Neurilemmoma is a benign tumor derived from the Schwann cells of the nerve sheath. The highest incidence of neurilemmoma occurs in the head and neck region; however, the nose and paranasal sinuses are rarely involved. Less than 4% of these tumors involve the nasal cavity and paranasal sinuses. To date, only six cases of nasal vestibule neurilemmoma have been reported.Two patients (a 32-year-old man and a 42-year-old woman) visited our clinic with complaint of a lump in the left nasal vestibule.Histopathological examination and immunohistochemical staining confirmed a neurilemmoma.The mass was completely removed via an intranasal approach.Neurilemmoma is easy to overlook because it occurs rarely in the nasal vestibule, but neurilemmoma needs to be considered as a differential diagnosis. Neurilemmoma occurs predominantly in the head and neck region, and the incidence of tumors involving the nasal cavity or sinuses is rare, with only 4% of all cases.22.1A 32-year-old male patient with a painless tumor, growing for several years, in the left nasal vestibule was admitted. Nasoendoscopy showed a protruding left nasal vestibule Fig. A. TenderA significantly deviated septum on the left side was observed, and therefore, the excision of the tumor of the nasal vestibule and septoplasty were performed simultaneously under general anesthesia. An incision of 1.5 cm from inside the left ala to the nasal vestibule was generated. Next, the nearby soft tissues were peeled off, and the oval-shaped tumor measuring 1.5 cm × 1 cm, covered with a smooth film, was detected and removed Fig. . Postope2.2A 42-year-old patient with a tumor, growing since the past year, in the left nasal vestibule was admitted. No pain or tenderness in the area was noted; however, she complained of left nasal congestion. A tumor protruding into the nasal cavity of the left nasal vestibule was observed using nasoendoscopy Fig. A. It was3 Tumors in the nasal cavity are generally associated with the most common symptom of nasal congestion around the lesion; other symptoms, such as pain, headache, or anosmia, may manifest with tumor growth. Based on the analysis of the clinical presentation of neurilemmoma in the nasal vestibule according to the Korean literature, most patients reported mild nasal congestion or presented no symptoms, except a few cases with pain or nasal bleeding (Table ,8,9 The severity of symptoms varies depending on the location of the tumor; for example, a tumor in the nasal vestibule can be easily identified by the patients in their early phase, and the disease may be diagnosed before symptom appearance due to the growing tumor.Neurilemmoma grows gradually with no accompanying subjective symptoms at the early phase; however, with tumor growth, pain appears due to pressure in the originating nerves.ng Table . However In this study, CT of neurilemmoma in the nasal vestibule showed a clear demarcation from the nearby areas, and the shadows of the inside were mostly heterogeneous similar to other reports from Korean literature. Destruction of nearby bones was observed in only one case. Bone destruction may occur in the case of large tumor size; however, both cases in this report presented a small tumor size <2 cm, which may explain the absence of bone destruction.Neurilemmoma generally appears as contrast-enhanced homogenous soft tissue shadow on the CT image; however, in necrotic cases or cystic degeneration, heterogeneous shadow or calcification may be observed. Further, large-size tumors can cause bone destruction or deformation due to pressure. During the excision, the affected nerves should be handled with care. Moreover, incomplete excisions are associated with a risk of recurrence. The recurrence rate is rare when tumors are completely excised. Therefore, a wide range of excision to the nearby tissues is unnecessary. Cases in this report did not have adhesion to the nearby tissues during the excision of tumors, and hence, the tumors were easily removed. Analysis of these two cases and other reported national and international cases suggests that pedunculated tumors might simply be excised. Additionally, the excision of a tumor on the mucous membrane requires minimally invasive surgery through the gum or a nasal incision. In contrast, surgical cases through the left nasal incision for neurilemmoma in the nasal septum or sinus have been reported,9,10; tumors in the nasal vestibule diagnosed early entails a surgical benefit since the disease is exposed and can be easily detected.Surgical removal is the best treatment option for neurilemmoma. Cases in this report included tumors in the lower part of the nasal vestibule; thus, the tumors might have originated from the lower ophthalmic branch of the maxillary branch in the trigeminal nerves or unbranched area. The nerve branch, thought to be the origin, was not identified during surgery, and there were no postoperative functional disabilities or sensory disabilities.Neurilemmoma in the nasal cavity is thought to originate from the ophthalmic branch, maxillary branch, or autonomic ganglion of the trigeminal nerve.For the excision of neurilemmoma in the nasal vestibule, most cases have reported surgery using local anesthesia, and only one case has reported general anesthesia for the surgery along with obstructive sleep apnea. In case 1 of this report, general anesthesia was performed for the simultaneous fixation of the nasal septum. In case 2, general anesthesia was performed based on the patient's preference due to a history of panic disorder. However, based on the size and the location of the tumor, local anesthesia would have been sufficient.,12 Therefore, surgical removal should be performed for treatment and accurate diagnosis, and a follow-up period is needed to confirm the recurrence of residual tumor in case of incomplete excision.Neurilemmoma is typically not malignant, but reports of transition into a malignant form after a long-term follow-up without surgical removal are available.Conceptualization: Sung Jae Heo.Data curation: Sung Jae Heo, A Young Kim, Jung Soo Kim.Formal analysis: Sung Jae Heo, A Young Kim, Jung Soo Kim.Investigation: Sung Jae Heo, A Young Kim, Jung Soo Kim.Methodology: Sung Jae Heo, A Young Kim, Jung Soo Kim.Project administration: Sung Jae Heo.Supervision: Sung Jae Heo, Jung Soo Kim.Writing – original draft: Sung Jae Heo, A Young Kim.Writing – review & editing: Sung Jae Heo, Jung Soo Kim.


