claA 42-year-old male presented with a history of soft tissue swelling over the lumbosacral region for the past two years. The patient was a farmer by occupation. According to the patient, the swelling had gradually increased in size to become the current size over two years. But the reason for now seeking medical advice was the large size of the lesion restricting his mobility and affecting farming and daily activity. Associated trauma history is not recalled by the patient. First, it started with swelling over the lower side of the back, then multiple discharging sinuses with granules over a period of two years. As it was huge in size, surgical resection was advised. On gross examination, it was approximately 12×9×4 cm in size and had multiple, irregular, greyish, whitish tissue pieces with skin attached all together. Periodic acid-fast (PAS) staining of tissue has shown branched septate hyphae of fungus Figures -1C. On hMycetoma is a rare pathology caused by either a filamentous fungus (eumycetoma) or by filamentous bacteria (Actinomycetes species) . MycetomThe grains discharged from sinuses differ in size, color, and consistency. These topographies can be utilized for quick provisional identification of causative agents . But graThe incubation period of these organisms fluctuates from several weeks to months . DevelopThe key differential diagnoses include chronic bacterial osteomyelitis, tuberculosis, and Buruli ulcer. Other deep fungal infections such as blastomycosis or coccidioidomycosis and leishmaniasis, yaws, and syphilis should be considered . IdentifAs this disease is generally found in low socio-economic strata in developing countries, where facilities for molecular diagnosis are inaccessible to common people. As well, due to the chronic painless nature of the disease, presentation is very late and surgical resection with antibiotic and antifungal coverage will become a mainstay of treatment. In this situation, the histopathological diagnosis will be a good diagnostic modality to differentiate between its fungal or bacterial origin and also for a better outcome for the patient. The unusual location of mycetoma should be considered along with keeping in mind the probability of another differential diagnosis of mycetoma especially tuberculosis which is more prevalent in developing countries.


We present a case of bilateral cystic lung metastases originating from cutaneous angiosarcoma (cAS) of the scalp in a 73-year-old man. He presented with hemoptysis and recurrent bilateral pneumothorax. The clinical, radiological, and histological features and a potential pathophysiological mechanism of pulmonary changes in cutaneous angiosarcoma are discussed. Cutaneous angiosarcoma is a rare neoplasm that originates from endothelial cells of blood vessels. It accounts for less than 1% of all soft tissue sarcomas and typically develops on the face or scalp .The lung is the most common site of metastatic involvement in cAS, which typically presents as cystic lesions . The symBecause of the low incidence and the peculiar radiological and clinical presentation, pulmonary metastasis of cAS is often misdiagnosed as mere pulmonary cyst. There are only a few case reports or case series describing cAS affecting the lungs.We report on a patient with a complex course of pulmonary metastasis of a cutaneous angiosarcoma of the scalp who developed rapidly growing cystic lesions, spontaneous bilateral pneumothorax, intrapulmonary bleeding, and hemoptysis.Two weeks after a first episode of right-sided pneumothorax, which had been treated by chest tube in a peripheral hospital, a 73-year-old male, ex-smoker since 2 years but 60 packyears, presented with recurrent pneumothorax on the right side and slight hemoptoe.The patient’s history included a parieto-occipital cutaneous angiosarcoma treated by tumor excision and radiation therapy 17 years previously, with local recurrence that had required resection and split-thickness skin grafting 3 years ago. In addition, he had had prostatectomy for carcinoma of the prostate 14 years ago. An outpatient CT scan because of chest pain 8 months previously had shown two thin-walled cysts in the right lower lobe. Despite not taking any anticoagulants, the patient had noticed one episode of slight hemoptysis 3 months ago. The CT scan following that episode had revealed an increase in number of the cysts , which showed subliminal 18F-fluorodeoxyglucose (FDG) metabolic activity with a standardized uptake value (SUV) of 1.7–2.04. Laboratory and microbiological investigations excluded alpha‑1 antitrypsin deficiency, histiocytosis X, pneumocystis carinii, SARS-CoV‑2, mycobacterial infection. As hemoptysis had subsided spontaneously, the patient had refused any invasive diagnostics.Thoracic CT scan again showed progression. The bilateral lesions had increased in maximum diameter by 3 to 6 mm each, and measured between 10 and 47 mm  have been administered without significant side effects. There has been no further recurrence of pneumothorax or hemoptysis and the patient is up and well.Two weeks later, the patient was re-admitted with severe recurrent hemoptysis. The cystic lesion in the left lower lobe had increased by 18 mm in maximum diameter, now comprising the majority of the left lower lobe with the coiling material in unchanged position. Emergency left lower lobectomy was done via thoracotomy. After an uneventful course, the patient was discharged to home care. Up to the time of writing, 1 year after the operation, 10 treatment cycles with paclitaxel  is a rare, aggressive malignant vascular neoplasm with an incidence of about 0.5 cases per 1,000,000 persons per year . They usThe lung is the most likely site for metastasis of cutaneous AS . BecauseIn most cases the first symptom of pulmonary spread of cAS is hemoptoe or hemoptysis , 12, 13.Radiologically, pulmonary cysts of variable size , 10–13 wMYC oncogene was positive in very few, singular cells. Therefore, considering the age of the patient and keeping in mind the fact that the primary had not been radiation induced, the pathologists decided not to proceed to an evaluation of CIC rearrangement. This marker, which indicates poor prognosis, is common in younger individuals and especially in cases associated with radiation therapy [Histopathology reveals cavities with thin walls, the inner surface of which is lined by tumor cells. They show a diffuse growth pattern, infiltrating the adjacent lung along collagen bundles. Necrosis or fibrosis is usually absent , 17. The therapy .A clear-cut mechanism for the peculiar growth pattern featuring thin-walled cysts has not yet been defined. However, the group of Masuzava et al. suggested a potential explanation. Similar to cells within the cysts in lymphangioleiomyomatosis (LAM), the cAS tumor cells produce matrix metalloproteinase 1 . This enzyme is capable of degrading interstitial collagen types 1 to 3 as well as elastin, all of which are components of the alveolar wall. Formation of a central necrosis within a solid metastasis along with a high proteinase activity is another possible mechanism for cyst formation , 18. TheRupture of cystic metastases at the lung surface causing pneumothorax or profuse bleeding may require resection. Yet, as also in our patient, lesions are usually localized deeply within the parenchyma with multiple bilateral spread foci. Therefore, complete resection is usually impossible due to both anatomical and functional reasons. Currently, paclitaxel seems to provide the best systemic treatment option, with long-term tumor control even in case of gross dissemination , 21.Cutaneous angiosarcoma (cAS) is a rare vascular malignancy. The lung is the typical and most common site of metastasis. Clinical symptoms include hemoptoe, spontaneous recurrent pneumothorax, and rarely hemothorax. Radiologically, multiple thin-walled cysts are found. The present case features the typical symptoms and radiological findings, emphasizing the importance of correct interpretation of pneumothorax and hemoptysis in patients with a history of cAS.