Prenatal anterior mediastinal teratomas are rare. Anterior mediastinal teratomas can cause edema during the perinatal period. Color Doppler ultrasonography and chest computed tomography (CT) are of great value in diagnosing neonatal anterior mediastinal teratomas. Here, we report a case of prenatally diagnosed neonatal anterior mediastinal teratoma. After birth, transthoracic echocardiography and chest enhanced CT showed a large solid mass in the pericardial cavity. Owing to compression of the heart, the tumor was completely removed 1 day after birth, and cardiopulmonary bypass was performed. Pathology results indicated an immature teratoma (Grade I). At 9-month follow-up, the patient remained in good overall condition without observed recurrences. Teratomas are a type of germ cell tumor, and the anterior mediastinum is a predilection site for teratomas. Teratomas account for approximately 1%–10% of anterior mediastinal germ cell tumors . In neonIn clinical diagnosis, the signs and symptoms of neonates with anterior mediastinal teratomas are often not characteristic. Prenatal color Doppler ultrasound can detect fetal anterior mediastinal tumors; postnatal cardiac ultrasonography can determine the cystic and solid nature of the tumor; and enhanced computed tomography (CT) can clearly show the density, calcification, and other tumor characteristics, as these are essential to diagnose teratoma . In clinA male neonate was prenatally referred to our hospital for an anterior mediastinal mass. Four-dimensional ultrasound at 26 weeks of gestation revealed a mixed mass in the pericardium of the fetus with pericardial effusion . The carThe child was born at our hospital at 39 weeks of gestation and was admitted to the neonatal intensive care unit. He was born to a mother who was gravida 4, para 2 (G4P2), and he had a birth weight of 3,500 g, body length of 51 cm, head circumference of 34 cm, and chest circumference of 33 cm. The Apgar score was 9-9-9 (1 point deducted for skin color). On examination, he was afebrile, with a pulse rate of 132 beats/min, respiration rate of 42 breaths/min, and blood pressure of 75/42 mmHg. A tumor marker test showed that carbohydrate antigen 125 (CA125) was 57.5 µ/ml , carbohydrate antigen 199 (CA199) was 200.6 µ/ml , and alpha-fetoprotein (AFP) was more than 1,210 ng/ml .Transthoracic echocardiography (TTE) showed a slightly hyperechoic mass in the right pericardial cavity, approximately 40 × 37 mm in size . The masBased on the above findings, the patient was diagnosed with an anterior mediastinal tumor. Considering the compression of the heart and aorta, surgery was indicated for the child. During the operation, a large solid mass, approximately 44 mm in size, was observed outside the right atrium, tightly connected to the right anterior wall of the ascending aorta. The mass had displaced the heart to the left, and the superior vena cava was compressed and posteriorly displaced . Blood pThe child was postoperatively transferred to the cardiac intensive care unit. Arrhythmia occurred, and electrocardiogram showed polygenic premature ventricular contractions and paroxysmal ventricular tachycardia. After continuous infusion of lidocaine and 5 J synchronized electrical cardioversion, the patient was successfully cardioverted. The arrhythmia lasted for approximately 10 min, and might be attributable to the increased right ventricular return blood volume and right ventricular dilation after the operation.Postoperative chest radiography and echocardiography revealed that the anterior mediastinal mass had been completely removed, the aorta was unobstructed, and cardiac function was good. Re-examination of the electrocardiogram showed no abnormalities. The neonate was extubated on the 5th postoperative day. Milk intake was increased to the normal range on the 12th postoperative day and the patient was transferred out of the intensive care unit. The patient’s weight increased from 3.5 to 3.65 kg and he was discharged on the 15th postoperative day.The neonate was followed up regularly. TTE 9 months postoperatively showed normal cardiac function with good recovery.Teratomas can be divided into congenital and acquired types; they occur mostly in the ovaries, testes, retroperitoneum, and mediastinum . MediastChildren with mediastinal teratomas may present with chest pain, dyspnea, or wheezing if the tumor is large and is severely compressing the surrounding tissues and organs. In the case of our patient, the right atrium and ascending aorta were compressed by the teratoma. Pericardial effusion and neonatal pneumonia were present, which might be caused by the teratoma.AFP concentration is increased in children with germ cell tumors and is of great significance in the diagnosis , treatmeIn terms of imaging, ultrasonography is of great value in the diagnosis of mediastinal teratomas because of the absence of ionizing radiation. Ultrasound can be used to identify cystic and solid masses and to check for pleural and pericardial effusion. In this case, ultrasonography showed that the mass was solid, with pericardial effusion. Chest CT has high sensitivity and practicability. A plain CT scan can show the material composition of the mass, such as calcification. CTA can show the blood supply of the mass and its relationship with the surrounding important blood vessels, thus helping in the formulation of surgical plans. For the differential diagnosis, mediastinal teratoma should be distinguished from congenital pulmonary airway malformation (CPAM) and diaphragmatic hernia. In this case, the CT findings showed mild enhancement of the lesions, and the blood supply vessel originated from the ascending aorta. There were no gas-containing vesicles or intestinal structures. Therefore, a diagnosis of CPAM or diaphragmatic hernia was not considered. Imaging examinations showed that the mass was severely compressing the right atrium, superior vena cava, and ascending aorta, and a large amount of effusion was observed in the pericardium. This supported the clinical diagnosis and provided clear indications for surgery.Complete surgical resection of mediastinal teratomas is the optimal treatment option. The purpose of the surgery is as follows: first, to clarify the nature of the mass; second, to relieve the compression of the mass on the surrounding tissue, thereby avoiding possible serious complications. However, anterior mediastinal tumors may exert different degrees of compression on important tissues, such as the heart, large blood vessels, and trachea, which may lead to the risk of cardiac arrest during general anesthesia in children. Therefore, it has been reported that extracorporeal membrane oxygenation or cardiopulmonary bypass technology may be used to provide perioperative life support for children . In our After the operation, the patient recovered and was discharged from the hospital without any related symptoms such as dyspnea or edema.Patients with benign or low-grade teratomas have a good prognosis after complete removal of the teratoma . The patAnterior mediastinal teratomas found prenatally and treated during the neonatal period are very rare. They are usually discovered incidentally during postnatal physical examination. Perinatal ultrasonography and CT play an important role in the diagnosis of anterior mediastinal teratomas. Based on reports in the literature and our experience, complete surgical resection is the optimal solution for the treatment of anterior mediastinal teratomas. If the mediastinal teratoma is closely related to the great vessels of the heart, extracorporeal surgery may be considered to avoid serious risks such as massive bleeding and cardiac arrest. Integrated diagnosis and provision of pre- and postnatal treatment is of great importance for early detection, prompt treatment, and good prognosis in cases of anterior mediastinal teratoma.


Hemorrhoidal disease is a common anorectal pathology. Complications post hemorrhoidectomy are rare. Postoperative complications following hemorrhoidectomy include bleeding (2%), infection (0.4–8%), urinary retention (15%), and constipation (15–30%).A 40-year-old of Asian background female presented to a tertiary colorectal service with large bowel obstruction post hemorrhoidectomy. This is the first case in the surgical literature describing large bowel obstruction secondary to extrinsic compression from urinary retention following hemorrhoidectomy. The patient developed urinary retention and obstructed defecation in setting of inadequate analgesia post hemorrhoidectomy. The patient required indwelling catheter insertion and aggressive constipation management to resolve symptoms. Histopathology from the hemorrhoidectomy did not reveal a malignancy.Anesthetic choice and postoperative analgesia are important factors to avoid the development of complications. A missed malignancy diagnosis must always be excluded with patients presenting post hemorroidectomy with bowel obstruction. Major cWe present an interesting case of a 40-year-old of Asian background female with large bowel obstruction 8 days post hemorrhoidectomy performed under general anesthesia. She presented with 3 days of abdominal pain and distension, no postoperative passage of stool or flatus, and nonbilious vomiting. Her general practitioner had started aperients without effect.Her abdomen was distended, silent, and tender across the lower abdomen without peritonism. Rectal examination revealed an external hemorrhoid, no palpable masses, no bleeding, and an empty rectum. An abdomen/pelvis computed tomography (CT) showed extremely distended bladder with bilateral hydronephrosis and hydroureter Figs. , 2, and An indwelling catheter (IDC) was inserted with 2.1 L urine drained, and an aggressive regimen of aperients was commenced. Stool was passed on day 1 of admission, but on day 2 trial of void (TOV) was unsuccessful. She continued on regular aperients, paracetamol, and oxycodone/naloxone 5/2.5 mg. A repeat TOV was successful on day 4. She continued aperients on discharge. Histopathology collected intraoperatively demonstrated hemorrhoids and nonmalignant fibroepithelial polyp.Large bowel obstruction is a rare complication post hemorrhoidectomy, and the presented case is the first reported in literature of large bowel obstruction post hemorrhoidectomy secondary to bladder distension.p = 0.044; odds ratio 2.43; 95% confidence interval 1.02–5.97) [Complications post hemorrhoidectomy include bleeding 2%), infection 0.4–8%), urinary retention 15%), and constipation 15–30%) [%, infect0% [%, in–8%, urin%, and co02–5.97) .et al. [et al. [Similar reports in the literature of large bowel obstruction due to extrinsic compression post hemorrhoidectomy include that from Vasudevan et al.  reportin [et al.  reportedInadequate pain management can lead to obstructed defecation and urinary retention , 10. BalWhile major complications post anorectal surgery are uncommon, this case study highlights the importance of identifying risk factors contributing to their development in order to reduce their likelihood in similar future clinical presentations and thus minimize patient morbidity .As bowel obstruction is a rare complication post hemorrhoidectomy, the findings warrant the need to exclude sinister pathologies. Screening questions for malignancy symptoms and baseline investigations to exclude an obstructive malignancy  should be performed. Obstructive symptoms with clinical suspicion of sinister pathology warrants exploration under anesthesia and flexible sigmoidoscopy to investigate for anorectal malignant pathology or an alternative missed sinister diagnosis.This case report depicts an interesting and rare complication post hemorrhoidectomy. Optimizing analgesia is essential in the postoperative period to limit development of urinary retention and prolonged or re-hospitalization. Avoiding spinal anesthesia in favor of general anesthesia and judicious use of intravenous fluids where able is also recommended. Considering the rarity of large bowel obstruction post hemorrhoidectomy, it is crucial to always exclude an obstructive malignancy.


