MRI–Negative Cushing’s disease continues to be a challenging disease despite better imaging and techniques. The situation can be more complicated in the setting of prior surgery or failed surgery. Often, a narrow surgical corridor is encountered with robust cavernous or intercavernous sinuses. Controlling venous oozing properly is critical to achieving better outcomes. In this video, the authors present a case of MRI–Negative Cushing’s disease after previous unsuccessful surgery. The pituitary tumor was detected on the left side of the gland, close to the cavernous sinus. Margin-plus resection is important if it can be achieved. Biochemical remission was achieved after surgery.https://stream.cadmore.media/r10.3171/2023.4.FOCVID2312The video can be found here:  This is an illustrative case showing our surgical strategy of pituitary and cavernous sinus exploration in MRI–Negative Cushing’s disease after previous unsuccessful surgery. This 46-year-old lady presented with 10 years’ history of edema, hypertension, and central obesity. Cushing’s disease was confirmed after a series of diagnostic tests. A transsphenoidal surgery was performed in another hospital 2 years ago. Unfortunately, they did not find the tumor, and biochemical remission was not achieved. The specimen sent for pathology was proved to be gland cells. The patient was transferred to our hospital. She lost her preoperative images during the house move. On admission, the pituitary MRI with contrast could not identify any definite lesions. There were multiple low-enhancing lesions in the gland, with the largest one on the left side close to the cavernous sinus. However, the pituitary stalk was slightly toward the left side, not supporting a left-sided tumor.1 Here are the key steps. First is a standard endoscopic endonasal approach to expose the sella and bilateral medial cavernous sinuses.2 Pack the cavernous or intercavernous sinuses if needed. Explore the left, followed by the right side of the pituitary gland toward the medial wall of the cavernous sinus. Resect the medial wall of the cavernous sinus if tumor invasion is suspected.3 Explore the cavernous sinuses if no tumor was found in the pituitary gland—finally, reconstruction. The patient was supine with the upper body elevated by 20° to facilitate venous drainage. The head was rotated 15° toward the operator to provide an ergonomic trajectory. HD endoscope, neuronavigation, intraoperative micro-Doppler ultrasound, and endoscopic microsurgical instruments were prepared.So our surgical plan was to explore the whole pituitary gland, including the cavernous sinuses, if necessary.Here is an intraoperative view of our exposure. As you can see, there was a scar on the right side, indicating the range of dura opening and surgical exploration of the previous surgery.4 Enlarged resection, including millimeters of the adjacent gland, is critical for surgical cure.1 The inferior margin, including the dura, could be easily achieved using a microscissor. The lateral margin was quite tenacious. A healthy, clean medial wall of the cavernous sinus, which was the scheduled lateral boundary of pituitary exploration, could not be obtained using this inside-out fashion.According to the surgical plan, we explored the left side first. Here we can see that the left cavernous and intercavernous sinuses were a little bit robust. After Doppler detection, we opened the ventral wall of the left cavernous sinus and injected hemostatic materials to control venous oozing. Now we opened the left sella dura with a sharp feather blade. The underlying orange-yellow gland tissue was partially removed. We used a small, angled pituitary curette to split the gland, carefully searching tumor-like tissues. Here we can see a gray-white bulging surface, indicating an underlying tumor. After cutting into it, we can see gray-white soft tumor-like lesions. The lesion was collected for pathological diagnosis. The intraoperative frozen section showed a pituitary tumor. We used small pituitary forceps to create an adequate space for the sucker to debulk this soft tumor. A pseudocapsule had not been formed for this tiny tumor.5 Sharp dissection helps to protect the ICA from laceration. Another critical point to avoid carotid injury is the identification of the inferior hypophyseal artery.5 It should be precisely coagulated and cut. Then the medial wall of the cavernous sinus, together with the tumor remnants, could be cut as a whole, creating a tumor-free lateral margin. Afterward, we resected additional millimeters of gland tissues at the superior and medial margins. Final exploration of this side showed the resection cavity was quite satisfied. The posterior wall of the cavernous sinus and the base of the posterior clinoid process was nicely exposed. Notice that pretreating the cavernous sinus with hemostatic materials injection helps maintain a clean surgical field, increasing safety during cavernous sinus exploration.6The medial wall of the cavernous sinus was dissected toward the midline, and we can see this medial wall was thick, indicating tumor infiltration. Here we should notice that the medial wall was connected to the cavernous ICA with the inferior parasellar ligament.We explored the right side as scheduled to exclude multiple tumors at the right gland. After Doppler detection, the dura was cut toward the right cavernous sinus. The right pituitary gland was explored toward the medial wall of the cavernous sinus. Here we can see the medial wall was healthy and thin. No tumor-like tissue was identified.7As no intraoperative CSF leak was created, a simple reconstruction was performed using collagen matrix and Gelfoam, wedged with a piece of semirigid collagen fleece and covered with fibrin glue.The patient tolerated the procedure well. Her ACTH quickly decreased to 3.5 pg/mL, and cortisol decreased to 0.7 μg/dL, indicating remission. Pathology found ACTH cell adenomas in the specimen from the left gland, and ACTH hyperplasia in the affected left medial wall of the cavernous sinus. Postoperative MRI demonstrated a nice resection cavity on the left side. Thank you.This work was funded by the Chinese Academy of Medical Sciences (grant no. 2019-I2M-5-008 to Y.W.) and the National Natural Science Foundation of China (grant no. 81602191 to M.S.).The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.Primary surgeon: Wang. Assistant surgeon: Shen, Shou. Editing and drafting the video and abstract: Shen. Critically revising the work: all authors. Reviewed submitted version of the work: all authors. Approved the final version of the work on behalf of all authors: Wang. Supervision: Wang.


To report a case with branch retinal vein occlusion secondary to a retinal astrocytic hamartoma in a patient with tuberous sclerosis complex.A fourteen-year-old boy, a known case of tuberous sclerosis complex, with multiple bilateral retinal astrocytic hamartomas was followed by 6 months intervals. In his last follow-up, 6 months after initial presentation, the patient developed angiographic signs of branch retinal vein occlusion (BRVO) in the superotemporal arcade of the right eye distal to one of the retinal astrocytic hamartomas. He underwent targeted retinal laser photocoagulation. No secondary complication related to BRVO was observed during the next six-month follow-up.And Importance: Although the co-occurrence of branch retinal vein occlusion and astrocytic hamartoma may represent an incidental finding, awareness of BRVO as a possible complication associated with retinal astrocytic hamartoma helps timely diagnosis and prompt treatment of this complication, improving the visual prognosis of these patients. He was unable to communicate verbally due to his intellectual disability. Skin examination revealed facial angiofibroma, ash-leaf lesions on the trunk, and shagreen patches A–C. He wPosterior segment examination revealed multiple bilateral creamy-white appearance lesions which were compatible with astrocytic hamartomas A and B. On fundus autofluorescence (FAF)  imaging of the right eye, the large superotemporal astrocytic lesion displayed a hyperautofluorescent core with surrounding hypoautofluorescent area. The superior lesion to the above-mentioned astrocytic hamartoma showed uniform hypoautofluorescence. In the left eye, FAF revealed a large astrocytic lesion superotemporal to the fovea with central hyperautofluorescence, and a hypoautofluorescence rim, along with a smaller hypoautofluorescent lesion next to the larger lesion C and D.Spectral-domain optical coherence tomography (SD-OCT)  through the lesions was performed. All tumors were confined to the inner retinal layers and typically appeared as dome-shaped retinal thickening with disruption of the normal layers. Compatible with retinal astrocytic hamartomas, these lesions featured hyporeflective centers surrounded by hyperreflective periphery, varying degrees of posterior shadowing, and abnormal vitreoretinal interfaces.Early-phase fluorescein angiography (FA)  revealed mild hypofluorescent regions caused by tumor blockage. During the late venous phase, leakage from astrocytic lesions caused hyperfluorescence over the tumors I–L.Follow-up visits every six months were planned. Fundus examination was conducted six months after initial presentation, which revealed a slight venous engorgement located distal to the superotemporal astrocytic hamartoma in the right eye -A. The SFA of the right eye in the early phase revealed hyperfluorescent areas along the superior retinal vein distal to the tumor, which had increasing hyperfluorescence due to leakage in the late phases D and E. In the left eye's FA, no new vascular abnormality was observed. The patient had targeted laser photocoagulation of the retina in regions of leakage . At the 3This case report presents a patient with TSC who presented with an extremely unusual ocular manifestation, an astrocytic hamartoma accompanied by BRVO. After conducting a literature review in April 2023 utilizing PubMed, Google Scholar, and Scopus , we did not find any similar report.,,,Bourneville initially characterized TSC in the 1880s. It is a multisystem, autosomal dominant condition caused by mutations in either TSC1 (encoding hamartin) or TSC2 (encoding tuberin).,In patients with TSC, many ocular manifestations have been recorded, including retinal astrocytic hamartomas, achromatic retinal patches, and, less frequently, iris and ciliary body pigment epithelium hamartomas.,OCT of astrocytic hamartomas typically reveals a dome-shaped hyperreflective mass arising from the retinal nerve fiber layer in conjunction with variable retinal disorganization, posterior shadowing, and intralesional optically empty spaces (OES), appearing as so-called moth-eaten spaces, representing intralesional calcification or cavitation.Depending on their calcium content, astrocytic hamartomas exhibit hyperautofluorescence on FAF imaging.On FA, early blockage owing to the tumor mass is seen during the choroidal phase, when the intrinsic tumor vasculature begins to fill, and hyperfluorescence gradually rises throughout the arterial phase. A possible leakage may occur in the late venous phase.Multiple ocular consequences of astrocytic hamartomas of the retina have been observed. These conditions include vitreous hemorrhage, retinal vascular anomalies including neovascularization, telangiectasia, and exudation, and vitreous seeding.The mechanism of vascular occlusion in astrocytic hamartoma-affected eyes remains unknown. As Vedantham et al. also mentioned in their BRAO study, the pathophysiology of venous blockage in our case may be owing to increased resistance and therefore delayed circulation in draining veins, which increases the likelihood of vascular obstruction.,,anti-VEGF therapy without requiring any evidence of pre-retinal or choroidal neovascularization.In this case, we preferred to do targeted laser photocoagulation of the retina in regions of leakage to reduce the amount of vitreous vascular endothelial growth factor (VEGF). Previous studies have shown that astrocytic hamartomas, especially in patients with TSC, may be intrinsically associated with VEGF signaling for their structure and exudative properties independent of their ability to promote neovascularization.In light of the patient's cognitive