Desmosis coli is a rare pathology presenting as slow transit constipation. In this case we would like to discuss the presentation and management of desmosis coli. A 14-month-old female hailing from western India with a history of chronic constipation presented with acute massive abdominal distension and vomiting. At laparotomy, a hugely dilated transverse and sigmoid colon with a transition zone at the lower sigmoid was found. A transverse stoma was done after taking multiple seromuscular biopsies. The patient underwent re-exploration on day 14 because of the non-functioning of the stoma and a fixed bowel loop. The histopathology report was suggestive of normal ganglion cells. Unfortunately, the stoma continued not to function. A dye study showed dye in the colon after 24 hours ruling out any anatomical obstruction. Histopathology slides were reviewed multiple times and reported lack of connective tissue of the colonic wall leading to the diagnosis of desmosis coli. The patient was started on gradual feeds and pro-kinetics and over the next 2 weeks the stoma started functioning slowly. Desmosis coli is a rare cause of constipation which should be suspected in cases where aganglionosis has been ruled out and the constipation is refractory to conventional therapy. Constipation is a common problem in children. Desmosis coli is a rare entity with only a handful of reported cases. It commonly presents as intractable slow transit constipation. We report a case of a one-year–old girl with chronic constipation that was subsequently diagnosed as desmosis coli, its clinical course and management with a review of the literature.A 14-month-old female, hailing from western India, with a history of chronic constipation, presented with acute massive abdominal distension and vomiting. At laparotomy, a hugely dilated transverse and sigmoid colon with a transition zone at the lower sigmoid was found (fig. 1). Transverse stoma was done after taking multiple seromuscular biopsies. The patient underwent re-exploration on day 14 because of the non-functioning of the stoma and a fixed bowel loop. The histopathology report was suggestive of normal ganglion cells. Unfortunately the stoma continued not to function. A dye study showed dye in the colon after 24 hours ruling out any anatomical obstruction. Histopathology slides were reviewed multiple times and reported as lack of connective tissue of the colonic wall leading to the diagnosis of desmosis coli (fig. 2). The patient was started on gradual feeds and pro-kinetics and over the next 2 weeks the stoma slowly started functioning.Constipation is a problem commonly encountered by paediatric surgeons all over the world. Although the exact incidence of constipation in Indian children is not known, according to a systematic review, world-wide incidence is 0.7% to 29% . The caudesmosis coli was introduced by Meier-Ruge, for a special pattern of structural abnormalities of the intestinal wall [The term nal wall . Partialnal wall . Two subnal wall . The connal wall . Meier-Rnal wall . Primarynal wall .A Pubmed and Dynamed database search was done using the term “Desmosis Coli”: there are only about five reported cases of desmosis coli. In a series of four cases published by Hubner & Meier-Ruge, the commonest presenting feature was late-onset constipation with encopresis. The patients underwent multiple therapies in the form of laxatives, enemas, colostomies, which were futile. Ultimately all patients were diagnosed by seromuscular biopsies to be cases of desmosis coli that were subsequently treated by partial or total colectomy . SimilarHistopathologically desmosis coli is characterized by loss of tendinous structures in circular and longitudinal muscles and a loss of the myenteric tendinous plexus fascia which abolish directed peristalsis . SimilarTo conclude, desmosis coli is a rare cause of constipation, which should be suspected in cases where aganglionosis has been ruled out, and the constipation is refractory to conventional therapy. Pathologists should be aware of this condition, which will help in the diagnosis. The treatment of desmosis coli is controversial and should preferably be tailored to suit the patient. Patients should be counseled regarding the nature of treatment, prognosis and the possibility of a permanent stoma.