Appendiceal mucocele is an extremely rare pathology accounting for 0.3-0.7% of all appendiceal pathology. It is characterized by appendiceal lumen dilatation by mucinous secretion collection. Though abdominal imaging and tissue Biopsy aids in diagnosis, suspicion should arise when a slight bulge or protrusion is seen on colonoscopy. We present a case of incidental appendiceal bulge found on a routine colonoscopy to evaluate abdominal pain that led to prompt diagnosis and management of appendiceal mucocele. Rokitansky first described appendiceal mucoceles as localized or diffuse dilatation of the appendiceal lumen by abnormal accumulation of the mucus . They reA 55-year-old Caucasian female with a past medical history of gastric polyps and a family history of colon cancer presented to the hospital for a routine colonoscopy. On pre-procedure evaluation patient also reported chronic intermittent mild diffuse abdominal pain, non-radiating with no alleviating or aggravating factors associated with on and off non-bloody diarrhea for the last two years. The patient denied anorexia or weight loss. The patient underwent a routine colonoscopy, which showed a bulge right next to the appendiceal orifice Figure . A compuDue to worsening symptomatology, she presented again to the hospital with right lower quadrant pain. She underwent an emergent hand-assisted laparoscopic appendectomy with resection of the base of the cecum. The appendiceal specimen taken during the procedure was positive for low-grade mucinous neoplasm Figure . The surMucinous appendiceal neoplasms (MAN) are rare entities in the domain of appendiceal tumors, characterized by neoplastic epithelial cells containing abundant cytoplasmic mucin secreted in the lumen of the appendix ,4. TheseIn cases where radical appendectomy is not viable, Right hemicolectomy is the standard care procedure. However, open surgery is a better option for large and giant tumors due to the risk of iatrogenic rupture and mucin spread in the peritoneal cavity . In our Patita et al. (2020) presented a 42-year-old male with persistent abdominal pain and constipation for one year, for which he underwent a colonoscopy that showed appendiceal mucocele. Biopsy taken during the colonoscopy resulted in drainage of the mucinous fluid . Like ouAppendiceal mucocele is a rare entity that can be missed during a routine colonoscopy. We emphasize that tissue changes and a protuberance or bulge around the appendiceal orifice on colonoscopy should prompt further evaluation. This may allow treatment to be instituted before metastasis if an appendiceal mucocele is found. The laparoscopic approach is the standard of care for patients with subsequent removal of appendiceal tumors.Recognition of a mucocele bulge during a colonoscopy is critical because it may pave the way for a correct diagnosis and guide further care. Cases like ours emphasize the utility of colonoscopy to aid in examining the root of persistent gastrointestinal complaints and diagnosing underlying pathology beyond the visible lumen on colonoscopy.


Spinal meningioma is a common intraspinal tumor, which mainly occurs in the thoracic spine. Ossified meningioma (OSM) is an extremely rare histological variant. Our article reports a rare patient with dorsal complete OSM and reviews this subject.A 68-year-old woman presented with a one-year history of progressive weakness in both lower limbs with gait disturbance. Physical examination revealed hypoesthesia with a sensory level below T10. Babinski and pathological signs on both sides were weakly positive. Magnetic resonance imaging (MRI) showed a mass at the T10 to T11 level causing severe compression of the spinal cord. Computed tomography (CT) showed complete ossification of the mass. 18F-Fluoro-deoxy-glucose positron emission tomography CT (18F-FDG PET/CT) scan combined with MRI revealed that the mass was an intradural extramedullary high-density ossified nodule. The patient underwent a gross total resection of the mass and pathologic examination indicated that the mass was a meningioma with diffused psammomatous bodies.We identified a rare case of dorsal complete OSM occurring in a 68-year-old woman. After complete surgical resection, although there were complications such as cerebral fluid leakage and fever, the patient finally recovered with a satisfactory result. Spinal Here, a case of dorsal complete OSM is reported and the relevant subject is reviewed.2A 68-year-old woman presented with a one-year history of progressive weakness in both lower limbs with gait disturbance. Physical examination revealed normal muscle force of both lower limbs and hypoesthesia with a sensory level below T10. Babinski and pathological signs on both sides were weakly positive.Magnetic resonance imaging (MRI) demonstrated a mass between the T10 and T11 levels causing severe compression of the spinal cord Figure 1Under general anesthesia, T9 to T12 transpedicular screw fixation was performed. Subsequently, the complete T10 to T11 spinous process and bilateral lamina of vertebra, and part of the spinous process and bilateral lamina of vertebra at the lower margin of T9 were removed under intraoperative neuromonitoring. Dorsal complete ossification of the intradural mass was revealed after full exposure of the dura of the corresponding segment Figure 4The postoperative examination reported no residual mass compressing the spinal cord Figure 63According to PubMed, including the current case, altogether 34 articles  involvinSpinal meningioma may originate from the arachnoid cap cells originating from the outer layer of the arachnoid mater and villi . AccordiAs demonstrated in The most OSMs have symptomatic but nonspecific clinical manifestations. The clinical features of these tumors include motor, sensory, and sphincter dysfunction, with different phenotypes depending on tumor location and nerve compression. Interestingly, all 43 cases of OSM demonstrated progressive myelopathy and worsened with time, but most patients did not report a history of symptoms within 2 years and some cases remained asymptomatic until events such as falls occurred. Depending on the peak age of onset, the mass considered asymptomatic or mild for a long time. The mass becomes unsteady after stimulation and may cause bleeding and displacement, which displace and cause nerve compression and worsen neurological symptoms.In terms of diagnosis, OSM can sometimes be detected in a digital radiograph (DR), small calcification or ossification can be further observed in a CT scan, and the size or extent of OSM can be determined by MRI. However, since imaging cannot distinguish ossification or calcification, the ultimate diagnosis should be determined by histopathological findings . In addiOnce spinal meningioma is diagnosed, surgical resection is the primary treatment, which can relieve spinal cord compression, restore limb motor function, and reduce the pain of patients. Most intradural meningiomas are epiarachnoid masses, and the arachnoid mater becomes a barrier to separate the tumor from surrounding normal tissues during surgery. However, the unique differentiation form of OSM causes calcification or ossification of the arachnoid mater, which leads to the disappearance of this natural barrier. Moreover, compared with general spinal meningioma, OSM often sticks to the surrounding nerve tissue, which may be due to its scant cellularity consisting of acellular concretions . Therefo4We presented a rare patient with a dorsal complete OSM in the thoracic spine. In the current report, only 1% to 5% of spinal meningiomas present with ossification, and the majority are in women. The diagnosis of OSM can usually be correctly diagnosed by observing the neuroradiological appearances. Surgical resection is the main therapeutic method for OSM, but it is somewhat challenging because tumor adhesion can prevent complete resection. In summary, treatment with GTR or STR often leads to clinical improvement with a low risk of late recurrence.Please contact the corresponding author if data is required.W-BX: Conceptualization, Data curation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing. N-KS: Conceptualization, Supervision, Writing – review & editing. D-XC: Validation, Visualization, Writing – original draft. D-QC: Formal Analysis, Visualization, Writing – original draft. YN: Investigation, Writing – original draft. FJ: Validation, Writing – original draft. G-XL: Conceptualization, Funding acquisition, Writing – review & editing. GR: Conceptualization, Funding acquisition, Project administration, Resources, Supervision, Writing – review & editing.


Intercostal lung hernias can be results of trauma or surgery. True spontaneous lung hernias thought to be a result of sudden acute increase in intrathoracic pressures are extremely rare. Only 51 cases have been reported in literature over the past four-and-half decades. We report a case of spontaneous chest wall posterior-lateral lung herniation that developed in a 73-year-old following severe coughing and straining during an episode of lower respiratory tract infection. Herein we present the unusual findings in the case and outline the pathophysiology of the problem and management options available. Lung herniation is defined as a protrusion of lung parenchyma outside of the thoracic cavity through a defect in the chest wall or diaphragm . The majThe usual symptomatology consists of pain which increases with coughing or straining. Chest wall ecchymosis and a soft, bulging, subcutaneous mass that protrudes from the chest wall and enlarges with the Valsalva maneuvre, coughing, or physical strain is evident upon examination. A computer tomography (CT) scan of the chest usually confirms the diagnosis .Although conservative observational management  and non-A 73-year-old male presented with a history of sudden right upper quadrant abdominal pain, swelling, and bruising in the right lateral chest wall secondary to recurrent episodes of coughing from a lower respiratory tract infection. He was a retired bricklayer with a past medical history of hypertension, atrial fibrillation on anticoagulation, dyslipidemia, obesity, obstructive sleep apnea, and arthritis. He had no surgical history and was a non-smoker.Over time, the bruising subsided, however he continued to have a bulge and localized pain. A CT scan of the chest revealed splaying of the eighth and ninth ribs with bulging of lung and perihepatic fat consistent with herniation . He was After initial evaluation, the patient proceeded to operative repair. The operation was performed under general anesthetic with double lumen endotracheal tube and right-sided lung isolation.An incision was made directly over the palpable defect in the lower anterolateral chest. The intercostal muscles of the eighth space were found to have been ruptured and splayed throughout the entire length of the space with a clearly identifiable fracture dislocation of the costochondral junction of the eighth rib. Interestingly, there was also a rupture of the anterolateral aspect of the diaphragm with herniation of part of liver into the chest. The parietal pleura was ruptured and it formed part of the hernia sac. There were adhesions of the liver to the lung parenchyma .After adhesiolysis, the diaphragmatic defect was repaired using double layer continuous and interrupted 2.0 prolene sutures and was also reinforced with a prolene mesh . The eighth intercostal space was closed with multiple figures of eight sutures using five Ethibond suture . The muscles, subcutaneous layers, and skin were closed in layers in routine fashion.The patient had an uneventful recovery and remains asymptomatic with no recurrence after 6 months .Herniation of the pulmonary parenchyma is usually eventuated by trauma or surgery. Spontaneous herniation is rare. Since it was first described by Dr Roland in 1499 , very liThe most widely used classification of pulmonary hernia is the Morell Lavellee Classification . This clThe biggest risk factors for developing a pulmonary hernia include end-stage COPD or morbid obesity. This appears to be related to the elevated intrathoracic pressure noted in these populations. Conditions or factors that cause poor healing such as diabetes, malnutrition, steroids are also noted as risk factors for developing a pulmonary hernia .Based on the clinical presentation and history of our case, we have classified it as an acquired spontaneous pulmonary hernia according to the Morell Lavellee Classification , 5. Our We opted for primary repair using strong non-absorbable sutures because the defect was easily repaired when the eighth and ninth ribs were brought close by traditional intercostal stitches. We did not feel the need for additional mesh repair.In conclusion, lung herniation after severe coughing is a rare entity but can become symptomatic and may need surgery. Prompt surgical repair is safe and avoids possibility of subsequent sequelae.