impairment and geographical distance from the retina clinic, targeted retinal photocoagulation was deemed the preferred treatment option. It is not possible to assert that targeted laser photocoagulation represents the optimal treatment modality for this particular patient. Rather, the selection of treatment options should be tailored to the individual patient, taking into account factors such as the risk of loss to follow-up and the stratification of treatment options, such as the potential risks associated with intravitreal injection in a patient with mental retardation.The approach that was employed in the present case has specific limitations. The presence of localized vasculitis-like appearance in the superior arcade of the right eye warrants consideration of inflammatory processes that may be secondary to conditions such as sarcoidosis or tuberculosis. In cases where there is concomitant astrocytic hamartoma and vasculitis-like appearance, it is advisable to conduct inflammatory workups in this group of patients. Alternatively, employing a multimodal imaging strategy, such as optical coherence tomography angiography (OCTA), may aid in the identification of non-perfused regions in the current patient, thereby necessitating additional assessments and interventions. And finally, the patient was identified as a known case of tuberous sclerosis complex; however, due to the absence of genetic testing, the pathogenic variant of the patient could not be determined. As a result, it is unclear whether the patient belongs to the TSC1 or TSC2 variants of tuberous sclerosis complex.4Although the co-occurrence of BRVO and astrocytic hamartoma may represent an incidental finding, awareness of BRVO as a possible complication associated with retinal astrocytic hamartoma helps timely diagnosis and prompt treatment of this complication, improving the visual prognosis of these patients.Written informed consent was obtained from the patient's family for publication of this case report and the accompanying images.No funding or grant support.All authors attest that they meet the current ICMJE criteria for authorship.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Knowledge of both normal and aberrant root canal anatomy is the key to any successful root canal treatment. A mandibular molar demonstrates considerable variations with respect to additional canals or roots. The clinician must aim to identify all possible canals with the help of any magnification aids. This report discusses the variations of the middle mesial canal in mandibular molars. The prerequisite of any endodontic therapy is to have familiarity with the root canal anatomy of the tooth. The pulpal cavity is the most complex structure in nature. Identifying all the portals of exit, debridement of the entire root canal system, and sealing all the exits with three-dimensional filling materials make endodontic treatment successful .Clinically, a mandibular molar has many anatomical variations, like the presence of additional roots in the distolingual or mesiobuccal aspect, C-shaped canal anatomy, and three canals in mesial or distal roots including a middle mesial canal (MMC) or middle distal canal (MDC), etc -5.The incidence of having an extra canal in the mesial root is 1-15% . The MMCFor the identification of this MMC, one must rely on multiple radiographs, cone beam computed tomography (CBCT), and another form of magnification aid such as magnifying loupes or dental operating microscopes in order to limit procedural errors during exploration of the third canal . This paper reports three cases with different variations of MMC in the mandibular first molar.Case 1A 23-year-old male patient presented with a complaint of pain in a left lower back tooth for the past one week. The pain increased on taking cold foods and at night. Clinical examination revealed the presence of deep caries with pain on probing. On radiographic examination, the presence of two roots and radiolucency involving the distal pulp horn of the left mandibular first molar no 36 were seen. The clinical and radiographic findings led to the diagnosis of dental caries with symptomatic irreversible pulpitis in 36.Protocol for TreatmentInformed consent was obtained from the patient before undergoing treatment. Inferior alveolar nerve block (IANB) was administered using 2% lignocaine hydrogen chloride (HCl) with 1:2 lacs units of adrenaline . The access cavity was prepared by endodontic access bur size 2  under rubber dam isolation. The access cavity was refined using Endo-Z bur (Dentsply-Sirona), exploration of the pulp chamber was done using an endodontic explorer, and the canals were negotiated using a size 10 K file . Four canals were initially located, two mesial and two distal.In order to enhance the magnification, an OPMI® pico dental operating microscope  was used. The bleeding spot was identified between the MB and ML orifices. Ultrasonic tips  were used to explore the MMC orifice and the canal was negotiated using a size 10 K file. The working length was determined by a ProPex Pixi Apex locator (Dentsply-Sirona). Finally, a total of five distinct orifices were identified: Mesially three  and distally two .The shaping and cleaning were carried out by ProTaper Universal NiTi rotary instrument (Dentsply-Sirona) in a crown-down manner as all the canals were wide including the MMC. Irrigation was carried out using 3% sodium hypochlorite solution  and Endoprep-RC . Canals were dried using paper points and obturation was done using warm vertical compaction with resin sealer . Post-obturation radiograph revealed that MMC merged with the MB canal at the middle third region. The access cavity was restored using a composite restoration  Figure . Case 2A 28-year-old male patient presented with a complaint of sensitivity and discomfort on a right lower back tooth for the past two weeks. Caries excavation was done followed by a pulp capping procedure using dycal and intermediate restorative material in the right mandibular first molar no. 46. The pain increased on the third postoperative day of the procedure. Radiographic examination revealed the presence of radio-opaque filling material involving the pulp in 46. The clinical and radiographic findings led to the diagnosis of failed pulp capping with symptomatic irreversible pulpitis in 46. The treatment protocol followed, was the same as explained in Case 1. In this case, five distinct orifices were identified: three mesially  and distally two . Post-obturation radiograph revealed that MMC was merged with the ML canal at the middle third region. The access cavity was restored using composite restoration (3M ESPE Filtek Bulk Fill) , distally one, and distolingually one orifice suggestive of radix entomolaris. After completion of cleaning and shaping, an intracanal medicament  was placed and the cavity was sealed with intermediate restorative material (IRM). During the second visit, the final shaping was done using ProTaper F2 and obturation was done using warm vertical compaction with resin sealer . Post-obturation radiograph revealed independent MMC and radix entomolaris in 46 , distal two roots  had one canal each. The existence of additional roots is unusual but does occur. The additional root, which was found distolingually, is called "radix entomolaris”, a name given by Carabelli et al. . The radIn Case 1 and Case 2, the mesial roots had canals with type XV Sert and Bayirli classification  (3-2) wh In a study conducted by Sherwani et al. in 2016 in the Indian population, 67% of MM orifice was found between MB and ML, 20 % was closer to ML orifice and 12% was closer to MB orifice . Nosrat The highly variable morphology of mandibular molars indicates that careful examination is mandatory. Failure to recognize the additional canals leads to unsuccessful treatment with persisting symptoms . The useAn understanding of the complex anatomy of the tooth is the key to the success of endodontic treatment. The varied location and configuration of the MMC make canal preparation and obturation more challenging. The careful interpretation of the radiograph, use of magnification, latest instruments, proper irrigation protocol, and sealing of all portals of exit leads to successful treatment.


The benign tumor central odontogenic fibroma (COF) accounts for less than 1% of all the existing odontogenic tumors. The mandibular or maxillary cortical plate is seen to show asymptotic diversification. It has been characterized as a benign jaw neoplasm. Radiographically, it primarily manifests as a multilocular radiolucency. Histologically, it comprises fibroblasts and mature collagen fibers. The popular choice for the management of COFs is enucleation, followed by the extraction of associated teeth. COFs have maintained a track record of showing rare chances of recurrence following surgery. COF was detected in a 38-year-old female who had edema in the lower right front tooth region. The lesion was surgically removed, and a histopathological examination was performed. Many case reports of COF have been stated in the literature. This indicates that cases of COF are not a rare appearance. A central odontogenic fibroma (COF) is considered to be an uncommon development of mature odontogenic mesenchymal cells. It is so scarce that reliable distributions of location, gender, and age cannot be ascertained . Those oThe COF is thought to be the periodontal membrane's counterpart to the peripheral odontogenic fibroma . Indeed,A 38-year-old female presented to the Department of Oral and Maxillofacial Surgery, Awadh Dental College and Hospital, Jamshedpur, India, with painless enlargement related to the region of lower front teeth Figure . The patBased on clinical, radiological, and histological results, COF was diagnosed, and the patient was counseled to undergo a long-term clinical investigation. After one year following surgery, there have been no signs of recurrence in the patient. The patient is still undergoing follow-up. An extraoral check confirmed the absence of edema. The temperature remained constant, with the color of the overlying skin unaltered. There were no palpable lymph nodes. The enlargement extended from the distal of the lower right canine to the mesial of the lower left first premolar on intraoral inspection. There was no indication of paresthesia. The lesion was solid and consistent. The lingual and buccal sulcus had been obliterated, and the overlying mucosa of that area was spotted with reddish and yellowish spots.A massive multilocular radiolucent lesion of the anterior jaw was shown by an orthopantomogram (OPG), extending from the distal of the lower canine in the right quadrant to the mesial surface of the lower left first premolar Figure . There wUnder general anesthesia, the lesion was enucleated via the vestibular route and sent for histological investigation Figure . All of The lesion can be seen in Figure COF has a slight female predilection as reported in our case and many other cases . GeneralWesley et al.  proposedFor most COFs, an incisional biopsy is recommended as the appearance indicates a more advanced disease . Needle Enucleation and curettage are used to treat COF . They eaHowever, certain cases of recurrence have been described. Jones et al. described a clinical scenario where the cancer returned 16 months following the surgical procedure . SvirskyIf a recurrence is noticed, Marx recommends reviewing both the initial pathology specimen and the biopsy material . A fibroGardner  sought cThe calcifying odontogenic lesions differ from the non-calcifying odontogenic lesions in that this lesion has amyloid staining but is not similar to the odontogenic fibroma (WHO type). Over 80 people have described single instances or case series in English literature so far ,16-21.Histopathological analysis  is necessary for every specimen in order to reach a final diagnosis among suspected differential lesions. The great variability in the radiologic appearance of the COFs means that it should be considered in the differential diagnosis of all radiolucencies found in the jaws. Since COFs have shown very low recurrence rates, an incisional biopsy followed by enucleation and curettage can be considered the preferred choice of management. Many case reports of COF have been stated in the literature.