The solitary fibrous tumor (SFT) is a tumor of uncertain histogenesis, affecting deep soft tissues, particularly the pleura (pulmonary) and extrapulmonary sites including thighs, retroperitoneum, other serosal surfaces, and cranial and spinal meninges. SFT and hemangiopericytoma are now considered the same entity, with general agreement on referring to this group of tumors as “SFT.” SFTs are generally benign tumors with small subsets of malignant ones. Moreover, they are well-circumscribed with a good prognosis after surgical resection. SFTs are uncommon in the head and neck and are quite rare in the parotid gland region. Here, we present a case of a 48-year-old female with SFT of the parotid gland region; the diagnosis was confirmed by positive immunohistochemical staining for Bcl-2, CD34, and STAT6. STAT6 immunohistochemistry is sensitive and specific for SFTs. A solitary fibrous tumor (SFT) is a rare soft tissue spindle cell neoplasm primarily affecting the pleura. In 1931, Klemperer and Rabin first described the tumor as a primary neoplasm involving the pleura and classified plural tumors into diffused and localized types . In receA 48-year-old female presented with a painless swelling in the right parotid gland region for 12 years. The mass was slowly increasing in size, especially over the past several months. Moreover, there was no history of constitutional symptoms. Her past medical/surgical history was unremarkable. Physical examination showed a right-sided parotid region, nontender, firm, immobile, smoothly countered mass without overlying erythema. There was no facial nerve paralysis or paresthesia. Cervical lymph nodes were not palpable.Magnetic resonance imaging (MRI) for the head and neck showed a large mildly lobulated lesion centered within the superficial lobe of the right parotid gland with extension anterior to the right mandibular ramus into the masticator space . The masFine-needle aspiration (FNA) was performed, which yielded mainly blood aspirate and no diagnostic material. The patient underwent a right total parotidectomy without complications.Macroscopically, the parotid gland measures 7.0 × 5.0 × 3.0 cm. Serial sections revealed a multilobulated nodular, pale to tan, rubbery mass measuring 6.5 × 5.0 × 2.3 cm, identified on the inked margin. Microscopically, the tumor was relatively well-defined and showed a thin fibrous capsule . There wImmunohistochemical studies were conducted using cytokeratin AE1/AE, EMA, S100, CD34, CD31, CD21, CD23, SMA, Bcl2, CD99, and STAT6. The tumor cells were strongly positive for Bcl2 and CD34  and showThe patient has been followed up for twelve months, with no signs of recurrence or complications.SFT is a rare neoplasm that involves the intrathoracic and extrathoracic sites. SFTs are derived from pluripotent fibroblastic cells . These tFurthermore, diffuse nuclear expression of STAT6 has been found to be a highly sensitive and specific immunohistochemical marker for SFT . RecentlIn conclusion, SFT of the parotid gland is a rare neoplasm that occurs most often in middle-aged patients, without a gender predilection, who have symptoms of a mass lesion for a long duration. SFT is diagnosed based on classical histologic and positivity for CD34, Bcl-2, and STAT6 (nuclear pattern), which aid in its distinction from other tumors in the differential diagnosis. A short follow-up period suggests a good prognosis, whether the tumors are histologically benign or malignant when managed by complete surgical excision.