A 29-year-old female who received assisted reproductive therapy (IVF) in ourinfertility clinic, at gestational age of 7w + 2d following embryo transfer,presented with a favorable rise of β-hCG level with no detectablegestational sac in the uterine cavity in the vaginal ultrasonogram. First doseof MTX (78) with simultaneous β-hCG titration of 110,000 pg/mL wasadministered. The patient underwent a second TVS in which a mass in favor ofmolar ectopic pregnancy was reported. With the suspicion of a molar EP thepatient underwent explorative laparotomy. A 3x4 cm mass which was found adjacentto the right ovary was resected. Final pathology report was compatible withpartial molar pregnancy. In the follow up period after surgical resection thepatient recovered completely without any recurrence. According to existing literature, apart from the rarity of ectopic molar pregnancy,its occurrence following assisted reproductive technology is exceedinglyuncommon.Here, we aim to report on a tubal partial molar pregnancy after In VitroFertilization (IVF). A 29-year-old female with a history of endometriosis andprimary infertility was referred to our clinic seeking fertility treatment. Herpartner had a diagnosis of abnormal sperm morphology and subsequent infertility. Thepatient had also a history of laparoscopy due to persistent ovarian cyst a yearbefore IVF, which was pathologically reported as serous cyst adenoma. She had a caseof well-controlled hypothyroidism; her past medical history was otherwiseunremarkable, and her medications included only prenatal supplements andlevothyroxine. She had decided to undergo IVF treatment and embryo transfer(ET).Following ET serial β-hCG titers were monitored and at day 40 following ET she presented to our clinic with an appropriate rise ofquantitative β-hCG . She reported to have no abdominal pain andvaginal bleeding. Her examination revealed a soft abdomen and her pelvic examinationhad no abnormal findings. A comprehensive TVS was performed and the findingsincluded endometrial thickness of 7 mm and a 27x21 mm hyperheteroechoic lesion withperipheral vascularization adjacent to the right ovary in favor of an ectopicpregnancy.2 of bodysurface area) was administered.According to elevated β-hCG level  and findings of ultrasoundsuggestive of EP, following consultation with the patient, methotrexate (MTX)therapy was initiated. A 78 mg of intramuscular MTX  is an extremelyrare entity. Hydatidiform moles arises due to abnormal fertilization of the ovum andsperm. It appears in two different forms: complete and incomplete (Several studies have shown that technical aspects of IVF are highly associated withincreased risk of EP such as assisted hatching, frozen embryo transfer, highertransfer volume, deep fundal transfer and multiple embryo transfer (Histologically partial molar pregnancies are characterized by heterogeneity invillous size, enlarged irregularly shaped villi with scalloped borders and secondarytrophoblastic pseudo-inclusions. As those cases are very rare, so reliance on onlyhistology may lead to overdiagnosis. Also, discrimination between partial mole andcomplete mole can be difficult, so ploidy investigation could be helpful (


Surgical resection plays a critical role in the curative therapy of patients with gallbladder cancer. However, extended resection for locally advanced gallbladder cancer is a controversial procedure because of the high operative morbidity, mortality, and poor prognosis after surgery, without consensus of its suitability. Several reports have described preoperative treatment modalities to reduce the risk of mortality and morbidity and improve the curability of surgery for locally advanced GBCA. However, only a few well-designed studies have verified the benefits of these preoperative strategies.A 62-year-old male patient presented to our department with a gallbladder tumor detected on abdominal ultrasound during an annual medical checkup. Multi-phase enhanced CT revealed a gallbladder tumor with a maximum diameter of 34 mm, invading the right hepatic artery, pancreatic head, hepatic flexure of the colon, and first portion of the duodenum. We diagnosed gallbladder carcinoma as cT4 cN0 cM0 cStage IVA in the Union for International Cancer Control (UICC) classification 8th edition. After administration of 12 cycles of gemcitabine and cisplatin plus S-1 regimen, tumor shrinkage was observed on computed tomography, and elevated serum CA19-9 levels were reduced to normal limits. After preoperative hepatic artery embolization, we performed gallbladder bed resection with pancreaticoduodenectomy (minor hepatopancreatoduodenectomy) and combined resection of the right hepatic artery and hepatic flexure of the colon. Histological examination revealed no evidence of lymph node metastasis (ypT4 ypN0 ycM0 yp Stage IVA in the 8th edition of the UICC). The proximal bile duct and dissected margins were negative.The combination of induction chemotherapy and preoperative hepatic artery embolization, followed by minor hepatopancreatoduodenectomy and combined resection of the involved arteries and partial colon, could be a feasible treatment strategy for patients with locally advanced gallbladder cancer invading neighboring organs. Surgical resection plays a critical role in the curative therapy of patients with gallbladder cancer (GBCA). However, some patients with GBCA are ineligible for curative surgery owing to delayed diagnosis from vague or non-specific symptoms, resulting in diagnosis at far advanced stages . As GBCAThere have been several reports of conversion surgery for advanced GBCA following chemotherapy to improve resectability and long-term outcomes . For theHerein, we present a case of advanced GBCA, achieving R0 resection by gallbladder bed resection with PD (minor HPD) with combined resection of the right hepatic artery and hepatic flexure of the colon, preceded by systemic chemotherapy, and preoperative hepatic artery embolization.A 62-year-old male patient presented to our department with a gallbladder tumor detected on abdominal ultrasound during an annual medical checkup. The serum carbohydrate antigen (CA) 19-9 was elevated . Multi-phase enhanced computed tomography (CT) scans revealed a gallbladder tumor with a maximum diameter of 34 mm, located at the peritoneal side of the gallbladder body , and no metastasis was detected. The patient did not experience more than grade 2 adverse effects, as defined by the Common Terminology Criteria for Adverse Events, version 5.0. Therefore, we planned to conduct conversion surgery.We considered the necessity of induction chemotherapy in the present case, which invaded the neighboring organs, with the aim of downstaging. We administered a gemcitabine and cisplatin plus S-1 (GCS) regimen, which proved to provide a longer survival period than the gemcitabine and cisplatin regimen for patients with advanced biliary tract cancer in a phase III trial . As a GCGiven the necessity of combined aRHA and RHA resection for R0 resection, postoperative liver ischemia was considered. Thus, we performed preoperative arterial embolization by an interventional radiologist using angiography. First, we embolized the aRHA using a coil and ensured no ischemic area in the right lobe of the liver by selective angiography of the RHA Fig. a. Then, th edition of the UICC Classification. After discharge, we administered S-1 as an adjuvant chemotherapy for 24 weeks. There was no evidence of recurrence on CT, 9 months after surgery  1 and 2. On POD 8, multi-phase abdominal CT revealed intraabdominal fluid around the anastomosis of the pancreas and jejunum, and we performed abdominal ultrasound-guided drainage of the fluid collection which was considered owing to postoperative pancreatic fistula. In addition, the patient did not experience any other postoperative complications and was discharged on POD 24. The pathological findings were as follows: advanced gallbladder cancer ypT4  ypN0 ycM0 ypStage IVA in the 8th edition. Radical resection, such as major HPD (two or more sections as an extension of liver resection), may be proposed to achieve R0 resection. However, according to the Japanese guidelines for biliary tract cancer, there is no general consensus on the benefits of major HPD for patients with GBCA because of the poor postoperative survival and high morbidity and mortality associated with this procedure [The GBCA presented in this case invaded the RHA with low likelihood of liver invasion as well as the pancreatic head, hepatic flexure of the colon, and first portion of the duodenum, defined as T4 in the UICC TNM Classification of Malignant Tumors 8rocedure , 11. ThuIn the present case, we planned conversion surgery after confirming a favorable response to induction chemotherapy. While R0 resection of GBCA is reported to contribute to long-term survival, R0 resection rates remain low in patients with GBCA involving neighboring organs, suggesting that careful case selection for resection is required . The medAn appropriate operative procedure should be determined based on the possibility of performing R0 resection and minimizing the risk of postoperative complications. Given minor HPD with combined resection of the tumor invading RHA as an alternative procedure to major HPD, the risk of liver ischemia due to the division of the hepatic artery is not well-known. The liver is reported to have collateral arteries, such as the interlobar hepatic artery at the hepatic hilus, right inferior phrenic arteries, and right adrenal arteries , 16. ThuThe reported median waiting period between preoperative hepatic artery embolization and surgery was 8 days . We initMinor HPD with combined resection of the RHA and partial colon after induction chemotherapy and preoperative hepatic artery embolization could be a reasonable treatment strategy for well-selected patients with locally advanced GBCA. This treatment strategy could be considered when GBCA invades the RHA, duodenum, and pancreas and does not massively invade the liver. Moreover, patients are expected to tolerate the planned treatment well. For patients with advanced GBCA, a favorable response after systemic chemotherapy could be useful information that contributes to conversion surgery.