Xanthogranulomatous oophoritis is a rare, chronic and non-neoplastic condition in which a heavy foamy histiocyte inflammatory infiltrate admixed with neutrophils, plasma cells, multinucleated giant cells, fibroblasts and foci of necrosis causing extensive tissue damage and organ destruction. The gallbladder and kidney are just two examples of the different organs that exhibit histological changes resembling xanthogranulomatous alteration. The present case involved a 40-year-old female who presented with a tuboovarian mass and was ultimately diagnosed with xanthogranulomatous oophritis, despite initial clinicoradiological suspicions for malignancy. Xanthogranulomatous oophritis is a significant entity because, clinically and radiographically, it resembles tumours of the ovary and hinges on a careful histopathological analysis to establish a diagnosis. A particular type of chronic inflammation known as xanthogranulomatous inflammation causes tissue damage by inflammatory cell infiltrate composed of lymphocytes, plasma cells, macrophages, multinucleated giant cells and neutrophils .Xanthogranulomatous oophoritis has been previously reported in the literature under various names, including xanthogranulomatous salpingitis-oophoritis, xanthogranulomatous inflammation of the ovary, and lipid cell granuloma of the ovary. In 1968 Roth published the first article describing a case of xanthogranulomatous oophoritis and since then, there have been almost 100 cases documented in the literature. Xanthogranulomatous oophoritis has an uncertain specific aetiology, although it's been postulated to result from chronic inflammation, infection, or autoimmune disorders .A unique type of chronic inflammation called xanthogranulomatous inflammation damages the affected tissue. This is an uncommon process that frequently affects the gallbladder and kidney. The stomach, anorectal area, testis, epididymis, urinary bladder, ovaries, fallopian tubes, endometrium and bones have all been implicated in the xanthogranulomatous inflammatory process .Xanthogranulomatous inflammation involving the female genital tract is rare and only impacts the endometrium. In the female genital tract, endometrium, fallopian tubes, or ovaries may be affected locally or completely by xanthogranulomatous inflammation, which, because of its rarity, could be misinterpreted for a malignant lesion and clinically manifests as a tumour in the pelvic cavity that extends to the surrounding tissues .In this case report, we present a rare instance of xanthogranulomatous oophoritis in a 40-year-old female and discuss its clinical presentation and histopathological findings.A 40-year-old female presented with the chief complaints of heavy, irregular cycles lasting six months, as well as intermittent abdominal pain. A solid right adnexal mass could be felt during vaginal examination. Her blood tests revealed hemoglobin of 9.4 g/dl, a modest increase in total leukocyte count , a moderate increase in erythrocyte sedimentation rate (44 mm at first hour), and a marginal increase in lactate dehydrogenase (488 IU/L). A 7.4 x 6 x 5.2 cm right ovarian mass that was suspected to be a malignancy was detected on ultrasound (USG) abdomen and pelvis. A computed tomography (CT) scan was performed and revealed a right adnexal mass measuring 7.9 x 6.5 x 5.4 cm that was multiloculated, cystic, and displaced the uterus laterally. Ovarian neoplasm was suggested as a possible diagnosis. Ziehl-Neelsen stain for acid fast bacillus and periodic acid schiff stain for fungal organisms were negative. The patient underwent a total abdominal hysterectomy.Grossly, the specimen consisted of uterus with attached bilateral adnexa Figure . The uteMicroscopic examination of the sections stained with hematoxylin and eosin (H and E) was done. Sections studied from right ovary revealed infiltration and replacement of the ovarian stroma by plasma cells, histiocytes, lymphocytes, foamy macrophages and occasional neutrophils. Areas of dense fibrosis are seen along with congested blood vessels Figure , 4. TherSalmonella typhi, Escherichia coli, Bacteroides fragilis, and Staphylococcus aureus have all been proposed as possible inciting etiological factors for this form of inflammation. Another explanation for this phenomenon is tissue necrosis, which is brought on by a prolonged infection and results in the ongoing release of lipids and cholesterol from the dead cells. The xanthomatous process begins as a result of macrophages phagocytosing these biological components [Xanthogranulomatous inflammation involving the female genital tract is an uncommon and distinct kind of persistent inflammation with tissue destruction in the affected organs . The etimponents .Staphylococcus species have late effects such as xanthogranulomatous oophoritis and salpingitis [Xanthogranulomatous oophoritis affects women of childbearing age, with an average age of 35.2 years. A two-year-old girl was the youngest patient with a known case report of xanthogranulomatous ovarian inflammation. It was also reported that a young girl, only 18 years old, had xanthogranulomatous ovarian inflammation . Punia epingitis . In theipingitis .According to Walther et al., the presence of foam cells makes malakoplakia an important differential diagnosis. This condition is then separated from xanthogranulomatous oophoritis by the presence of basophilic Michaelis-Gutmann bodies, which are missing in the latter. Michaelis-Gutmann bodies are cytoplasmic concentric calcific structures that are indicative of malakoplakia and are absent in xanthogranulomatous inflammation. Immunohistochemical stains, such as CD68 for histiocytes, CD20 for B cells, and CD3 for T lymphocytes, are useful in making the diagnosis . The infXanthogranulomatous oophoritis is an interesting case, which mimics ovarian tumours in terms of its clinical and radiological features. The key to effective management is nailing an accurate diagnosis. For its diagnosis, a histopathological examination is crucial. To prevent a misdiagnosis or overdiagnosis of cancer, it is essential to be aware of this entity. In order to prevent radical surgery and for early diagnosis of xanthogranulomatous oophoritis, the majority of patients taking intrauterine contraceptives, those with pelvic inflammatory illnesses, and those with endometriosis require close follow-up.


Mucinous adenocarcinoma of the kidney is rarely reported in the literature. We present a previously unreported mucinous adenocarcinoma arising from the renal parenchyma. A 55-year-old male patient with no complaints showed a large cystic hypodense lesion in the upper left kidney on contrast-enhanced computed tomography (CT) scan. A left renal cyst was initially considered, and a partial nephrectomy (PN) was performed. During the operation, a large amount of jelly-like mucus and bean-curd-like necrotic tissue was found in the focus. The pathological diagnosis was mucinous adenocarcinoma, and further systemic examination revealed no clinical evidence of primary disease elsewhere. Then the patient underwent left radical nephrectomy (RN), and the cystic lesion was found in the renal parenchyma, while neither the collecting system nor the ureters were involved. Postoperative sequential chemotherapy and radiotherapy were administered, and no signs of disease recurrence were observed over 30 months of follow-up. Based on a literature review, we summarize the lesion with rarity and the associated dilemma in preoperative diagnosis and treatment. Given the high degree of malignancy, a careful history analysis accompanied by dynamic observation of imaging and tumor markers is recommended for the diagnosis of the disease. Comprehensive treatment based on surgery may improve its clinical outcomes. Mucinous adenocarcinoma is a class of malignant tumors characterized by the secretion of massive mucus and the microscopic presence of extracellular mucus lakes, which may spread and transfer to the periphery with the mucus . Most muA 55-year-old man presented with a large cystic mass of the left kidney without any subjective discomfort. Fifteen years before admission, he was diagnosed with a left renal cyst and subsequently underwent three paracenteses combined with anhydrous alcohol sclerotherapy. Thereafter, he received regular color Doppler ultrasound or computed tomography (CT) examinations. The objective data showed the cystic lesion measuring 6.4 × 5.5 cm in 2013, 9.5 × 7.6 cm in 2017, and 10.0 × 8.2 cm in 2019 with partial cyst wall calcification , carbohydrate antigen 72-4 (CA72-4), and carcinoembryonic antigen (CEA) indexes were elevated . A CT scan of the head and chest showed no evidence of metastasis, and a repeated abdominal CT scan revealed a localized encapsulation of gas and effusion  of the left kidney was performed on June 19, 2020, during which dense adhesions with adjacent organs were observed. In gross specimen examination, a cystic mass of approximately 6.0 × 5.0 × 5.0 cm was seen immediately within the renal capsule with no visible invasion of the collecting system Figure 3One month after the radical surgery, a dynamic contrast-enhanced CT scan revealed a cystic lesion in the original left kidney area measuring 8.0 × 5.7 cm in cross-section  for the publication of any potentially identifiable images or data included in this article.HoZ, MZ, and YX composed the manuscript and literature review. MW, JD, and XZ collected the case details. YZ and NX were involved in the editing and collation of the images. PH contributed the part of radiotherapy. MZ contributed the part of pathology. JZ, GS, and HaZ revised the manuscript. PS censored and revised the article critically. All authors contributed to the article and approved the submitted version.