Lympangioma cavernosum in the abdominal cavity is a rare benign tumour. In most cases, such tumours are diagnosed in the oral cavity and neck. The aim of this paper is to present our clinical observations and review of existing literature to draw attention to this disease. A 25-year-old woman was admitted to our department for a symptomatic tumour in the lesser curvature of the stomach. The patient was first operated on as a three-year-old child because the tumour extended from the back wall of the stomach to the gastro-colonic ligament. The medical records showed that it was a benign tumour; however, no diagnosis was specified. No symptoms were observed for 22 years. Currently, the patient is admitted for epigastric pain. Abdominal computed tomography revealed an extensive mass located between the left segments of the liver and the lesser curvature of the stomach. The patient was operated on, and the tumour was completely removed. The patient’s postoperative course was uneventful. Histopathological examination of the lymphangioma cavernosum was performed. Two months after the operation, the patient did not report any complaints. The first descriptions of lymphangiomas were presented in the literature by Redenbacker in 1828 . CavernoCapillary hemangiomas (Lymphangioma simplex).Cystic lymphangioma (Cystic hygroma).Cavernous lymphangioma.In terms of the histopathological structure, lymphangiomas can occur as:Hemolymphangiomas, which are another type of lymphangioma, are composed of both lymphatic and blood vessels .The first type of lymphangioma (Lymphangioma simplex), also known as capillary lymphangioma, usually occurs in the oral cavity, specifically the mandible; but it can also occur on the trunk and limbs. Moreover, it affects the skin and subcutaneous tissue and is diagnosed mainly in neonates and older children ,12.The second type of lymphangioma (cystic hygroma or cystic lymphangioma) most often develops in the neck .Cavernous lymphangiomas are rare lesions found in the mediastinum and sometimes in the abdominal cavity . Within So far, only a few cases of lymphangioma in the lesser curvature of the stomach have been described in existing literature. The rarity of lymphangioma in the abdominal cavity, especially close to the stomach, prompted us to present our case and review of the literature to draw attention to this disease during the differential diagnosis for patients.In some cases, endoscopic examination is helpful, while endoscopic ultrasound (EUS) examination is the decisive factor sometimes .In the clinical course, it is necessary to distinguish cavernous lymphangioma of the gastrointestinal tract from other cystic tumours, mainly vascular, and from lymphatic vessel dilatations (lymphangiectasia). The latter can develop from inflammatory processes, but also due to blockage by a neoplastic tissue, requiring clinical explanation. These changes are usually asymptomatic and diagnosed incidentally .A 25-year-old female patient was referred to the Department of General, Transplantation, and Liver Surgery at the Medical University of Warsaw due to a symptomatic tumour in the lesser curvature of the stomach. The patient complained of epigastric pain and pressure, especially after meals.At three years old, the patient was hospitalised in the Paediatrics Surgical Department due to peritoneal symptoms and radiological signs of impaired gastrointestinal patency. The patient underwent emergency surgery where an enormous, soft lesion extending from the back wall of the stomach to the gastro-colonic ligament was found intraoperatively. According to the operative description, the tumour was completely removed. In the postoperative period, a lymphatic outflow through the drain from the peritoneal cavity was observed up to the 20th day of hospitalisation. Moreover, on the fifth postoperative day, there was bleeding in the operated area, which manifested as the outflow of blood through the drain. This complication was treated conservatively. The child was discharged in good general condition on the 25th day of hospitalisation. The medical records from that period stated that it was a benign tumour, without specifying the diagnosis. The patient’s current symptoms occurred three months prior to admission to our department. Due to abdominal pain, gastroscopy was performed, revealing a spherical bulge, approximately three cm in diameter, with no mucosal changes. There was a slight thickening of the mucosal folds. The lesion was soft and susceptible to pressure using an endoscope. The lesion was located along the lower region of the lesser curvature. The gastric specimens collected for histopathological examination revealed chronic mucosal inflammation only with no signs of metaplasia.Three-phase computed tomography (CT) scan revealed an extensive mass measuring 10 × 4 cm between the left segments of the liver and the lesser curvature of the stomach. The lesion was well-defined, fluid dense, and did not contain solid elements. Within it, there were vessels with an undistorted course. The mass occupied the space in front of the body and tail of the pancreas, descending further down the back of the stomach and duodenum. A,B.The patient was qualified for elective surgery. The presence of an approximately seven-cm long soft tissue extending along the lesser curvature of the stomach, closely connected to the stomach wall, was found intraoperatively . The tumThe patient’s postoperative course was uneventful. The patient, with a healed wound, was discharged on the 10th day of hospitalisation. Two months after the operation, during the control visit, the patient did not report any complaints. On gross examination, the resected specimen had a non-encapsulated, spongy, focally gelatinous mass measuring 7 × 5 × 2 cm. Microscopically, thin-walled, dilated vessels with