Adrenal schwannoma (AS) and periadrenal schwannoma (PAS) are exceedingly rare Schwann cell tumors that develop from the adrenal medulla and periadrenal peripheral nerves respectively. The underlying genetic events are elusive.We searched our institutional database for AS/PAS cases and reviewed the histology and clinical outcome. Comprehensive molecular work-up was performed.SMARCB1 or NF2 mutations, alterations previously associated to schwannoma at other anatomical sites. The postoperative period was without complications for all patients, and follow-up did not show any signs of relapse or metastatic disease.We found reports of 4 AS/PAS cases diagnosed between 1992 and 2022 among the 1248 adrenal lesions submitted for histopathology during the same time period (0.32%). Two patients were male, two were female, and the age span was 59–80 years. Median size was 70 mm (range 50–100 mm), and from a radiology perspective, the lesions were initially suspected of malignant lesions originating from either adrenals or kidneys. Hormonal analyses were normal in all cases. Histologically, three cases were annotated as cellular AS or PAS, and one case was annotated as microcystic AS. Molecular characterization using focused next-generation sequencing did not identify AS/PAS are rare neoplasms that are most often benign, and the molecular etiology is most likely not related to mutations in established schwannoma-related genes. Since these tumors may be misinterpreted as malignant, knowledge of this entity is essential for radiologists, endocrinologists, surgeons and pathologists. Rare neoplasia of the adrenal gland such as ganglioneuroma, ganglioneuroblastoma, neuroblastoma, schwannoma and malignant peripheral nerve sheath tumors may arise as stand-alone entities or as composite tumors intermingled with pheochromocytoma. Whereas the definitions of some of these lesions have been widely accepted, the histological, molecular and clinical parameters of these entities are somewhat obscure.NF2 and/or SMARCB1 tumor suppressor genes [Schwannoma is a peripheral nerve sheath tumor originating from Schwann cells. Although reported in a wide variety of ages, the incidence seems to be highest in middle-aged patients. Schwannomas are mostly sporadic tumors arising predominantly on the limbs or in the head and neck region, but cases have been reported for many parenchymatous organs as well as the retroperitoneum –3. Subseor genes –14.Adrenal schwannoma (AS) is defined as a schwannoma arising in the adrenal medulla. If the schwannoma develops in close proximity to the adrenal gland, the suggested terminology is periadrenal schwannoma (PAS). AS/PAS are rare lesions, with less than 200 cases published to date . NotablyIn total, we found three AS cases and one PAS case during 1992 to 2022 (with 1992 as the starting year given the earliest inputs in our electronic search system). We used the Systematized Nomenclature of Medicine (SNOMED) code T93*** to retrieve all 1248 histopathologically diagnosed adrenal lesions during these years, specifically looking for M956** . This search function generated four cases corresponding to 0.32% of diagnosed cases. The patient charts and pathology reports of each case were reviewed. As the quality of the staining may deteriorate over time, blocks were recut and restained for hematoxylin-eosin (H&E). We defined AS as a schwannoma arising within the adrenal medulla, and PAS as schwannoma arising in peripheral nerves in close association to the adrenal gland. We considered SOX10, S100 and GFAP immunohistochemistry essential to the diagnosis, and therefore stained any case lacking one or several of these markers in their original report. Furthermore, all four cases were subjected to molecular characterization using an established next-generation sequencing (NGS) pipeline  used in clinical routine at the Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden. In brief, this platform interrogates DNA and RNA extracted from formalin-fixated paraffin embedded tissue for mutations in 126 genes  and >1700 gene fusion variants in 88 genes. The methodology regarding nucleic acid extraction and sequencing has been previously published .The overall clinical, histopathological and immunohistochemical findings are presented in Table en bloc removal of the retroperitoneal, left-sided tumor along with the spleen. The removed lesion weighed 750 g, including 300 mL of cystic fluid, measuring 100 × 100 × 100 mm. Histology was consistent with a tumor in direct association to the adrenal medulla, composed of bland spindle cells against a myxoid background, with scattered microcystic structures. Immunohistochemistry revealed positivity to SOX10, S100, GFAP and vimentin while showing negative stain for pan-cytokeratin, and the Ki-67 proliferation index was 1%  scan performed previously in his home country revealed a cystic expansivity measuring 100 mm suspicious of originating from the pancreatic tail. He presented at our hospital with diffuse abdominal pain. A gastroscopy was performed, but no significant findings were reported. Repeated CT scan showed an unaltered lesion compared with the previous examination, but the radiologists indicated a possible left renal origin. No lesions suspicious for metastases were detected. He underwent open surgery three weeks later, including 18F-FDG PET/CT) showed an adrenal mass with an assumed necrotic center and viable periphery , (the tumor rim showed an attenuation of 30 HU), was seen just cranial to the right kidney, suspected of originating from the right adrenal gland Fig. . A gastrery Fig. . She wasery Fig. . HistoloThe patient was a 59-year-old female of Hispanic origin with a history of psoriatic arthritis and fibromyalgia who previously underwent appendectomy for appendicitis. She lacked family history suggestive of adrenal tumors or other cancers. She presented at the emergency department with abdominal pain, and a CT scan was performed to rule out nephrolithiasis. A 50 mm hyper-vascular lesion was seen cranially to the left adrenal vein, with attenuation of 28 HU, suspected of originating from the left adrenal gland. Two enlarged lymph nodes were seen caudally to the left renal artery. Hormonal workup was normal, including plasma metanephrines, the cortisol level post 1 mg overnight dexamethasone suppression test and aldosterone/renin ratio. No hypertension was seen. She underwent open surgery two weeks later, including removal of the tumor and the enlarged lymph nodes. The removed lesion weighed 113 g, measuring 53 × 50 × 50 mm Fig. . The his18F-FDG PET/CT showed high uptake in both the pulmonary mass and in the left adrenal tumor , the latter suspected initially to be metastatic lung carcinoma Fig. . An 18F-mor Fig. . Cytologmor Fig. . The fin18F-FDG PET/CT, are rarely used in the diagnostic work-up of AS and PAS, and the few reported cases investigated with this modality show a widespread distribution in terms of uptake, possibly due to differences in histological subtyping and cellular composition [18F-FDG uptake only, most likely correlating to the wide-spread central degeneration of tumor tissue, while the 18F-FDG uptake in patient 4 was enhanced.AS and PAS are infrequently encountered lesions in the clinical setting, and hence the data regarding histological attributes, molecular drivers and clinical presentation is limited. A recent meta-analysis from 2022 identified 169 published AS cases . The majHistologically, most AS and PAS cases are described as either conventional or cellular, while other histological subtypes are rare. A conventional AS/PAS exhibits hypercellular areas (denoted as “Antoni A”) intermingled with palisading spindle cells (Verocay bodies) as well as various amounts of hypocellular areas (“Antoni B”). Cellular AS/PAS cases, however, usually lack Antoni B areas and the Verocay bodies that are seen in conventional AS . In our NF2 and SMARCB1 mutations have been reported in schwannomas from other anatomical sites [The focused NGS screening did not detect any pathogenic variants or gene fusion events in this small case series. Although al sites –14, we dAs expected, all patients in this series were free of metastatic disease. In fact, only a few cases of AS with malignant transformation have been reported , 23. TwoWe conclude that AS and PAS are rare lesions with a radiologically heterogenous presentation. As the lesions might be misinterpreted as malignant during preoperative workup, increased knowledge of these entities is of importance for radiologists, endocrinologists, surgeons and pathologists alike.


Scalp arteriovenous malformations (AVMs) are rare lesions that arise due to a pathological fistulous connection between scalp arterial feeders and draining veins without the involvement of capillary beds. Here, we report a case of a 17-year-old male who presented with an enlarging, pulsatile, mass in the scalp of the parietal region with mild headaches and was diagnosed with a scalp AVM that was treated successfully with endovascular trans-arterial embolization. Scalp AVMs are uncommon extracranial vascular abnormalities that neurosurgeons hardly ever see. To precisely define the angiographic architecture of an AVM and to organize further management, digital subtraction angiography is crucial. Scalp arteriovenous malformation (AVM), also termed as cirsoid aneurysms were first described by Brecht in 1833 ,3. BasedLesions are usually detected by physical exam and then confirmed by CT or MRI. However, the best diagnostic tool for this entity is cerebral angiography. Cerebral angiography is useful to delineate the anatomy of scalp AVMs and determine the nature of feeding vessels, and assists surgeons in planning the most suitable and least invasive surgical plan . BecauseA 17-year-old male presented to the clinic complaining of a pulsatile right-sided parietal mass for two years, accompanied by mild frequent headaches that were relieved by analgesia. Earlier, the mass did not cause any symptoms and was small in size, but the patient booked his visit when it started to enlarge and when the frequency of headaches increased. There was no history of trauma or infection before the mass. On physical exam, a pulsatile mass with minor hair loss was noticed. The patient had normal motor and sensory functions and cranial nerve examination was unremarkable. His past medical, surgical, and family histories were insignificant. A brain MRI showed tortuous dilated signal void vessels in the scalp of the right parietal region measuring approximately 2.3 cm x 1.7 cm suggestive of a scalp AVM  liquid was performed under general anesthesia Figure .After embolization, the size of the mass instantly decreased, and the pulsation faded. Without any neurologic deficits, the patient experienced an excellent recovery and was sent home. On follow-up after 12 months, the results of the cerebral angiography were negative for the scalp AVM recurrence and no cutaneous necrosis was observed.Scalp AVMs are uncommon vascular abnormalities with unclear pathogenesis ,15. ApprMultiple hypotheses have been proposed to explain the pathogenesis of non-traumatic scalp AVMs . One hypDepending on where the feeding arteries originate, scalp AVMs are divided into two groups. The first group is called primary scalp AVMs in which the feeding arteries originate from branches of the ophthalmic, external carotid, or vertebral arteries, and the veins drain into the venous system of the scalp. In the second group, scalp AVMs originate from outflow vessels of intracranial vascular anomalies .The clinical manifestations of scalp AVMs are influenced by their size. Lesions initially present as tiny subcutaneous growths and grow into huge, disfiguring masses ,9. OtherAfter thorough history taking and physical examination, CT, MRI, and angiography are the main steps in the diagnosis of these vascular malformations. Scalp hemangiomas and sinus pericranii are two examples of extracranial vascular pathologies that may be distinguished via vascular imaging .Generally, symptomatic lesions require intervention. Other than for cosmetic reasons, the goal of treating these lesions is to avoid the long-term effects of the ongoing shunting from the arterial system (high pressure) into the venous system (low pressure) . These lTransvenous or transarterial endovascular embolization for managing scalp AVMs has been carried out successfully. Moreover, percutaneous injection of sclerosing agents has been used in selected cases. These procedures also run the risk of side effects such as hair loss, skin necrosis, skin sensitivity, discomfort, and leakage of embolization material into the bloodstream . Our patThe most popular technique for treating scalp AVMs permanently is surgical excision ,30-32. TThe most recently published case report of scalp AVM by Briones et al. featured a 49-year-old man who presented to the ER with a giant AVM of the right temporal area accompanied by a large amount of bleeding . The preShi et al. highlighted the significance and effectiveness of endovascular arterial embolization through a direct percutaneous puncture in the management of scalp AVMs . They prIn a retrospective case series by Karki (&) Roka, a male predominance in scalp AVMs was observed with a 4:1 male-to-female ratio . The stuUng et al. presented an interesting case of a slowly progressing scalp AVM in a 19-year-old male diagnosed four years prior . The patIn this study, we have reported the first case of a scalp AVM in an adolescent patient in Jordan who was treated successfully with endovascular transarterial embolization. Scalp AVMs are uncommon extracranial vascular abnormalities that neurosurgeons hardly ever see. When they result in cosmetic or functional issues, surgical excision is advised. Vascular imaging performed before surgery is essential for identifying AVM morphology and assisting in therapy choices.