Laryngotracheoesophageal cleft (LTEC) is a rare disease in which the larynx and trachea communicate posteriorly to the esophagus. It is often associated with other congenital malformations, particularly gastrointestinal anomalies. Herein, we report a case of LTEC associated with a gastric polypoid lesion in bronchial tissue.A gastric mass was detected in a male fetus since week 21 of gestation using fetal ultrasonography. Esophagogastroduodenoscopy performed after birth revealed a pedunculated polypoid lesion of the gastric fornix. The patient experienced frequent vomiting and aspiration pneumonia, which persisted after nasoduodenal tube feeding. Communication between the airway and esophagus was suspected. Laryngoscopy performed 30 days later revealed an LTEC (type III). Partial gastrectomy was performed when the patient was 93 days of age. Histopathological examination revealed tumor consisting of cartilage tissue covered with a layer of respiratory epithelium.The gastric tumor associated with LTEC exhibited structures mimicking bronchial tissue. LTEC occurs because of foregut maldevelopment, and the tumorous respiratory tissue in the stomach may have been formed from the same abnormal foregut development event as LTEC. Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly in which the larynx and, in severe cases, the trachea is posteriorly communicated to the esophagus. The abnormality is believed to be caused by failed fusion of the tracheoesophageal septum, which normally begins approximately 4 weeks after conception .Reportedly, LTEC frequently coexists with other congenital malformations. Anomalies of the gastrointestinal system are also frequently observed . Herein,A newborn male, weighing 2,377 g, was born at 37 weeks and 3 days of gestation by elective cesarean section and was admitted to the neonatal intensive care unit. A gastric mass with a mosaic-patterned internal echo was detected on fetal ultrasound since week 21 of gestation  Fig. .Fig. 5LaAt 93 days of age, the patient underwent resection of the gastric tumor via partial gastrectomy. The abdomen was opened through a subcostal oblique incision. The tumor was palpable on the posterior wall of the fundus, near the gastric cardia. After mobilizing the gastric fornix, the gastric wall adjacent to the tumor pedicle was incised using an endoscopic view. The tumor was then cored out along the full thickness of the gastric wall to which the pedicle was attached Fig. . The gasA laryngoscopic repair of the LTEC was performed at 198 days of age, thereby successfully preventing aspiration pneumonia. The patient was discharged 315 days of age.The excised gastric polypoid lesion measured 2.7 × 1.6 × 1.5 cm and was lined by a smooth mucosal layer. The cut surface had a solid and myxoid appearance. The epithelium was composed of multilayered columnar epithelium around the pedicle and multilayered squamous epithelium at the apex. The subepithelial stroma was edematous, and structures mimicking bronchial glands were observed. A layer of cartilage formed an inverted U-shape in the stroma, which served as the backbone of the polypoid lesion  is defined as the continuity between an isolated piece of respiratory tissue  and the esophagus or stomach . Cases o stomach . We beliMeanwhile, LTEC is considered to result from arrests in the separation of the laryngotracheal groove and premature foregut . LTEC isTo the best of our knowledge, this is the first case report to describe a gastric tumor mimicking bronchial tissue associated with LTEC. A gastric lesion associated with LTEC may indicate a lesion related to abnormal foregut development rather than an entirely separate neoplastic lesion.


Soft tissue involvement in extramedullary plasmacytoma (EMP) is an exceptionally rare occurrence within the spectrum of plasma cell neoplasms. This case report presents the unique scenario of a patient who developed a soft tissue mass EMP subsequent to receiving radiation therapy for a solitary bone plasmacytoma at a distinct anatomical site. The primary objective of this report is to elucidate the clinical characteristics, diagnostic complexities, and management considerations associated with this uncommon presentation. Through a comprehensive review of existing literature, we aim to provide valuable insights and expertise to healthcare providers involved in the assessment and treatment of similar cases. Extramedullary plasmacytoma (EMP) is a rare plasma cell neoplasm characterized by the proliferation of abnormal plasma cells outside the bone marrow. It represents approximately 3-5% of all plasma cell tumors and is often found in mucosal sites such as the upper respiratory tract or gastrointestinal tract ,2. Soft The diagnosis and management of EMP pose significant challenges due to its rarity and varied clinical presentation. EMPs can occur as primary lesions or secondary to underlying plasma cell dyscrasias, such as multiple myeloma (MM) or solitary bone plasmacytoma (SBP) . They arRadiation therapy is considered the standard treatment for localized EMP, providing excellent local control and favorable outcomes . HoweverIn this case report, we present the clinical course of a 74-year-old male who initially presented with nasal pain, leading to the diagnosis of a left sinonasal plasmacytoma. The patient underwent radiation therapy in the fall of 2020 for the bone lesion, which resulted in complete resolution. However, the patient developed lower back pain and left leg weakness approximately 24 months later, ultimately diagnosed as soft tissue EMP. This case highlights the need for thorough evaluation and surveillance despite the successful treatment of bone plasmacytomas to detect and manage potential soft tissue involvement.The objectives of this case report are to shed light on the rarity of soft tissue involvement in EMP, discuss the diagnostic challenges faced in identifying soft tissue EMP, and provide insights into the appropriate management strategies for this unique clinical presentation. By presenting this case and conducting a comprehensive literature review, we aim to enhance the knowledge and awareness among medical oncologists regarding this rare manifestation of plasma cell neoplasms, thus facilitating accurate diagnosis and tailored treatment approaches for similar cases in the future.A 74-year-old male with a past medical history of hypertension, hyperlipidemia, and isolated left sinonasal plasmacytoma status post radiation therapy without definitive information on dose or irradiation method, presented to the outpatient clinic with a three-week history of low back pain and left lower extremity weakness. The patient had received radiation therapy as a treatment modality for sinonasal plasmacytoma. Regrettably, subsequent to the intervention, the patient's trajectory was hindered by a lapse in follow-up. Subsequent to outpatient magnetic resonance imaging (MRI) with and without contrast, the presence of two substantial paraspinous components was detected as shown in Figures A CT-guided biopsy of the mass was performed, which showed a proliferation of plasma cells, as shown in Figure The patient then presented to the emergency department a few days after the biopsy due to worsening intractable back pain and was admitted for suspected cord compression. The patient described the pain as being sharp and radiating down the left leg, unchanging with position, and not associated with urinary symptoms or sensory disturbances. Neurosurgery service was consulted and they recommended to follow up on the biopsy results, clearing the patient for discharge afterward, as the patient did not exhibit any neurological symptoms with consideration for radiation therapy. The biopsy later showed positivity with CD138 immunostaining, consistent with a plasma cell neoplasm, as depicted in Figure After his discharge from the hospital, the patient's pain and deficits in neurological symptoms regressed, prompting his return to the emergency room after three days. In response, the expertise of surgical oncology was consulted, collaborating in conjunction with the medical oncology services of the hospital. This collaborative effort led to the recommendation of administering pulse steroids with intravenous daily dexamethasone and radiation therapy. After thorough deliberation, both surgical oncology and neurosurgery concurred on pursuing a joint surgical debulking strategy to address the tumor, driven by the severity and rapid progression of the patient's symptoms. This was to be succeeded by a regimen of outpatient radiation therapy.The subsequent surgical intervention encompassed an extensive resection of the left paraspinous mass, inclusive of muscle group resection and retroperitoneal resection. This was succeeded by a targeted L3 lumbar hemilaminectomy and medial facetectomy. Regrettably, a few hours following the procedure, the patient encountered a substantial episode of postoperative bleeding, necessitating an emergent return to the operating room. The ensuing exploration of the surgical cavity uncovered a hematoma within the left retroperitoneal space, stemming from apparent bleeding to the patient's laminectomy site. Hematoma evacuation and comprehensive washout were performed. Consequently, the patient was admitted to the neurosurgical intensive care unit for closer monitoring and care.Over the ensuing days, the patient's recovery progressed favorably, marked by a notable absence of ongoing bleeding or leg pain. This recuperative trend prompted his eventual discharge, supplemented with home health care support for outpatient follow-up and radiation therapy as recommended by a radiation oncologist.Soft tissue involvement in EMP is an exceptionally rare phenomenon, with only a limited number of reported cases. This manifestation represents a more aggressive form of plasma cell neoplasms, with an estimated incidence ranging from 1.7% to 4.5% . The undThe occurrence of a soft tissue mass EMP subsequent to radiation therapy for a solitary bone plasmacytoma introduces a unique aspect to the clinical course of plasma cell neoplasms. This unusual presentation necessitates careful consideration by medical oncologists, as it poses several important challenges and management considerations. Heller et al. conducted a data analysis encompassing a literature review spanning the years 1998 to 2021, focusing on the anatomical distribution of EMPs. The findings of this analysis revealed a prevailing localization of EMPs in the upper aero-digestive (UAD) tract, accounting for 62.4% of cases, while the remaining 37.6% were situated in non-UAD regions. Among the non-UAD localizations, the gastrointestinal tract accounted for 31%, the lung region for 8%, the urogenital tract for 9%, and other non-UAD areas constituted 52%. It is noteworthy that the dataset did not explicitly address soft tissue localizations, likely due to their rarity; however, it can be inferred that soft tissue EMPs might exhibit a distribution similar to EMPs in general [The diagnosis of soft tissue EMP poses a challenge due to its rarity and nonspecific clinical presentation. Differentiating it from other benign or malignant soft tissue tumors requires a high index of suspicion, particularly in patients with a history of plasma cell neoplasms. To evaluate the extent of disease involvement and guide treatment decisions, imaging modalities, such as magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT), are crucial. Histopathological