different sizes, lined by a flattened endothelium without atypia A,B, and Most abdominal lymphangiomas  are cystic in nature and are in the mesentery and retroperitoneal space ,8,9. LymIn another patient, a tumour in the gastric wall was removed during gastrectomy .According to current literature, the mean age of patients with gastric lymphangiomas is 47 years old (5–79 years). Haemangiomas occurred at a similar frequency in both men and women. In most cases, tumours were found accidentally during surgery for other reasons, and the patients did not report symptoms directly related to the tumour.These tumours manifest clinically at the end of the second year of life and, similar to our patient, depend on the location . These iTherefore, making a correct diagnosis before surgery is difficult because of the non-specific symptoms with varying severity. To properly plan surgical treatment, it is necessary to perform sonography, CT, or magnetic resonance imaging (MRI) of the abdominal cavity to obtain information about the nature of the haemangioma, its location, size, and involvement of adjacent organs. Within the abdominal cavity, lymphangiomas are most often located within the mesentery or retroperitoneal space, although localisation within organs or the abdominal wall is also possible. In sonography, these are anechoic structures, possibly containing small areas of debris. CT and MRI examinations with contrast agents usually present as cystic, fluid-filled structures, often with a thickened wall and septum. Sometimes, these lesions may show signs of previous bleeding or infection. Moreover, being located within the small intestinal wall may predispose to intussusception .Preoperative imaging tests allow for suspicion of lymphangioma; however, the final diagnosis including the subtype of the lymphangioma is made based on histopathological examination of the postoperative material.The most common treatment for patients with gastric lymphangioma is operative.In 2020, a study was published presenting an extensive meta-analysis of the treatment of patients with angiomas, including those in the lymphatic system. It emphasises that a large group of patients with abdominal lymphangiomas do not have symptoms and are detected incidentally. They recommended that this group of patients be subjected to clinical observation, and the decision to treat should be made based on the location of the lesion, its size, whether it tends to increase, and above all, symptoms such as abdominal pain, vomiting, and gastrointestinal obstruction. The authors do not recommend sclerotherapy of lesions located in the abdominal cavity , both due to the recurrence of lesions and the possibility of complications. In symptomatic patients, especially when the lesion in the abdominal cavity becomes enlarged, surgery is recommended, bearing in mind the risk of complications .In the present case, the decision was made to perform an operative treatment on the patient.The question of whether the lymphangioma is a true neoplastic tumour, a hamartoma, or lymphangiectasia remains a controversial issue . Most reThe cause of the haemangioma is incorrect and lacks connections with the venous system or their abnormal budding from the embryonic veins. Lymphangioma can also develop from fragment sequestration of lymphoid tissue and its lack of connection with the lymphatic system .Most lymphangiomas occur in childhood and are located where the primary lymphatic sac develops (primitive limfatic sac), which are the head, neck, and inguinal region. They often increase in proportion to the patient’s age.Lymphangiomas develop much less frequently in adults, probably due to a minor defect or damage to the lymphatic system, compensated under normal conditions. Factors leading to increased lymphatic volume may lead to haemangiomas .It is possible that some haemangiomas are acquired lesions caused by an obstruction in the lymphatic system, for example, during surgery, trauma, radiotherapy, infection, or chronic inflammation.The benign nature of lymphangiomas is generally accepted. However, the development of haemangioma may also result from neoplastic proliferation of the endothelium or lymphatic stromal cells secondary to the dysregulation of certain growth factors. Experimental studies in mice with anti-amphiregulin demonstrated the potential therapeutic effect of this drug in patients with lymphangiomas .In most cases, the diagnosis of lymphangioma is difficult for pathologists. The presence of haemorrhages, relatively numerous smooth muscle cells within the wall of the lymphatic vessels, and venous malformation may suggest haemangioma cavernosum. In the latter case, the diagnosis of lymphangioma is supported by the presence of lymphocyte clusters in the stroma and greater regularity of vascular spaces lined with loosely located endothelium.The differential diagnosis of abdominal lesions may include multicystic mesothelioma, microcystic adenoma of the pancreas, other vascular tumours that may contain dilated vascular spaces , and myxoid sarcoma. Sometimes, the picture may suggest an angiomyolipoma or myelolipoma. Immunohistochemical staining is the basis for differential diagnosis in doubtful cases. Typical lymphangioma endothelial cells are positive for D2-40 (podoplanin), PROX1, and CD31. The CD34 reaction is variable, and smooth muscle cells surrounding the cystic spaces show reactivity with SMA.Abdominal lymphangioma is a rare benign tumour that is usually asymptomatic and detected incidentally. Sonography (sometimes EUS), CT, or MRI with contrast are helpful in the preoperative diagnosis, although they can also provide an unambiguous diagnosis. Therefore, surgery is recommended. The final diagnosis was made via histopathological examination of the postoperative material using immunohistochemical staining.