Clival chordomas are locally invasive midline skull base tumors arising from remnants of the primitive notochord. Intracranial vasculature and cranial nerve involvement of tumors in the paraclival region necessitates image guidance that provides accurate real-time feedback during resection. Several intraoperative image guidance modalities have been introduced as adjuncts to endoscopic endonasal surgery, including stereotactic neuronavigation, intraoperative ultrasound, intraoperative MRI, and intraoperative CT. Gross total resection of chordomas is associated with a lower recurrence rate; therefore, intraoperative imaging may improve long-term outcomes by enhancing the extent of resection. However, among these options, effectiveness and accessibility vary between institutions. We previously published the first use of an end-firing probe in the resection of a clival chordoma. End-firing probes provide a single field of view, primarily limited to depth estimation. In this case report, we discuss the benefits of employing a novel minimally invasive side-firing ultrasound probe as a cost-effective and time-efficient option to navigate the anatomy of the paraclival region and guide endoscopic endonasal resection of a large complex clival chordoma. Clival chordomas are complex midline skull base tumors with high recurrence rates. Gross total resection of these lesions is important, as it is associated with improved long-term outcomes . HoweverAlternatively, intraoperative ultrasound (IOUS) presents a fast, cost-effective, and recently widely available option. IOUS provides real-time visualization of nearby anatomy, allowing the surgeon to estimate the extent of resection and the location of critical structures with greater confidence , 8. BothThe patient is a 63-year-old female who initially presented to otolaryngology in 2021 with a six-month history of intermittent hoarseness and difficulty swallowing. She stated that she first became aware of the hoarseness after contracting COVID-19 one year earlier, though her symptoms have become more significant within the past six months. Additionally, she reported a six-month history of difficulty swallowing solid and liquid foods, thick nasal drainage, globus sensation, and a constant urge to clear her throat. The patient mentioned that she works as a daycare director, which occasionally requires significant vocal strain, and often carries a “spit cup” due to difficulty swallowing saliva throughout the day.Her past medical history includes hypertension and gastroesophageal reflux disease. She has no history of stroke or intubation and no surgical history. She has a 40-pack-year history of cigarette smoking and currently smokes one-half pack of cigarettes daily. There is no relevant family history. At presentation, the patient denied dyspnea, otalgia, unintentional weight loss, hemoptysis, or throat pain  for the publication of any potentially identifiable images or data included in this article.KB drafted the manuscript, created the ultrasound model, and prepared operative video, figures and figure legends. CT approved radiological images, provided guidance, created 3D reconstructions of preoperative imaging. AR provided writing assistance and direction. ZK provided pathology images and descriptions. SS collaborated with MZ to perform the endoscopic endonasal surgery. MZ provided care to the patient, collected intraoperative ultrasound images, and provided important critical feedback on intellectual content. All authors contributed to the article and approved the submitted version.


Pleomorphic liposarcoma (PLS) is typically found in the lower and upper extremities. PLS arising in the gastrointestinal (GI) tract is extremely rare. Here, we reported a case of a 71-year-old female with a history of rectal adenocarcinoma presenting with small bowel obstruction. Small bowel resection was performed and revealed a 7.8 cm transmural mass in the jejunum. Histology reviewed a heterogenous epithelioid malignant tumor with intracytoplasmic fatty droplets scalloping the nucleus consistent with lipoblasts in some cells and others with numerous PAS/diastase+intracytoplasmic eosinophilic globules. Scattered multinucleated giant cells were also present. Mitotic count was up to 80/10 HPFs including some bizarre mitotic figures, and Ki67 proliferation index was approximately 60%. Immunohistochemistry demonstrated that the malignant cells were negative for pancytokeratin, CD117, DOG1, SMA, desmin, MyoD1, ERG1, CD34, CD31, SOX10, Melan A, and S100. INI1 was retained. Beta-catenin showed normal membranous staining. P53 was diffusely positive suggestive of mutant phenotype. Fluorescence in situ hybridization (FISH) assay was negative for MDM2 amplification and DDIT3 rearrangement. The overall morphologic and immunohistochemical features supported a diagnosis of high-grade pleomorphic liposarcoma. Diagnosis of PLS can be challenging due to its rarity in GI tract and lack of specific biomarkers, and histomorphology with identification of lipoblasts remains the gold standard. Pleomorphic liposarcoma (PLS) is the rarest subtype of liposarcoma accounting for 5-10% of all liposarcomas of soft tissue –4. PLS aA 70-year-old female had a complex medical history and a rectal adenocarcinoma status postchemoradiation and lower anterior resection in the late 1990s. She subsequently underwent multiple surgical procedures to try to reconnect the colon to rectum, but this was failed due to pelvic scarring. She underwent a revision of the end colostomy in 2000, relocating it from the left to the right side of the abdomen with an ileostomy. Since then, she had intermittent bouts of vomiting and abdominal pain that necessitated multiple hospital visits for possible small bowel obstruction. During the most recent hospital admission for the same complaint in May 2021, her abdominal CT scan revealed the presence of partial small intestinal obstruction caused in part by a parastomal hernia and by a new jejunal mass that was absent on 2020 and 2019 CT scans, indicating a rapidly growing nature of the tumor. A laparoscopic small bowel resection and repair of parastomal hernia were performed.The jejunal resection specimen revealed a 7.8 × 6.9 × 2.2 cm exophytic mass. On cut surface, the mass lesion showed a transmural heterogenous solid tumor with areas of hemorrhage and necrosis . MultiplPleomorphic liposarcomas are rare aggressive sarcomas exhibiting local recurrence and metastatic rate of 30-50% and an overall 5-year survival rate of ~60% . In a 57Radiation therapy has been recognized as a risk factor for developing postradiation sarcoma (PRS), although the incidence of PRS is extremely low ranging from 0.03% to 0.2% with the median period of 11 years post therapy . In our PLS rarely presented an incidental finding after resection of small bowel due to obstruction. Diagnosis of PLS can be challenging due to lack of specific biomarkers, and histomorphology and identification of lipoblasts remain the gold standard.