examination remains the gold standard for confirming the diagnosis of soft tissue EMP. Fine-needle aspiration cytology or core needle biopsy can provide samples for evaluation. The histological features of soft tissue EMP include a proliferation of mature plasma cells with eccentric nuclei, abundant cytoplasm, and distinct perinuclear hofs. Immunohistochemical staining plays a vital role in confirming the plasma cell origin and excluding other potential differential diagnoses such as lymphoma or metastatic carcinoma .Additionally, SBPs and solitary extramedullary plasmacytomas (SEPs) are distinguished from MM by the lack of the following criteria: anemia, hypercalcemia, renal insufficiency, or lytic bone lesions that may be attributed to MM. Additionally, diagnosis also requires bone marrow biopsy and immunoglobulin/light chain evaluation, to rule out MM . FurtherThe management of soft tissue EMP necessitates a multimodal approach, which is tailored to the specific characteristics of the individual patient and the extent of the disease. When feasible, complete surgical resection is often recommended, as it improves local control and may potentially enhance patient outcomes . RadiatiThe prognosis of soft tissue EMP varies, with reported five-year survival rates ranging from 60% to 80%. Both SBP and SEP have similar median survivals, with SBP at 10 years and SEP at 11 years. Several factors can influence the prognosis of soft tissue EMP, including advanced age, high-grade disease, extensive soft tissue involvement, and systemic dissemination. These factors should be considered when assessing the patient's overall prognosis and treatment plan. Long-term follow-up is crucial in soft tissue EMP to monitor for disease recurrence or progression and to initiate appropriate interventions promptly if necessary. Regular clinical evaluations, radiological assessments, such as MRI or PET-CT, and laboratory tests are vital components of the follow-up protocol to detect any potential changes in disease status and ensure timely intervention .Soft tissue involvement in EMP is an exceptionally rare manifestation within the spectrum of plasma cell neoplasms. This case report has shed light on the unique scenario of a patient who developed a soft tissue mass EMP subsequent to radiation therapy for a solitary bone plasmacytoma at a different anatomical site. Diagnosing soft tissue EMP can be challenging due to its rarity and nonspecific clinical features. Therefore, maintaining a high index of suspicion is crucial, especially in patients with a history of plasma cell neoplasms. Radiological imaging along with histopathological examination play essential roles in confirming the diagnosis and guiding treatment decisions.Long-term follow-up is crucial in monitoring for disease recurrence or progression, as soft tissue EMP can have variable prognoses. Regular clinical and radiological assessments, coupled with appropriate laboratory investigations, aid in the early detection of potential complications and the prompt initiation of necessary interventions. This case report highlights the need for further research and collaboration to enhance our understanding of the etiology, pathogenesis, optimal treatment approaches, and prognostic factors specific to soft tissue EMP. By presenting this case and reviewing the available literature, we aim to contribute to the collective knowledge of medical oncologists and provide valuable insights for managing similar cases in the future.


Like all surgical fields, bariatric surgery has evolved immensely, so much so that previous procedures are now obsolete. For instance, the jejunoileal bypass has fallen out of favor after severe metabolic consequences resulted in prolonged morbidity and even mortality. Despite this, several patients persevered long enough to develop other pathology, such as cancer. This progression has been validated in animal models but not human patients. Nonetheless, contemporary surgeons may encounter situations where they must resect and re-establish intestinal continuity in patients with this antiquated anatomy. When faced with this scenario, the question of whether or not the previously bypassed small bowel can be safely reunited plagues the surgeon remains unanswered. Unfortunately, the literature does not effectively answer this question, even anecdotally through case reports or series. Therefore, we share our experience with three patients who developed colon cancer following jejunoileal bypass and subsequently underwent oncologic resection with simultaneous reversal of their jejunoileal bypasses. While previous weight loss procedures may seem historic, modern surgeons still encounter these anatomic relics. The jejunoileal bypass (JIB), first performed on a human in 1954, involved an end-to-side anastomosis between the jejunum and terminal ileum . DependiJS is a 72-year-old gentleman who underwent JIB in the 1980s. He has no additional contributory history. Despite laxatives, he presented to the emergency department with abdominal pain, distention, nausea, vomiting, and obstipation for 3 days. A colonoscopy 1 year prior was negative for polyps. A computed tomography (CT) scan upon presentation showed a 3.4-cm stenotic segment in the mid-transverse colon. Proximal to this, the ascending colon and the transverse colon were dilated and fluid-filled, with the cecum measuring 9.5 cm. There was also a loop of small bowel anastomosed to the transverse colon just proximal to the stenosis. The patient's carcinoembryonic antigen (CEA) level was 18.2. He had a bowel movement the day following admission. The day after, he underwent a colonoscopy, which showed an anastomotic obstruction in the mid-transverse colon. There was erythematous and necrotic tissue with thick and firm mucosa. Biopsies showed adenocarcinoma. The patient was discharged 6 days following admission in stable condition, including tolerance of a diet and bowel function.Outpatient screening CT chest was negative for metastatic disease. Shortly after that, he was taken electively to the operating room for an extended right hemicolectomy with ileocolic anastomosis and reversal of JIB. Intraoperatively, the patient's anatomy revealed an end-to-end JIB, with 80 cm of bowel in continuity from the ligament of Treitz to the colon and the out-of-circuit small bowel anastomosed to the mid-transverse colon, in the end-to-side fashion, just proximal to the obstructing malignancy. The extended right hemicolectomy removed the malignancy and terminal ileum distal to the end-to-end anastomosis, which was roughly 20 cm from the ileocecal valve , 3. NextPostoperatively, the patient was started on total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). A CT scan on post op day (POD) 7, given no bowel function, showed diffuse ileus and slow passage of oral contrast. Flatus on POD 9 prompted a clear liquid diet, advanced to a gastrointestinal (GI) soft diet the following day with bowel movements. On POD 12, he was discharged in stable condition without TPN. Six weeks later, he was seen in the outpatient setting, with only complaint of mild constipation. He was instructed to follow up in 4 months for CEA, colonoscopy, and CT. Unfortunately, he was lost to follow-up.NW is an 81-year-old woman who underwent JIB in the 1970s. She has no additional contributory medical history. She was initially admitted to the medical service for pneumonia while experiencing anemia. This prompted a workup for a GI bleed. Esophagogastroduodenoscopy (EGD) showed a 10-cm segment of salmon-colored mucosa. Biopsy was significant for Barret's. A colonoscopy the following day revealed a transverse colon mass, with the biopsy containing adenocarcinoma. At this point, general surgery was consulted. A chest, abdomen, and pelvis CT scan highlighted bilateral pulmonary embolisms and a concerning liver lesion. The liver lesion was further characterized via magnetic resonance imaging (MRI), which was significant for a 2.6-cm segment 6 mass. She subsequently began FOLFOX chemotherapy. Following four cycles, a repeat MRI scan showed stability of the area. Repeat CT chest showed a few stable lung nodules under 5 mm. a few weeks later, an abdomen and pelvis CT scan, prompted by clinical concerns of obstruction in the clinic, showed nothing acute. However, a short interval repeat CT scan showed a small bowel obstruction with a transition zone in the right lower quadrant. She was therefore admitted. Unfortunately, she was unable to advance her diet and required supplementation with TPN.She underwent an urgent open extended right hemicolectomy, intraoperative liver ultrasound, and small bowel anastomosis secondary to the reversal of JIB. Biopsy of the liver lesion was not possible given its posterior location, but intraoperative communication with interventional radiology (IR) confirmed that a percutaneous biopsy would instead be achievable. Intraoperative findings were significant for about 200 cm of small bowel out of circuit with the distal end anastomosed to the transverse colon in an end-to-side hand-sewn fashion, which was the site of the colon cancer. The specimen included 5 cm of large bowel distal to the colon cancer, 5 cm of the distal defunctionalized small bowel limb, and just proximal to end-to-end anastomosis of the in-continuity small bowel. Reconnection of the bowel required the blind end of the small bowel in discontinuity to be anastomosed to the distal jejunum via stapled isoperistalic side-to-side anastomosis, followed by the distal end of the small bowel previously in discontinuity being anastomosed to the colon via stapled isoperistaltic side-to-side anastomosis. Pathology revealed moderately differentiated adenocarcinoma. Of 18 lymph nodes, none were positive. The final pathologic staging was T3N0M1.By POD 8, she was tolerating a GI soft diet. She was discharged on POD 12. The patient was readmitted a few weeks later for sepsis and midline drainage, which necessitated brief admission to the ICU, vasopressors, and an infectious workup. Since this sepsis was considered secondary to her existing line, this was removed. The remainder of this hospitalization was uncomplicated, with her being discharged without further antibiotics. She presented a few months later secondary to failure to thrive, given poor PO intake. Therefore, EGD and percutaneous gastrostomy were performed without complications. An abdomen and pelvis CT scan revealed an acute PE, which was anticoagulated, and a 4-cm right hepatic lobe lesion, increased from 2 cm from previous imaging. She was ultimately discharged in stable condition on tube feeds. MRI 6 months later was significant for a 6.3-cm heterogenous lesion in the posterior right hepatic lobe and possible satellite lesions. Y 90 embolization was performed that month. A chest, abdomen, and pelvis CT scan a few months later showed disease progression, specifically numerous new bilateral pulmonary and hepatic metastases, as well as retroperitoneal and pelvic lymphadenopathy. Given the previous side effects of chemotherapy, the patient opted against further systemic therapy. She also declined hospice care. She ultimately passed away.SM is a 72-year-old woman with a relevant medical history of a JIB 45 years ago and s/p left hemicolectomy in 2013 for Lynch syndrome manifesting as adenocarcinoma. A colonoscopy and associated biopsy in 2021 diagnosed her with recurrent cancer at her colorectal anastomosis. Following a negative staging CT scan, she