Bladder paraganglioma is characterized by headache, palpitations, hypertension, blurred vision, or sweating during voiding. Transurethral holmium laser resection is a safe and efficacious alternative method for the resection of bladder neoplasms.A 24-year-old female had a 2-year history of intermittent headaches, palpitation, and sweating during micturition.Physical examination revealed a rise in the patient's blood pressure to 180/90 mmHg after micturition. Laboratory examination found that the blood catecholamine metabolites were significantly increased. Abdominal ultrasound and computed tomography (CT) scan indicated a 37 mm × 31 mm paraganglioma situated at the right anterolateral wall of the bladder. A diagnosis of bladder paraganglioma was considered based on a comprehensive evaluation of the physical examination, laboratory examination, ultrasound and computerized tomography scan.Preoperative oral administration of a nonselective α-adrenergic receptor antagonist  accompanied by a high-sodium diet and generous fluid intake, was initiated 2 weeks before the surgery to stabilize intraoperative hemodynamics. As the patient was newly married and nulligravid, management with transurethral resection was considered superior to open or partial cystectomy and was selected as the treatment method.Transurethral holmium resection of the bladder paraganglioma was successfully performed with blood loss less than 20 ml and well-controlled intraoperative blood pressure. The 1-year follow-up results demonstrated well-controlled symptoms. Cystoscopy and evaluation of blood catecholamine metabolites revealed no disease recurrence.Transurethral holmium laser resection is a good alternative approach for the resection of bladder paraganglioma, given its advantages of safety and efficacy. Although many studies have confirmed the effectiveness of transurethral resection, there is a lack of evidence regarding the rationale for choice of the appropriate surgical method for patients. Transurethral holmium laser resection had less intraoperative and postoperative complications, including obturator nerve reflex, transient hematuria and postoperative bladder irritation. In this report, we demonstrate the clinical features, pathological characteristics, and prognosis of a functional bladder paraganglioma, treated by transurethral holmium laser resection.Pheochromocytomas and paragangliomas are rare neuroendocrine tumors, characterized by the potential to secrete catecholamines from chromaffin tissues of the adrenal medulla and extra-adrenal sympathetic paraganglia, respectively.2A 24-year-old female was admitted to our hospital, complaining of a 2-year history of intermittent headaches, palpitation, and sweating during micturition without any past medical history or comorbidities. Two months before admission, physical examination revealed elevated blood pressure of 180/100 mmHg after micturition. Abdominal ultrasound and CT scan were performed, which demonstrated a 37 mm × 31 mm tumor located at the right anterolateral wall of the bladder, with intense early arterial phase enhancement , dome (21.6%), anterior wall (19.1%), side wall (13.6%), triangle area (11.1%), and neck (3.7%). %).,10Bladder paraganglioma is a rare subtype of bladder tumor, which was first reported by Zimmerman et al in 1953.,12 Functional bladder paraganglioma can manifest as clinical and resting types. Hypertension, dizziness, palpitations, and even syncope during urination are specific manifestations of the clinical type, owing to catecholamine secretion. The patient in this case demonstrated the clinical type of bladder paraganglioma. While the clinical symptoms of the resting type are concealed, it leads to the secretion of a large amount of catecholamines into the blood, which eventually cause symptoms. Patients exhibiting the resting type usually have microscopic or gross hematuria as the main clinical manifestations, and there are no symptoms such as hypertension caused by catecholamine secretion, which is detected only by imaging examinations.According to secretion of catecholamines by the tumor, bladder paragangliomas can be divided into functional and non-functional types. Ultrasound examination revealed the tumor as a hypoechoic or isoechoic mass, and color Doppler ultrasound showed an abundant blood supply to the tumor. Bladder paraganglioma appears as a circular mass growing into the bladder on a plain CT image. The enhanced CT scan shows that the bladder paraganglioma is significantly enhanced in the arterial phase and weakened in the excretion phase. This is a typical feature, which is important for preoperative positioning and qualitative diagnosis. Cystoscopy can be used for complete visual inspection of the tumor. For patients with suspected bladder paraganglioma, high pressure on the bladder or squeezing the tumor during the cystoscopy should be avoided to prevent catecholamine secretion, which may lead to a hypertensive crisis. Bladder paraganglioma often appears as a single mass, which is significantly different from the cauliflower-like appearance commonly seen in transitional epithelial cancer. In early bladder paraganglioma, the surface of the tumor mucosa is usually normal on cystoscopy, and biopsy results are mostly negative. In advanced bladder paraganglioma, cystoscopy frequently reveals hyperemia, calcification, or necrosis of the bladder mucosa, which is difficult to distinguish from bladder cancer. According to previous studies, 61.6% of bladder paragangliomas confirmed by postoperative pathological diagnosis were misdiagnosed as bladder cancer or intramucosal bladder tumors, and only 28.9% of bladder