Lhermitte-Duclos disease (LDD), or dysplastic cerebellar gangliocytoma, is a rare benign tumor characterized by unilateral hemispheric cerebellar expansion. It is linked to mutations in the phosphatase and tensin homolog (PTEN) gene, which inhibit the phosphatidylinositol-3'-kinase pathway, leading to increased cell division and defective neuronal migration. This study aims to compare the clinical, radiological, histopathological, surgical resolution, and follow-up characteristics of reported cases of this rare condition. An in-depth search of LDD patients' clinical records at our institute between 2003 and 2023 was conducted, in addition to a systematic literature review on PubMed. Three patients with a diagnosis of LDD were found. Cerebellar abnormalities, varying headaches, and visual impairment were all present clinically. On T2 in the posterior fossa, all three MRI scans displayed the typical hyperintense parallel streak appearance. The histopathological report showed that large ganglion cells had replaced the granular layer, Purkinje cells had degenerated, the molecular layer had become hyper-myelinated, and synaptophysin and chromogranin were positive. Partial tumor resection and avoiding intracranial hypertension were the main goals of treatment. Genetic follow-up was conducted for all three patients. Neurosurgeons must be aware of LDD to provide close genetic monitoring despite the benign nature of the tumor because of its link to Cowden syndrome and elevated risk of cancer in other organs. Lhermitte-Duclos disease (LDD), or dysplastic cerebellar gangliocytoma, is a rare benign tumor characterized by unilateral hemispheric expansion of the cerebellum . This tuSymptoms of the disease can vary widely but may include headaches, difficulty with balance and coordination, and problems with vision or hearing . DiagnosIn this article, we present three cases retrieved from our institution's database dating from 2003 to 2023.Case 1In 2012, a 44-year-old female, with a family history of unspecified cerebral tumors, was brought to the outpatient clinic due to cephalea and right-sided gait lateropulsion, which she had experienced for the last seven years. A CT scan revealed hydrocephalus. Thus, a ventriculoperitoneal shunt was placed. In September 2013, she started experiencing cephalea and dizziness. MRI displayed a left cerebellar hemispheric lesion with a “tiger stripe” appearance , so he arrived again with an ophthalmologist who referred to a neurologist, who indicated image studies. Thus, he was referred to our institution. An MRI was performed at his arrival, and obstructive hydrocephalus and a right cerebellar lesion were found. Thus, the patient was referred to the emergency department. His physical examination showed nystagmus, dysmetria, dysdiadochokinesia, and ataxia. Frontal cephalea worsened with the Valsalva maneuver, presenting occipital cephalea. Strength was conserved in all extremities, and muscle stretch reflex was +++/+++++ in every extremity. The patient was admitted to the hospital with right cerebellar syndrome and hydrocephalus diagnosis. Two days later, he underwent surgery to achieve partial resection; cortectomy was performed in the right cerebellar hemisphere, and going deeper with Mallis and Surgicel, the lesion was partially removed. The patient was discharged three days after for home care. Histopathological examination confirmed a dysplastic gangliocytoma of the cerebellum Figure .The patient experienced persistence of the symptoms after four weeks, so he underwent a reintervention without any complications during the postoperative phase and was discharged after three days. The lesions were analyzed by neuropathologists at the institution, and the genetic analysis confirmed a positive result for LDD.LDD is a rare condition, with approximately 230 cases reported in the literature, typically affecting patients aged between 30 and 50. There is no sex preference. LDD is a rare brain tumor in the posterior fossa, described as a hamartomatous lesion due to abnormal development and unilateral hemispheric expansion of the cerebellum.This disease has been described in different terms throughout history, including gangliocytoma, ganglioneuroma, Purkinjeoma, granule-molecular hypertrophy of the cerebellum, and granule-cell hypertrophy.The nature of LDD, pathogenesis, and the exact genetic basis are unknown. However, a germline mutation of phosphatase and tensin homolog on chromosome 10q23 is considered widely as the underlying defect . IndividAlthough many cases of LDD have not been studied for genetic alterations, some series describe patients with this disease who previously had breast cancer or a history of multiple neoplasms, including colon carcinoma and polyps . In our The classical description of this disease in MRI is a non-enhancing mass in the posterior fossa that appears hypointense on T1 and hyperintense on T2-weighted images. It appears with linear parallel striae, giving the cerebellum a “tiger stripe” appearance. Some authors have proposed that the regions of T1 and T2 prolongation correspond to the central portion of the folia; their changes in signal intensity may be due to demyelinated central white matter. On the other hand, isointense areas represent the outer segment of the molecular layer . Klisch This particular appearance at MRI may be sufficiently unusual to suggest the diagnosis of LDD preoperatively, and it is also useful to determine the margins in surgical planning. A differential diagnosis of LDD is cerebellar infarct because it is visualized as a non-enhancing lesion with mass effect. However, an acute clinical presentation and changes in appearance on subsequent MR images obtained over days or weeks make confusion with LDD unlikely .Complete tumor removal is not usually performed due to the technical difficulty associated with the tumor’s location. Additionally, the pathogenesis of these tumors results from hypertrophy of the cerebellum's granular layer. Therefore, complete removal would also entail the removal of the cerebellum itself. The dysplastic lesion grows very slowly; initial treatment usually involves resolving secondary hydrocephalus. Subsequently, surgical resection is the curative option, with some reported cases of recurrence .Macroscopically, DGC shows thickened folia with surface pallor or yellow discoloration. In some cases, white matter cavitation can be found. The histological hallmark of DGC is an enlargement of cerebellar cortical thickness by large dysplastic ganglion cells . These gRecognizing LDD is of paramount importance, despite its infrequent occurrence. Although this condition may be rare, understanding its characteristics and presentation is crucial for early detection and appropriate management. Although noncancerous, LDD is associated with Cowden syndrome, a genetic disorder characterized by multiple noncancerous growths and an elevated risk of certain cancers in other organs. Due to this association, regular monitoring and genetic counseling are necessary to identify at-risk individuals and implement appropriate screening measures. The primary treatment objective for LDD is the surgical removal of the tumor and alleviation of intracranial hypertension. By recognizing the unique features of LDD and its potential implications, healthcare professionals can ensure early diagnosis, prompt intervention, and comprehensive care for individuals affected by this rare condition.


An abdominal inflammatory myofibroblastic tumor (AIMT), is a rare benign tumor composed of inflammatory and other mesenchymal cells. It can affect the entire body, predominantly in children and young adults. The diagnosis is challenging considering the wide clinical presentation and can often be mistaken for malignant tumors.We report a rare case of a 46-year-old female patient, who presented with intermittent abdominal pain weight loss, and an abdominal palpable mass. Abdominal ultrasound found a well-defined 18 cm, rounded mass, with solid and cystic components. Abdominal CT demonstrated a well-defined, hypodense, retro gastric mass of 20 cm, with thickened wall and heterogenous enhancement. The mass had contact with the pancreatic tail, transverse colon, spleen, left kidney pedicles, abdominal aorta, superior mesenteric vein, and mesaraic trunk with no invasion signs. The mass was initially thought to be pancreatic cancer, but given the large size, other diagnoses like sarcoma, lymphoma, or abdominal hydatid cyst were suggested. Endoscopic ultrasound found a rounded retro gastric mass of 18/12 cm, with a thickened wall and well-limited calcifications. The content was both cystic and solid with mobile vegetations, with no visible Doppler flow. The mass had contact with the body and tail of the pancreas, spleen hilum, the upper pole of the spleen, and the hepatic pedicle behind, with no invasion sign. After a multidisciplinary team meeting, a decision was taken to perform surgical resection with mass resection, distal splenopancreatectomy, and transverse and sigmoid colectomy. Pathological and immunostaining results were consistent with inflammatory pseudotumor. The postoperative recovery was uncomplicated. The patient remains asymptomatic with no obvious signs of metastasis or recurrence.AIMT represents a reel diagnostic challenge. Clinical symptoms are unspecific. Radiological and endoscopic features can often be mistaken for malignant tumors. Surgical management remains to be the best therapeutic option. We report a rare case of AIMT treated by surgery with complete resection. We suggested a long-term follow-up given the local recurrence risk. An inflammatory myofibroblastic tumor (IMT), also known as an inflammatory pseudotumor or myofibroblastic pseudotumor, is a rare benign tumor composed of various inflammatory and mesenchymal cells . It can A 46-year-old woman without any past medical history was referred to our gastroenterology unit in February 2022 to evaluate an intra-abdominal mass detected by ultrasound in a nearby hospital. The patient had intermittent abdominal pain for three months. She reported a weight loss of 2 Kg over the past two months. Physical examination revealed a palpable mass of 18 cm, extending from the left hypochondrium to the left flank. Laboratory results, including complete blood count, C-reactive protein, and tumor markers, were all within reference ranges. Abdominal ultrasound found a well-defined, heterogeneous, rounded abdominal mass with a solid and cystic component measuring 18 cm  revealed a round retrogastric mass of 18 cm by 12 cm, with flaky and well-limited calcifications; the content was both cystic and solid with mobile vegetation. It had no visible Doppler flow, and the mass had contact with the body and tail of the pancreas, the spleen hilum, the upper pole of the spleen, and the hepatic pedicle behind without invasion sign. The mass was in contact with the gastric wall with no invasion sign Figure .After a multidisciplinary team meeting, the decision was made to perform a laparotomy for diagnosis and treatment. Exploration revealed a large cystic mass of 20 cm in close contact with the tail pancreas, spleen, left kidney, transverse, and sigmoid colon, with multiple peritoneal adhesions. No liver lesions or peritoneal carcinomatosis were detected. It was decided to perform the mass resection, with distal splenopancreatectomy and transverse and sigmoid colectomy Figure .Macroscopically, the mass had a cystic aspect with dark fluid content, thickened fibrous wall, and vegetation. Histological study revealed a well-limited myofibroblastic tumor proliferation, with bundles of regular fibroblasts and clusters of dense collagen. Congestive vessels and inflammatory infiltrate of lymphocytes, plasma cells, and eosinophils were detected. Tumor proliferation adheres intimately to the pancreas, spleen, and transverse and sigmoid colon with no invasion signs. The immunohistochemical study stained negatively for PS100, STAT6, ALK, desmin, CD117, and CD34. A diagnosis of an intraabdominal pseudo-inflammatory tumor was determined, given the histopathological results. The patient’s postoperative recovery was uncomplicated. She was discharged from the hospital on day seven. The patient is asymptomatic with no obvious signs of metastasis or recurrence over the 15-month follow-up.IMT is rare and benign and often occurs in young patients ,2. AIMT EUS is performed for better diagnostic accuracy if radiological results were inconclusive for subsequent treatment. The role of EUS in diagnosing pancreatic masses, non-pancreatic, and retroperitoneal lesions is well established . EriksonHowever, the diagnosis of AIMT in EUS remains challenging, and fine needle aspiration biopsy is ineffective . A surgiSurgery with complete resection is recommended as the first therapeutic option of AIMT. Chemotherapy and radiotherapy have limited roles as adjunctive treatments. High-dose steroids or imatinib may be indicated in inoperable tumors . AIMT isThis case highlights that AIMTs are a diagnostic challenge because they usually mimic malignant tumors. Surgical management remains the best therapeutic option. The prognosis is often favorable but requires long-term monitoring, given the risk of recurrence. The case presented was treated by surgery with complete resection and a long-term follow-up was suggested considering the local recurrence risk.