was taken to the operating room for a JIB reversal, total abdominal colectomy, total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and multiple incisional hernia repair. The JIB reversal required anastomosing the previously out-of-circuit small bowel, attached to the transverse colon, proximally in the side-to-side fashion to the jejunum remaining in circuit and distally, also in the side-to-side fashion, to the rectum. The TAH and BSO were secondary to her history of Lynch syndrome. The closure repaired the incisional hernias primarily.Postoperatively, she tolerated a clear liquid diet on POD 5, a full liquid diet on POD 6, and ultimately a GI soft diet on POD 7. She was discharged in stable condition on POD 8. She was seen in the outpatient setting without any complaints. Following readmission 1 month postoperatively for abdominal pain, a CT scan was significant for an abdominal wall fluid collection, which was managed with an IR drain. Persistent nausea prompted a repeat CT scan a week later, which showed pneumoperitoneum and a large air-containing fluid collection with concern for associated contrast material. This prompted a return to the operating room for exploratory laparotomy. Intraoperative findings included a distal small bowel perforation, not at either prior anastomosis. This area was resected, she was left in discontinuity, and a temporary wound vacuum was placed. A day later, she returned to the operating room for an end ileostomy and mucous fistula, the latter of which was created with the small portion of distal small bowel remaining. Tube feeds were started later in the day, with extubation the following day. Four days later, she was transferred to the regular nursing floor with speech-approving thin liquids. She was discharged to a skilled nursing facility, tolerating a regular diet then.Pseudomonas infection. Cultures reflected this. A repeat CT scan and a left-sided abscessogram showed the known encapsulated fluid collection, with the known leak appearing smaller. The left-sided IR drain was upsized, while one of the right-sided drains was removed following another abscessogram. The patient was coded with an ultimate return of spontaneous circulation following advanced cardiovascular life support. Further workup was significant for a PE, for which a heparin drip was started. Bilateral pneumothoraces, likely related to the chest compressions, required chest tubes. Not long after, the family made the decision for a palliative extubation. Shortly after that, the patient passed away.She was readmitted a week later secondary to altered mental status, decreased left-sided movement, and left-sided neglect. The stroke team workup included an MRI that showed acute small bilateral parietal infarcts. Sepsis workup given altered mental status was significant for persistent fluid collections in both the abdomen and abdominal wall; however, all were smaller than previous. The intra-abdominal collection was managed with an IR drain. Her mentation and inability to protect her airway required intubation; however, she was extubated shortly after that. Repeat CT the following day showed an obvious bowel leak with contrast extending into a large encapsulated air and fluid collection in the right lower quadrant, near the IR drain, overall decreased in size, pneumoperitoneum, and an enterocutaneous fistula. She was made nothing by mouth (NPO), a PICC was ordered for TPN, and another large bore drain was placed by IR. Ongoing dark ostomy output and anemia prompted workup by GI, including negative esophagogastroduodenoscopy, ileoscopy, and computed tomography angiography (CTA). CTA findings led to an additional IR drain into the left side, which ultimately became enteric. Finally, push enteroscopy showed a possible vascular malformation, treated by argon plasma coagulation. The midline enterocutaneous fistula appearance turned blue/green with a sweet odor, characteristic of a in vivo, bile acids have been shown to induce carcinogenesis in colorectal cells (The pathogenesis of colonic carcinogenesis following JIB has been outlined in animal, specifically rat, models following exposure to carcinogens. One study validates the anecdotally experienced hyperplasia of the bowel remaining in the circuit, with JIB increasing the colorectal length by 17% and weight by 29% and crypt depth in the middle and distal thirds by 33% and 25%, respectively. There was also a doubling of cell proliferation in the middle third and a tripling in the distal third. Ultimately, the large bowel tumor burden was significantly increased in the bypassed rats at 30 weeks, but only 28% of these tumors were malignant. Interestingly, their data for increased bypassing of the small intestine, up to 99%, indicated no significant enhancement of large bowel tumor yields, suggesting weight reduction to be protective against colorectal neoplasia (al cells . Howeveral cells . Anotheral cells . With reOur institution’s institutional review board did not require patient consent for publication.


The pectoralis major musculocutaneous flap (PMMF) is a pedicled flap often used as a reconstruction option in head and neck surgery, especially in cases with poor wound healing. However, applying PMMF after esophageal surgery is uncommon. We report here, the case of a successfully repaired refractory anastomotic fistula (RF) after total esophagectomy, by PMMF.A 73-year-old man had a history of hypopharyngolaryngectomy, cervical esophagectomy, and reconstruction using a free jejunal graft for hypopharyngeal carcinosarcoma at the age of 54. He also received conservative treatment for pharyngo-jejunal anastomotic leakage (AL), then postoperative radiation therapy. This time, he was diagnosed with carcinosarcoma in the upper thoracic esophagus; cT3rN0M0, cStageII, according to the Japanese Classification of Esophageal Cancer 12th Edition. As a salvage surgery, thoracoscopic total resection of the esophageal remnant and reconstruction using gastric tube via posterior mediastinal route was performed. The distal side of the jejunal graft was cut and re-anastomosed with the top of the gastric tube. An AL was observed on the 6th postoperative day (POD), and after 2 months of conservative treatment was then diagnosed as RF. The 3/4 circumference of the anterior wall of the gastric tube was ruptured for 6 cm in length, and surgical repair using PMMF was performed on POD71. The edge of the defect was exposed and the PMMF (10 × 5 cm) fed by thoracoacromial vessels was prepared. Then, the skin of the flap and the wedge of the leakage were hand sutured via double layers with the skin of the flap facing the intestinal lumen. Although a minor AL was observed on POD19, it healed with conservative treatment. No complications, such as stenosis, reflux, re-leakage, were observed over 3 years of postoperative follow-up.The PMMF is a useful option for repairing intractable AL after esophagectomy, especially in cases with large defect, as well as difficulties for microvascular anastomosis due to previous operation, radiation, or wound inflammation. Anastomotic leakage (AL) after esophagectomy reportedly occurs in 3.0–30.0% of patients with an associated mortality rate of 7.2–35% , 2. AlthA 73-year-old man presented to our hospital with the chief complaint of dysphagia. He had a history of hypopharyngolaryngectomy, cervical esophagectomy, reconstruction using a free jejunal graft, and permanent tracheostomy for hypopharyngeal carcinosarcoma at the age of 54 (19 years ago). In addition, he received conservative treatment for pharyngo-jejunal AL followed by radiation therapy. He also had a history of paroxysmal atrial fibrillation, right retinal artery occlusion, right internal carotid artery occlusion, cerebral artery stenosis, and hypothyroidism.His upper gastrointestinal endoscopy revealed a mass lesion with submucosal elevation at the upper thoracic esophagus, below the esophago-jejunal anastomosis Fig. a. ContraThen thoracoscopic total resection of the remaining esophagus followed by reconstruction using a gastric tube via the posterior mediastinal route was performed. In the cervical procedure, due to significant existing scar-tissue and adhesions due to previous surgeries and radiation therapy, careful dissection was required to avoid injury of the free jejunal pedicle. The distal side of the jejunal graft was cut at 1 cm proximal to the previous anastomosis Fig. a and re-A gastric tube–free jejunal anastomotic leakage was observed on the 6th postoperative day (POD6) with open drainage and daily wound irrigation continued. Although inflammation of the wound reduced after conservative treatment, the 3/4 circumference of the anterior wall of the gastric tube was ruptured for 6 cm in length  fed by thoracoacromial vessels and 4th anterior intercostal branches of the internal thoracic vessels, were prepared by integrating with skin, fat tissue and feeding vessels. Intraoperative blood flow visualization using indocyanine green (ICG) fluorescence confirmed sufficient blood supply at the edge of the anastomotic sites. Then the skin of the flap and the wedge of the leakage were hand sutured via double layers with the skin of the flap facing the intestinal lumen .Surgical repair for RF after esophagectomy requires sufficient debridement of surrounding tissues, dead cavity filling, and patches larger than the leakage to prevent re-leakage and/or stricture. Autogenous tissues are used for the surgical repair of intractable AL. The free gastrointestinal graft, such as free jejunal graft, is favored for head and neck reconstructions, as the risks of stenosis or fistula are lower. However, this requires microvascular anastomosis . A free To date, 20 cases in total are reported have undergone reconstruction using PMMF for AL after esophagectomy Table . Most ofIn RFs following retrosternal or posterior mediastinal reconstruction in which the defect was too large to primary close, PMMF was inserted to the defect with the skin side of the flap placed on the lumen side, avoiding both overextension and stenosis –14.The skin directed toward the lumen was thought to prevent damage of the flap from exposure to digestive fluids, as well . Re-leakIn the present case, the defect extended to 3/4 circumference of the anastomosis and was contaminated with digestive fluid, so primary closure was difficult. In addition, due to the previous reconstruction using a free jejunal graft and radiation therapy, as well as history of carotid artery occlusion, securing a recipient vascular bed for microvascular anastomosis was also considered difficult. Taken together, the PMMF was selected for reconstruction with the skin surface inward to successfully repair.In post-irradiation cases such as the present case, considerable technical tips for designing the PMMF are to obtain a larger PMMF with sufficient thickness of fat tissue so that the gap could be filled after removal of scar tissue around the fistula, and to confirm the maintenance of blood flow at the margins with intraoperative blood flow visualization using ICG fluorescence.PMMF is a useful method to treat intractable anastomotic leakage after esophagectomy, especially in cases with large defect, as well as difficulties in microvascular anastomosis due to previous operation, radiation, and wound inflammation. This surgical option may enable surgeons to aggressively perform radical surgery for high-risk cases in which surgical resection is the only curative treatment.