paragangliomas were diagnosed preoperatively. In view of the high rate of misdiagnosis of bladder paraganglioma, its possibility should be considered before surgery in patients with atypical urothelial cancers, such as bladder submucosal tumors. For functional tumors, metaiodobenzylguanidine radionuclide imaging and positron emission tomography show better sensitivity and specificity, especially in the detection of multiple, metastatic, or recurrent lesions.The preoperative qualitative diagnosis of bladder paraganglioma primarily relies on blood and urine catecholamine levels, 24 h urine vanillylmandelic acid, and other tests. Localization diagnosis relies on ultrasound, enhanced CT scan, and cystoscopy. Ultrasound is the most commonly used modality to diagnose bladder paraganglioma.The final diagnosis of bladder paraganglioma depends on histology and immunohistochemistry examination. Immunohistochemistry is positive for Cg A, Syn, S-100, CD56, and negative for CK and CEA in bladder paragangliomas.The grading of adrenal pheochromocytoma and paraganglioma (GAPP) is a risk stratification tool used to predict metastasis and patient prognosis. The full score is 10 points, 0–2 scores are divided into well-differentiated type, 3–6 into moderately differentiated type, and 7–10 into poorly differentiated type. Approximately 68% of paragangliomas are well-differentiated, with metastatic and 5-year survival rates of 3.6% and 100%, respectively; approximately 22% are moderately differentiated, with a metastatic and 5-year survival rates of 60% and 66.8%, respectively; and approximately 10% are poorly differentiated, with metastatic and 5-year survival rates of 88.2% and 22.4%, respectively. Transurethral resection has the advantages of less trauma and reproducibility; however, its application in the treatment of clinical bladder paraganglioma is still controversial. According to the study by Pahwa et al, high pressure on the bladder and tumor resection during the operation would lead to the release of a large amount of catecholamines, resulting in dramatic fluctuations in blood pressure. Moreover, these tumors are mostly located in the muscular layer, and the intraoperative resection might not be complete, increasing the probability of tumor recurrence.Surgical resection is the first choice of treatment for bladder paraganglioma. Commonly used surgical methods include partial cystectomy, transurethral resection and radical cystectomy. The choice of surgical method should be based on the specifics of the patient and the technical strength of the operator, in order to reduce the risk and maximize patient protection. Partial cystectomy has the advantages of less interference to tumors, relatively stable intraoperative blood pressure, and low recurrence rate. With the advancement of laparoscopic technology over recent years, laparoscopic and robot-assisted laparoscopic partial cystectomy have the potential to replace traditional open surgery, being a safe and promotion-worthy choice.Considering the newly-married, nulligravid female, transurethral resection was a better option than partial or complete cystectomy. Compared to traditional transurethral resection with electrocision, transurethral resection with holmium-yag is endowed with lack of obturator reflex, good bleeding control, and clear demarcation of anatomical relationships between the tumor and muscular fibers. Although the 1-year follow-up including blood catecholamine metabolite levels, pelvic CT scan, and cystoscopy revealed satisfactory results, a life-long follow-up is still required to monitor recurrence. Some previously reported cases of bladder paraganglioma are summarized in Table We acknowledge patient for her cooperation and trust to our therapy.Conceptualization: Xin Gou.Data curation: Xin Zhu, Mi Zhou, Haitao Yu, Youlin Kuang, Yong Chen, Heqiu Li.Methodology: Xin Zhu, Youlin Kuang, Yong Chen, Heqiu Li.Writing – original draft: Xin Zhu, Mi Zhou, Haitao Yu.Writing – review & editing: Xin Gou.


Emergency physicians can use point-of-care ultrasound to diagnose inguinal hernias as well as their potential complications, including small bowel obstruction, incarceration, and even strangulation. We provide an overview of the sonographic appearance of inguinal hernias, as well as the diagnostic criteria of serious complications. In this case report, point-of-care ultrasound findings included a non-reducible inguinal hernia associated with significant bowel dilation in multiple loops without signs of intestinal ischemia or necrosis. The Emergency Department (ED) assessment of patients with suspected inguinal hernia involves establishing the diagnosis and classifying patients into the category of uncomplicated reducible hernia and those with incarceration and/or strangulation. In cases with an incarcerated hernia, it is imperative to determine if it is associated with strangulation, which leads to bowel necrosis, or if there are other complications, such as a small bowel obstruction. Certainly, a small bowel obstruction secondary to a hernia is one of the most frequent causes of abdominal pain requiring surgical intervention . PatientA 43-year-old male, with a history of a prior indirect inguinal hernia that did not require surgical intervention, presented to the ED with acute right scrotal swelling that had commenced three hours prior to his ED arrival. The patient, a construction worker, had been lifting heavy objects at work and noted the sudden onset of lower abdominal pain, associated with the swelling of his right hemi-scrotum. He was nauseous but denied vomiting, back pain, dysuria, hematuria, fever/chills, or diarrhea. He had no chronic