An adenomatoid odontogenic tumor (AOT) is a benign epithelial lesion, being the fourth most common among all odontogenic tumors. Usually presents as slow painless growth that sometimes leads to facial asymmetry. Many cases are detected by radiographic studies, and the indication for biopsy and surgery is secondary to this finding. We report a case of a 17-year-old man with a history of left mandibular painless swelling since 4 months ago, associated with facial asymmetry and hard consistency. An imaging study showed an extensive unilocular radiolucent lesion to the basilar arch, with defined limits and with peripheral hyperdense areas located only vestibular to the lesion. The histopathology was composed of odontogenic epithelial cell proliferation, with epithelial nodular and duct-like structures, rosettes of spindled epithelial cells with eosinophilic material, calcifications, and fibro-osseous reaction. Surgical conservative excision including the affected tooth is the treatment of choice and recurrence is rare. The histologic findings of reactive fibro-osseous proliferation in AOT should be interpreted as a reactive change in the tumor capsule and not as an adnexal lesion. We present an atypical case of AOT with reactive fibro-osseous reaction. Despite clinical aggressive behavior, conservative surgical treatment could be the treatment of choice. Additionally, we emphasize the importance of histopathological examination together with the imaging study of radiolucent lesions of the maxillary bones. Key words:Adenomatoid Odontogenic Tumor, Odontogenic tumor, fibro-osseous lesion. Adenomatoid odontogenic tumor (AOT) is a benign epithelial lesion, being the fourth most common among of all odontogenic tumors , represeThis lesion has been named in several ways: epithelial odontoma, cystic epithelial tumor, adamantinoma, mandibular tooth germ cyst, development cyst associated epithelial tumor, adenoameloblastoma, ameloblastic adenomatoid tumor . FinallyThere are different points of views in the literature regarding if it is a neoplastic or hamartomatous lesion . In prevet al. 4), however, 88% of cases are diagnosed in the second and third decades of life (Rick 8). Gender and anatomical site, apparently are related to age of occurrence; before 30 years of age maxillary anterior site is more frequently affected. After 30 years of age, mandibles are more frequently affected, and males more than females; although AOT generally has a 2:1 female to male ratio , whose size was 30x22x15mm; and the second, a thick cystic like membrane of 30x25x15mm, brownish color, which was firm when cut , almost invariably show imaging characteristics of a benign odontogenic lesion such as a well-demarcated radiolucency may present radiopacities, almost always unilocular, regular edge, pericoronary or juxtacoronary location and an average diameter between 1 to 3 cm. (Rick 8). Interestingly, in our case more aggressive radiographic features than usual were observed, such as the presence of root resorption, thinning and perforation of bone Tables and bulging of the basilar border.et al. also presented as a unilocular radiolucent lesion with resorption of the apices of the involved teeth. But the cases reported by Naidu et al. were described as mixed lesions, due to the presence of calcifications in the center of the lesion, without root resorption of the related teeth and with poorly defined limits.The AOT reported by Li et al. and Li et al. the fibro-osseous proliferation enveloped the AOT peripherally as a shell. Both papers, interpret this feature as a secondary reactive proliferation in the capsule of the AOT.Histopathologically, as in the cases reported by Naidu Enucleation of the lesion is the appropriate treatment for these cases with close follow-up including clinical and radiographic examinations . It is nThe nature of AOT is controversial, and it is considered to be either neoplastic or hamartomatous. Studies based on its clinical behavior, such as its small size in most cases, minimal potential growth and no recurrence, radiographic features, and the absence of true neoplastic behavior and malignant transformation, suggest a rather hamartomatous nature . HoweverOther studies ,12 suggeet al. no association was found between the presence of the KRAS proto-oncogene mutation and the clinical characteristics of AOT, such as lesion size, location, clinical variants, patient age and capsule thickness. The mutation would not be conditioning for lower or higher tumor aggressiveness (According to Coura siveness .In addition, the activation of the MAPK/ERK pathway has been reported, evidenced by the immunohistochemical expression of proteins of this pathway such as EGFR, KRAS, BRAF, among others, in AOT epithelial cells. However, EGFR expression is not exclusive to AOT, and is also observed in the odontogenic epithelium of dental germs and epithelial debris, suggesting that its expression is regulated during odontogenesis. Some EGFR patterns have been linked to the potential to develop various odontogenic cysts and tumors such as radicular cysts, dentigerous cysts, keratocysts, ameloblastomas, and ameloblastic fibromas ,12.et al. and Li et al.AOT is a benign odontogenic tumor that can have different clinical presentations. The reported case corresponds to a AOT associated with a peripheral fibro-osseous reaction, similar to the cases of Naidu et al. and Li et al.Unlike conventionally described AOT, the behavior of the lesion was more aggressive, presenting root resorption, expansion and perforation of slabs, unlike conventionally described AOT, similar to that reported by Naidu The histologic findings of reactive fibro-osseous proliferation in AOT should be interpreted as reactive changes in the tumor capsule and not as an adnexal lesion. Despite the histological findings reported, the conservative surgical treatment could be the treatment of choice for this type of tumor, maintaining close follow-up, including clinical and imaging examinations.We emphasize the importance of histopathological examination together with the imaging study of radiolucent lesions of the maxillary bones.


Aneurysms are characterized by focal dilation of the blood vessel wall due to weakening. The involvement of two layers of the vessel wall is classified as a pseudoaneurysm while the involvement of all three layers is called a true aneurysm. Involvement of neoplastic lesions is rare, but the few reported cases have been associated with pulmonary artery pseudoaneurysms as opposed to true pulmonary artery aneurysms (PAAs). Our case of a true left PAA of a patient with metastatic sarcoma of the lung shows an association that has previously not been reported to the best of our knowledge. Aneurysms are clinical disorders characterized by focal dilation of the blood vessel wall due to weakening ,2. The iThis article was previously presented as an abstract at the Chest Virtual Congress on June 26, 2020, and at Aga Khan University's 12th Health Sciences Research Assembly from December 14 to 18, 2020.A 53-year-old gentleman presented to a tertiary care hospital in August 2017 with a dry cough and low-grade fever. He had previously been in his usual state of health until one week prior when he developed these symptoms along with chest pain. He also had a weight loss of 4 kg during this time. He reported visiting multiple local physicians since the onset of his symptoms and a CT scan performed upon the request of his primary care physician incidentally was suggestive of two PAAs (7.7 x 4.0 cm and 7.4 x 8.0 cm) surrounding thrombosed sections of the left pulmonary artery (PA). A review of systems revealed that he had a decreased appetite but normal sleep and bowel habits. His past medical history was significant for diabetes mellitus (DM) and hypertension (HTN). He was not taking any medications at the time of admission.On examination, he was tachycardic, but his other vitals were normal. A general physical examination revealed no significant findings. Cardiovascular, abdominal, and neurological examinations were normal while the respiratory exam revealed decreased air entry on the left side. Laboratory findings at the time of admission were suggestive of iron-deficiency anemia and revealed a significantly elevated erythrocyte sedimentation rate (ESR) of 63 mm/hr. Glycosylated hemoglobin HbA1c) was elevated at 8.90% and fasting glucose was also deranged. Blood urea nitrogen (BUN) was mildly elevated at 30.7 mg/dl while creatinine was within normal ranges at 1.05 mg/dl . However, the values are unfortunately not present in our electronic health record system since they were likely done from an outside laboratory. Due to resource limitations and financial constraints, a bronchoscopy was performed preoperatively on the table to save costs. An elective left pneumonectomy and subsequent tissue biopsy were performed under general anesthesia. Intraoperative findings revealed extensive inflammation and venous congestion of the left lung. A tissue sample consisting of two fragments (aggregate size of 1.5 x 1.0 cm) sent for a frozen section revealed a neoplastic lesion. Immunohistochemical stains showed WT1 cytoplasmic positivity. Large biopsy samples were taken and remnant tissue from the pericardial surface was also removed. There were no intraoperative complications. A gross examination of the biopsy samples revealed a tumor 7 x 7 x 6 cm in size. Histopathology of the left lung section revealed a neoplastic lesion arranged in sheets. An immunohistochemical stain was also performed Table . PleuralPostoperatively, he was started on intravenous (IV) antibiotics and IV fluids. Pain management and chest physiotherapy were done as well. Oncology was taken on board and he was started on adriamycin and ifosfamide. His pre-discharge labs were normal, and he was discharged on postoperative day five. In the postoperative period, he had one readmission for pleural effusion and empyema at the six-month mark, for which he electively underwent video-assisted thoracic surgery (VATS) and decortication. He remained stable postoperatively and was discharged on postoperative day three. He was then started on adriamycin/ifosfamide cycle therapy as an oncology out-patient.In the one-year follow-up after his VATS, he had one readmission for sepsis, developed brain metastases in April 2018, and was started on radiotherapy. On his last follow-up in January 2019, around 1.5 years after his initial presentation, he was doing fine with no complications; however, on a phone follow-up on a later date, it was found that the patient had expired. The date of the phone follow-up was not recorded, so it can be assumed that he expired sometime after January 2019.PAAs are clinical abnormalities characterized by focal dilation of the blood vessel wall due to weakening ,2. InvolClinical manifestations range from asymptomatic  to shortPAAs or PAPAs are etiologically classified as congenital or acquired. Congenital causes are due to congenital heart defects or connective tissue abnormalities. The former’s suggested pathophysiology relates to increased hemodynamic sheer stress that is often associated with left-to-right shunts ,6.Acquired PAAs or PAPAs are sub-classified into infectious, vasculitis, pulmonary artery hypertension, chronic pulmonary embolism, chronic inflammatory lung disease, neoplasms, trauma, and iatrogenic causes . InvolveAcquired PAAs and PAPAs can be attributed to multiple causes; however, association with malignancy is rare with a majority of the reported cases presenting with PAPAs. This is either due to primary lung cancers or metastatic cancers to the pulmonary artery causing wall erosion. The association reported above is unique, as it narrates the case of a 53-year-old gentleman who presented with a true PAA as opposed to PAPA secondary to metastatic sarcoma of the lung, an association, which, to the best of our knowledge, has not been reported yet.