Dear Editor,Meningioma is the most common tumor of the central nervous system (CNS). Except for the CNS, it can be detected at a rate of 1-2% in the head and neck region. Primary pulmonary meningiomas (PPM) are extremely rare. They are detected incidentally as a solitary pulmonary nodule during radiological examinations. On computerized tomography (CT), the lesions are generally seen as a uniform and homogeneous mass. Although they are usually benign and the prognosis is excellent, they may be subject to misdiagnosis and overtreatment. . Here weA 57-year-old male patient with cough had been on follow-up for five years. His medical history included 30 pack-year smoking history, hypertension, arrhythmia, and hypercholesterolemia. In 2015, a well-circumscribed lesion 10 mm in diameter had been detected in the subpleural area of the left lower lobe with thorax CT. There was no pathological uptake of 18F-FDG on PET-CT. The patient was put on radiological follow-up. There was no change in the nature of the nodule during the 3-year follow-up period and in the control thorax CT obtained in 2018, and the follow-up was continued with chest x-rays. During follow-up in January 2020, it was determined that the chest nodule had a similar appearance with the previous follow-ups, but there was a slight increase in density, and a newly developing nodule with a size of 7 mm had appeared in the neighboring parenchyma . Based oPPMs are usually asymptomatic lesions that appear incidentally. However, patients with large tumors may have symptoms related to the localization, such as chest pain and cough. It has been reported that the lesion is generally detected between the ages of 40 and 60. Since the first case-report by Kemnitz in 1982, about 60 cases of PPM were published in the English literature . In accoIn conclusion, PPMs mostly appear radiologically in the form of pulmonary nodules, are usually benign, and have a good prognosis. PPM should also be kept in mind in the differential diagnosis of SPN.The authors declare no conflicts of interest.


The primary challenge in benign LCCSTs, which are typically multifocal and bilateral tumours affecting young males, is to confirm the diagnosis to avoid radical intervention and preserve fertility potential. Patient clinical presentation, laboratory results, diagnostic radiological tests along with confirmatory histopathological studies, are the cornerstones in such cases, nevertheless genetic testing is warranted, as LCCSTs can be part of genetic syndrome such Carney complex. We present a case of bilateral benign LCCSTs in young male managed with testicular preservation approach with characteristic clinical, radiological and histopathological features.Testicular Large cell calcifying Sertoli cell tumours  Sertoli cell tumours are further categorized as large cell calcifying Sertoli cell tumor (LCCSCT), sclerosing Sertoli cell tumour or Sertoli cell tumour not otherwise specified.preservation approach. The traditional approach of radical orchiectomy of such tumours may be an overtreatment of a benign pathology especially in cases of bilateral testicular involvement. In such instances,a testicular preservation approach is advisable to maximize future fertility potential.Sertoli cell tumours a young male, managed with testicular sparing surgery, avoiding radical orchiectomy.We report a case of bilateral multiple LCCSCT with characteristic radiological and histopathological features in 2one day. There was no history of trauma and no features of infection. On physical examination, both testicles were nontender and mobile with multiple hard masses. Additionally, he had skin pigmentations and freckling on his back. The laboratory workup was within normal limits. Serum tumour markers including LDH, AFP and BhCG were also normal  was done and showed six masses on the right testis and three on the left testis, with calcifications and cystic change and no signs extra testicular invasion  showed Extensive calcifications in both testes with multiple lobulated heterogenous lesions A and B, invasion C and D. cryopreservation, patient underwent right inguinal excisional testicular biopsy with excision of four well-circumscribed lesions, each less than one cm, surrounded by healthy testicular tissue which was preserved.Surgical intervention, after sperm , there is no evidence of marked pleomorphism, necrosis, or atypical mitosis   D.The case is followed annually by cardiology, endocrine, dermatology, and orthopedic team along with follow up with urology for annual testicular ultrasound to detect the development of any new lesions.A final diagnosis of large cell calcifying Sertoli cell tumour was made. Genetic testing is positive for a pathogenic mutation c.491_492del in the PRKAR1A gene-confirming Carney Complex. Patient was kept on follow up for any signs of extra testicular extension or involvement of other systems as part of carney complex. 3confirming the diagnosis to avoid radical intervention, especially in cases of bilateral disease, to preserve fertility potential. As in our case, an 18-year-old male with bilateral tumours, the endocrine and fertility functions of the testis were of major concerns.LCCSCTs are rare testicular tumours with a frequency of 0.4–1.5 %. Benign LCCSTs are multifocal and bilateral tumours with a mean age of presentation of 17 years, compared to the malignant LCCSTs are typically unifocal and unilateral disease that occur in older patients with mean age of 39 years.diagnosing LCCSTs. For instance, ultrasound can demonstrate bilateral testicular enlargement, with or without microcalcifications, increased vascular flow in proximity to the calcified area on colour doppler ultrasound, along with the absence of soft or cystic tissues. These ultrasonographic features rises the suspicion of LCCSCTs. Nevertheless, the characteristic ‘Christmas tree-like’ appearance of multiple lesions in syndromic LCCSCTs are almost pathognomonic. LCCSCTs can also be seen as a round, smooth, and hyperechogenic area, or multiple hyperechogenic spots.,role of MRI is to exclude other causes like lymphoma, as LCCSCTs have no specific appearance on MRI.feature of LCCSCT was the testicular US features of extensive bilateral calcifications, the MRI only ruled out other cases with no added value in the radiological diagnosis.Radiological evaluation plays a key role in The differentiation between malignant and benign cases requires clinical, radiological and histopathological features with immunochemical tests, as detailed above.LCCSCT has peculiar morphology. The tumour shows nodular growth pattern composed of nests and trabeculae of pale to eosinophilic epithelioid cells interspersed with hypocellular myxoid stroma rich in neutrophils. Potentially malignant tumours are characterized by the presence of ≥1 adverse pathologic features; size>4 cm, extra testicular growth, necrosis, marked nuclear atypia, vascular invasion, and >3 mitotic figures/10 HPFs.We report a rare case of bilateral benign LCCSCT with typical features on radiological and histopathological evaluation, treated with excisional biopsy and preservation of healthy testicular tissue.4requires an interaction between clinical, radiological, and histopathological features. Given the benign nature of LCCSCTs, it is advisable to consider a testicular-preserving approach once malignant masses are ruled out."LCCSCTs are rare testicular tumours; diagnosis Ibrahim A. khalil: Conceptualization, Data curation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing, Investigation. Mohamed Hatem: Conceptualization, Writing – original draft. Khaled A. Murshed: Data curation, Investigation, Writing – original draft. Majd Alkabbani: Validation, Writing – review & editing. Nagy Younes: Conceptualization, Supervision. Khalid Al Rumaihi: Resources, Supervision, Validation.The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter or materials discussed in the manuscript.


Pure androgen-secreting adrenocortical tumors are a rare but important cause of peripheral precocious puberty.TP53 gene, molecularly confirming underlying Li–Fraumeni syndrome.Here, we report a pure androgen-secreting adrenocortical tumor in a 2.5-year-old boy presenting with penile enlargement, pubic hair, frequent erections, and rapid linear growth. We confirmed the diagnosis through laboratory tests, medical imaging, and histology. Furthermore, genetic testing detected a pathogenic germline variant in the Only 15 well-documented cases of pure androgen-secreting adrenocortical tumors have been reported so far. No clinical or imaging signs were identified to differentiate adenomas from carcinomas, and no other cases of Li–Fraumeni syndrome were diagnosed in the four patients that underwent genetic testing. However, diagnosing Li–Fraumeni syndrome is important as it implies a need for intensive tumor surveillance and avoidance of ionizing radiation.TP53 gene variants in children with androgen-producing adrenal adenomas and report an association with arterial hypertension.In this article, we emphasize the need to screen for The online version contains supplementary material available at 10.1186/s13256-023-03889-y. Pure androgen-secreting adrenocortical tumors are a rare but important cause of peripheral precocious puberty.Molecular genetic analyses have become increasingly important in the workup of pediatric endocrine tumors, including adrenocortical malignancies.Established factsA pure androgen-secreting adrenocortical adenoma can be the first presentation of Li–Fraumeni syndrome.Androgen-secreting adrenocortical tumors can be associated with arterial hypertensionNovel insightsPeripheral precocious puberty (PPP), contrary to central precocious puberty (CPP), is caused by the autonomous secretion of androgens or human chorionic gonadotropin (hCG). Differentiating CPP from PPP in males is relatively straightforward and based on clinical and hormonal findings. In CPP, boys have testicular growth and elevated gonadotrophin levels, whereas in PPP, testicular volume is prepubertal and gonadotrophins are suppressed. However, diagnosing the cause of PPP can be more challenging, and includes neoplasms such as Leydig cell tumors, hCG-producing germ cell tumors, and androgen-secreting adrenocortical tumors (ACT) .ACT are very rare in children; they can be benign or malignant, and their reported annual incidence is 0.2–0.3 new cases per million per year . HoweverA 2.5-year-old boy presented with a 6-month history of penile enlargement, pubic hair, frequent erections, and rapid linear growth. Delta height was + 1.19 standard deviation score (SDS) in the past 8 months. Previous medical and family history was unremarkable, and exposure to exogenous testosterone was excluded. On physical examination, his weight was 19.1 kg (+ 2.5 SD), height 101 cm (+ 1.7 SD), systolic blood pressure 138 mmHg (> 99th percentile), and diastolic 75 mmHg (95th–99th percentile). Tanner stage was A1 P4 G3, and penile length was 6.8 cm. He had symmetrical prepubertal testes  without palpable abnormalities. Skin and oral examination were normal. Repeated blood pressure readings in the following weeks were all above the 95th percentile. His bone age was 3.5 years, as per the Greulich–Pyle scale. Serum gonadotrophin levels were prepubertal, while testosterone , androstenedione , and dehydroepiandrosterone-sulfate (DHEA-S) levels  were elevated, approaching the adult reference range. Serum electrolytes, 17-OH-progesterone, adrenocorticotropic hormone (ACTH), renin, aldosterone, and cortisol levels were normal, as were repetitive 24-hour urinary free cortisol excretion and urinary catecholamine levels :c.473G > A, p.(Arg158His) (conform ClinVar database https://www.ncbi.nlm.nih.gov/clinvar), at an allelic frequency of 71%. Targeted Sanger sequencing on DNA from a whole blood sample subsequently confirmed the heterozygous germline presence of this pathogenic TP53-variant, confirming the diagnosis of LFS , which identified a pathogenic We conducted a literature search in Pubmed using the query “androgen AND adrenal AND pediatric AND (carcinoma OR adenoma)”. From the 76 retrieved articles, we selected 7 reports with detailed clinical and histological data. Finally, we retrieved 16 detailed case reports using citation searching. We summarized their clinical and histological findings, and when available, the results of genetic testing in Table The median age at diagnosis was 4 years (range: 2 months–18 years), and there was a female sex bias . All patients had clinical signs of androgen excess, such as pubic hair before 8 years of age or voice deepening in five cases. In 5/7 male cases, patients had rapid or early penile growth, while clitoral hypertrophy was reported in just 2/9 female cases. In 6/16 cases, there was facial acne, and a single subject (a 3-year-old boy) had precocious axillary hair development. In 2/3 female patients older than 12 years , there was primary amenorrhea, but one adolescent girl had regular menses.TP53 gene variants was performed in 4/16 patients. Here, to the best of our knowledge, we report for the first time an underlying pathogenic TP53 variant in childhood PASACT.Testosterone levels were elevated in all patients, and all investigated children had normal serum cortisol, 24-hour urinary free cortisol, and plasma adrenocorticotropic hormone levels  and the normalization of androgen levels after surgery confirmed the diagnosis of a pure androgen-secreting adrenal adenoma. However, the histology of ACT in children is challenging, as the classical Weiss criteria used in adults often misclassify childhood ACT as carcinomas . TherefoTP53 are found in approximately 45–80% of children with adrenocortical carcinomas and a negative family history of LFS  found in the presented case has been reported multiple times, and the resulting p.R158 substitution hits a functional part of the TP53 DNA-binding domain , 4 were positive for a history of childhood adrenocortical carcinoma (ACC) [Both benign and malignant ACTs are reported in genetic tumor syndromes, such as Beckwith–Wiedemann syndrome, Carney complex, and LFS. In LFS, adrenal carcinomas have mainly been reported. In our case, there were no clinical signs of a tumor predisposition syndrome, and the family history was negative for tumors. Germline pathogenic variants in y of LFS , 29. More missed . Nonetheecreting . The tumecreting . Therefoood ACTs . In a lama (ACC) . Furtherma (ACC) .TP53 variant for clinical follow-up. Missense variants, including p.Arg158His, differ from null variants as patients with missense variants present approximately 9 years earlier than those with other TP53 variants, including null mutations, suggesting an additional oncogenic effect in TP53 missense variants [It is important to identify the underlying type of variants . Correspvariants . Thus, ivariants .The arterial hypertension in the present case posed an additional diagnostic challenge, since both an excess of circulating secreted adrenal hormones and their metabolites or renal artery compression by a large ACT, with concomitant secondary hyperaldosteronism, were possible. Urinary cortisol excretion, renin–aldosterone state, and normal urinary catecholamines were normal, and renal artery compression was not detected. Furthermore, the rapidly normalized blood pressure after tumor resection strongly suggests a tumor-driven mechanism. Androgens have a blood-pressure-elevating effect. This has been studied in both animal models and humans. Blood pressure decreased after castrating male rats and increased after administration of testosterone both in normotensive female and in normotensive male rats . SimilarAndrogen-secreting tumors should be part of differential diagnosis in children with PPP. Clinical, biochemical, and imaging features are important for diagnosing an androgen-secreting ACT, but cannot differentiate benign from malignant tumors. Molecular genetic testing is important to ascertain whether an ACT is related to a specific genetic tumor predisposition syndrome, including LFS, even when histologically considered as having a favorable prognosis. Arterial hypertension can be associated with pure androgen-secreting adrenocortical adenomas in children.Additional file 1: Table S1. List of 165 analyzed cancer-related genes.


Subcutaneous scalp manifestations of diffuse large b-cell lymphoma are uncommon and can be an easily overlooked diagnosis. Today we report a rare case of a 60-year-old male with a previous history of treatment and removal of multiple benign cysts who presented to the office for the removal of a subcutaneous mass on the left occipital scalp. Intraoperatively the mass did not resemble a cyst. Pathology results showed diffuse large b-cell lymphoma, highlighting the importance of thorough management of subcutaneous masses. Diffuse large b-cell lymphoma (DLBCL) represents approximately one-third of all non-Hodgkin’s lymphomas ; extranoA 60-year-old white male presented to the clinic for the removal of a subcutaneous mass on the left posterior scalp that had been present for 1-2 months. The patient’s medical history was significant for sebaceous and pilar cysts, hypogonadism, chronic kidney disease, hyperlipidemia, hypertension, depression, and anxiety. The patient’s surgical history included shoulder surgery and cyst excisions. His previous cyst excisions were a combination of sebaceous and pilar cysts that had been located on the back, face, and scalp, but none had been located on the left posterior scalp where this lesion presented. The mass was approximately 5cm x 5cm in size and presented as a smooth solitary subcutaneous mass without skin involvement or ulceration. No associated cellulitis or drainage. It was smooth and oval, longer horizontally and located midline along the left lower posterior scalp. The patient had noted pain with pressure or palpation to the area and difficulty lying on the left side of the head. Left unilateral anterior cervical lymphadenopathy was appreciated on exam. The patient was treated on the clinical diagnosis of an infected sebaceous cyst and was previously prescribed a 10-day course of doxycycline without improvement.Excision by general surgery was performed. Intraoperatively the mass did not appear to resemble a cyst, nor did it have a cystic consistency. The mass was tan-white, rubbery, and fixed to the surrounding tissues during the removal. Successful removal showed an ellipse of skin and underlying soft tissue measuring 4.5 x 2.1 x 1cm. The skin surface showed marked irregularity. Sectioning revealed diffuse tan-white induration of the subcutaneous soft tissues.Pathology results showed a diffuse infiltrate of lymphoid cells with a bimodal pattern of large and small cells showing mitotic activity and scattered foci of necrosis seen throughout, consistent with a malignant lymphoma. Further special staining revealed tumor cells to be positive for CD20, CD10, and BCL2. There was focal weak positivity for BCL6. The tumor cells were negative for CD3, which stains the background reactive T cells. The tumor is negative for CD5, C-MYC and MUM1. Immunostains for kappa and lambda light chains were non-contributory. High proliferative activity (80%) is seen on immunostain for KI-67. The histologic appearance and immunophenotype fit best with the diagnosis of diffuse large b-cell lymphoma. A positron emission tomography (PET) scan was ordered showing diffuse lymphoma involved both above and below the diaphragm  every three weeks, which can be curative in 60% of cases, but DLBCL resistant to R-CHOP therapy has unfavorable outcomes . DLBCL wOur hope is that our case can offer a presentation of malignancy that can be detected during routine examinations. This case acts as a reminder to remain diligent in screening for and treatment of subcutaneous masses even in cases where the patient has a history of multiple benign subcutaneous growths.Subcutaneous presentations of DLBCL are a rare finding. When managing scalp masses, a diagnosis of DLBCL should be considered and a thorough workup should be completed. A history of benign subcutaneous lesions does not mean rarer conditions such as DLBCL should be excluded from the differential. This case highlights the importance of a thorough workup of subcutaneous skin lesions and offers a unique and rare presentation of DLBCL to monitor for.