Falciform ligament hernias are a rare type of internal hernia that occurs through an abnormal opening in the falciform ligament of the liver. This is the case of a 38-year-old female who presented with a symptomatic enlarging ventral bulge near her umbilicus and was treated with a robotic-assisted laparoscopic falciform hernia repair with mesh. The nonspecific clinical manifestation of a falciform ligament hernia and the low sensitivity of computerized tomography (CT) for these hernias make them hard to diagnose preoperatively. Falciform ligament hernias are mostly attributed to congenital defects, but recently an iatrogenic etiology has also been proposed, given the prior history of laparoscopic surgeries in more recent cases. In our case report, we demonstrate that a robotic-assisted laparoscopic approach is a safe and effective means of correcting this hernia, with an outline of the current literature. An internal hernia is a protrusion of abdominal viscera through a peritoneal or mesenteric aperture, remaining within the boundaries of the abdominal cavity . A falciThis is the case of a 38-year-old female with a past medical history of laparoscopic umbilical herniorrhaphy as a child and uterine fibroids status post-myomectomy. She presented with a symptomatic, enlarging ventral bulge near her umbilicus, not related to her previous surgical incision. She stated that the bulge was tender to palpation and enlarged with activity. Her preoperative workup included magnetic resonance imaging (MRI) to better diagnose soft tissue. This revealed an incarcerated ventral hernia containing only fat Figure . It was The patient was brought to the operating room and prepped, and draped in the normal sterile manner. The abdomen was insufflated with a Veress needle, ports were placed, and the robot was docked. Initially, the hernia was not visible; therefore, the falciform ligament was taken down with electrocautery Video . This alThe fascia was closed using a 0-Polydioxanone (PDS) stitch in a figure 8 pattern Video . During Falciform ligament hernias are exceedingly rare hernias that were first identified in the 1930s and have since increased in incidence, with most of the known cases having been diagnosed in the last two decades . As was The nonspecific clinical manifestation of falciform ligament hernia suggests an important role in radiological findings in the management of these patients. Anecdotally, the diagnosis of falciform ligament hernia by radiological evaluation of CT imaging has been demonstrated with findings such as clusters of small intestine below the diaphragm surrounding the hepatic falciform ligament, as well as dilated ileal loops between the abdominal wall and liver with the point of stricture at the supposed falciform ligament site ,5. HowevWhile falciform ligament hernias are mostly attributed to congenital defects, an iatrogenic etiology has also been proposed, given the prior history of laparoscopic surgeries in more recent cases . SpecifiIn response to the increasing incidence of falciform ligament hernias in association with the rise in laparoscopic surgical approaches, several risk reduction strategies have been proposed. Internal herniation may be prevented by placing the subxiphoid trocar just to the right of the midline during laparoscopic cholecystectomy . RemovalFalciform ligament hernia is a rare but increasingly prevalent subtype of internal hernia associated with the modern ubiquity of laparoscopic surgery that must be considered in the differential diagnosis of acute onset of abdominal pain and symptoms suggestive of obstruction. In this case report, we show that robotic-assisted laparoscopy is a safe and effective treatment for falciform ligament hernia.


Splenic abscess leading to rupture and pneumoperitoneum is a very rare condition that is limited to a few case reports. In this study, we first introduced a case of an adolescent girl with a medical history of diabetes mellitus who presented with left upper quadrant abdominal pain and fever. Ultrasound revealed an abscess in the spleen and a computed tomography (CT) scan of the abdomen revealed evidence of pneumoperitoneum secondary to the rupture of this abscess. The patient underwent splenectomy without postoperative complications.Secondly, we reviewed and discussed the current literature on this topic which predominantly denotes that the pneumoperitoneum following splenic abscess rupture mostly occurs in the immunocompromised status, without a specific predominant infectious agent but the culprit is a gas-forming organism, acute abdomen ensues if the diagnosis is delayed, diagnosis is via abdominal CT when there is hemodynamic stability otherwise exploratory laparotomy uncovers the diagnosis, and splenectomy with broad-spectrum antibiotic therapy is the mainstay of treatment. Splenic abscess is an infrequent but potentially life-threatening disease Herein, we report a case of pneumoperitoneum that occurred following perforation of a splenic abscess in an adolescent girl with a medical history of diabetes mellitus and then discuss and review reported cases in this subject area. To the best of our knowledge, this is the first case in the literature that describes this extremely rare complication in the pediatric population.A 14-year-old female patient was admitted to the emergency department suffering from abdominal pain and fever. Her symptoms began approximately 2 weeks before presentation when she developed progressive abdominal pain in the left upper quadrant (LUQ) region. She also reported having intermittent low-grade fever during her disease course. According to these symptoms, she received supportive treatment with a presumptive diagnosis of transient viral infection. However, her symptoms did not abate and her pain intensity increased and was associated with constant fever resulting in her hospitalization. Her medical history was notable for type I diabetes mellitus since 5 years ago and vesicourethral reflux but with no recent urinary tract infection. There was also no history of abdominal trauma, sickle cell anemia, malignancy, or use of immunosuppressive medications. On physical examination, a temperature of 38.4°C was noted, and vital signs were otherwise normal. Diminished lung sound was detected at the base of the left lung and LUQ tenderness, and splenomegaly were noticed on abdominal examination.Laboratory data demonstrated leukocytosis  and elevated inflammatory markers . Abdominal ultrasound showed splenomegaly with a splenic diameter of 130 mm craniocaudally and a subcapsular well-defined heterogeneous hypoechoic region in 40 × 29 mm size containing echogenic foci with comet tail artifact in favor of air bubbles at the lower pole of the spleen without vascularity in color-doppler ultrasound. Mild ascites in the pelvic cavity were also found. These findings were mostly compatible with splenic abscess. Transthoracic echocardiography was performed which showed no evidence in favor of endocarditis as a potential origin of splenic abscess. Empirical antibiotic treatment with ceftriaxone and metronidazole was started. The day after admission, an abdominal CT scan with and without intravenous contrast was performed to confirm the diagnosis of splenic abscess  and 2. IGiven the aforementioned imaging findings, and no changes in the patient's clinical condition a midline laparotomy was planned and performed, revealing the presence of pus and blood in the peritoneal cavity. After draining these bloody, purulent fluids, and due to damage to most parts of the splenic tissue, the splenectomy was performed without complications. Blood and abscess cultures were sent out, which resulted in negative. Pathological assessment of the extracted spleen reported splenic tissue with multiple subcapsular purulent inflammatory areas and there was no evidence of malignancy. Eventually, immunization against encapsulated bacterial pathogens was prescribed and the patient was discharged 5 days after admission with a suitable clinical condition.We presented a case that was afflicted by a splenic abscess whose rupture led to pneumoperitoneum. Based on a comprehensive review of the literature, we found only 10 case reports illustrating pneumoperitoneum following the rupture of a splenic abscess In the majority of these available cases (70%), an immunocompromised condition was notable. Diabetes mellitus in 4 ,8 and huKlebsiella pneumoniae and anaerobe Prevotella intermedia in pus culture from the splenic abscess Enterobacter cloacaeEscherichia coli (E coli), Morganella morganii, and Proteus mirabilis from the perisplenic fluid and positive blood culture for b-hemolytic Streptococcus E coli and negative blood culture E coliE coli and Prevotella intermedia to be the cause of splenic abscess which could become complicated by pneumoperitoneum.Pneumoperitoneum results from the gas released through fermentation by gas-producing organisms within the splenic abscess Apart from typical symptoms of splenic abscess which are classically the triad of fever, left upper quadrant tenderness, and leukocytosis and were noticed in almost all patients in the early course of their disease, pneumoperitoneum following ruptured splenic abscess presents with acute abdomen in 80% of reported cases with signs of diffuse abdominal tenderness, rebound tenderness or involuntary muscle guarding of the abdomen ,11,12. OThere is another hypothesis we made for the patient's presentation that we did not find any relevant data in existing case reports and it is the role of the location of splenic abscess in its propensity for rupture. In our case, the location of the abscesses was subcapsular and we suppose that the superficial situation of the splenic abscess makes it more prone to rupture into the peritoneum causing pneumoperitoneum.The diagnostic approach was quite diverse among case reports. Chest X-rays for pneumoperitoneum and exploratory laparotomy to investigate the cause which showed splenic abscess rupture were utilized in 4 patients ,5,10,11,Except in 1 patient, in all the other case reports, splenectomy was disclosed as the mainstay of treatment (90%) . It was Rupture of a splenic abscess is a very rare but potentially life-threatening condition that should be suspected as a cause of pneumoperitoneum, especially in immunocompromised patients. Its diagnosis is confirmed with abdominal CT if the patient is hemodynamically stable, otherwise diagnosed with exploratory laparotomy, and is best treated with broad-spectrum antibiotic therapy and splenectomy.EZ was the patient's physician and conceptualized the study. MGM wrote the initial draft and AP and MV revised the manuscript.All methods were performed in accordance with the relevant guidelines and regulations comprising the Declaration of Helsinki.No identifiable information was disclosed in writing this case report; however, written consent was obtained from the patient for publishing his medical data for scientific purposes.


Ganglioneuroma is a rare, benign, well-differentiated neurogenic tumor most commonly located in the posterior mediastinum or retroperitoneum. Giant ganglioneuromas are even less common; this is only the 19th reported case in literature to date. We present a case of a giant retroperitoneal ganglioneuroma in a five-year-old child, which on imaging mimicked a mesenteric cyst and posed various challenges in its management. Histopathology later confirmed our misdiagnosis and revealed the tumor to be a ganglioneuroma. This unique case serves as a lesson for clinicians to not operate before receiving histopathological confirmation of their diagnosis. Ganglioneuroma is a rare neurogenic tumor with a prevalence of one per million population. Usually, ganglioneuromas are very slow-growing, and they hardly ever cause symptoms. Symptomatic cases are those where the mass effect of the growth is seen ,2. We prA five-year-old girl was brought by her parents with complaints of abdominal distension and generalized abdominal pain for five months. On examination, the patient was vitally stable, fairly built, and well-nourished, with no family history of any abdominal masses or neoplasms. Abdominal examination revealed a single, 12×10 cm sized oval lump, freely movable in both horizontal and vertical axes, firm in consistency and dull on percussion in the epigastric, umbilical, hypogastric, left lumbar, and left iliac fossa quadrant  than the one seen in our patient. The largest was reported by Kirchweger et al. and measured a massive 35×25×25 cm . MoreoveFor ganglioneuromas, CECT and MRI are the main preoperative noninvasive diagnostic modalities, while the gold standard investigation remains histopathology. A lesson learned from this case is that preoperative ultrasonography or CT-guided biopsy is a necessity for definitive diagnosis and to delineate the line of management. Over-reliance on radiological findings for deciding the definitive line of management should be avoided. Cases like the present one should preferably be managed at a health center well-equipped with a catheterization lab and cavitron ultrasonic surgical aspirator (CUSA), by a team composed of surgical oncologists, vascular surgeons, and interventional radiologists. Subtotal or near-total excision of the tumor should be the goal of the surgery.