medical conditions and took no medications.9/L  and a lactic acid of 2.16 mmol/L .On physical examination, the patient appeared in significant discomfort. Although there was no abdominal tenderness to palpation, the right hemi-scrotum was markedly swollen and exquisitely tender to palpation. His physical examination was otherwise normal including vital signs that were within normal limits. His laboratory results revealed a white blood cell count of 12.9 x 10The emergency physician performed a PoCUS of the scrotum to further assess the etiology of the patient’s severe pain. Using the linear transducer  , the clinician scanned the right testicle in the longitudinal and transverse position. The testicle appeared normal, but dilated loops of the bowel were noted in the scrotum (Figures When using US to detect inguinal hernias, the high-frequency linear transducer is normally used, given the superficial nature of the structures that the clinician needs to visualize. Both the soft tissue of the abdominal wall and the native scrotal structures are examined and evaluated. Sometimes even small indirect inguinal hernias can be seen lateral and superficial to the inferior epigastric artery and descending downwards towards the scrotal sac . SonograCT and MRI are the imaging modalities of choice when evaluating hernias. In the ED, CT is utilized much more frequently than MRI, however, given its relative speed and availability. Yet, PoCUS is also often readily available, less expensive, uses no ionizing radiation, and allows for dynamic assessment. Furthermore, in the developing world, US is often the only imaging option to evaluate patients with abdominal pain . In one In this case, an emergency physician performed a scrotal ultrasound which identified dilated loops of bowel in the scrotal sac with evidence of preserved bowel wall blood flow, suggesting an incarcerated hernia that was not yet strangulated. As a result, the emergency physician was able to quickly mobilize the surgical consult service and expedite the patient’s care. PoCUS is a truly valuable tool in the ED for the rapid assessment and diagnosis of patients who present with abdominal and/or scrotal pain.


Sciatic nerve impingement via a tumor of or trauma to the proximal subgluteal region creates a considerable surgical challenge that is debated in the literature. The neurosurgery literature favors the infragluteal approach, while in orthopaedics, the transgluteal approach is preferred. The goal of our study was to present an operative technique for the infragluteal approach to the subgluteal region with a step-by-step procedural guide to increase awareness among orthopaedic surgeons of alternative surgical approaches to the sciatic notch. We retrospectively reviewed the case of a 62-year-old female found to have a subgluteal myxoma who underwent the infragluteal approach for tumor excision. We then highlighted the anatomic considerations via cadaveric dissection photographs, artistic renditions, and intra-operative images. Our patient underwent tumor resection and sciatic nerve exploration via the infragluteal approach with a successful outcome. In comparison to other approaches in the literature, the infragluteal approach provides a safer dissection with more options for an extension of the exposure and potentially fewer functional deficits. We conclude that orthopaedic surgeons should strongly consider utilizing this approach to the sciatic notch rather than a transgluteal approach. Tumors of the gluteal region present a considerable surgical challenge as this area has important structures including the sciatic nerve and the gluteal neurovascular bundles. There are multiple situations in which exploration of the sciatic nerve in the gluteal region is indicated, including trauma, tumors, or nerve entrapment. Sciatic nerve impingement from tumors in the subgluteal region has been previously discussed in the literature and can have a significant impact on the quality of life for patients -5. SeverIn the neurosurgical literature, the proximal sciatic nerve is commonly accessed via the infragluteal approach. This approach was initially discussed in 1920 by Stookey  and thenIn orthopaedics, the literature on approaches to the sciatic notch is scarce. There appears to be a greater focus on utilizing the transgluteal approach however as compared to the infragluteal approach to access this region. The transgluteal approach, originally described by von Langenbeck and further modified by Kocher in the late 1800s, became popularized in the orthopaedic world by Moore in the mid-20th century as the simplified posterior approach . This apThus, while orthopaedic surgeons tend to utilize the transgluteal approach as described, It appears that the neurosurgery literature favors the infragluteal approach. When there is insufficient literature to support one procedure from another, surgeons tend to choose the approach of which they have been exposed during training. Given the differences in their respective backgrounds and training between peripheral nerve surgeons and orthopaedic surgeons, it is not surprising that they would differ in which approach they would use. The goal of our study was to present an operative technique for the infragluteal approach to the subgluteal region with a step-by-step procedural guide to increasing awareness among orthopaedic surgeons of alternative surgical approaches to the sciatic notch.An abstract entitled Infragluteal Exposure for Resection of Subgluteal Tumors: A Surgical Technique Guide For Accessing the Sciatic Nerve and Notch; A Report of Two Cases was presented at the Pennsylvania Orthopaedic Society (PAOrtho) 2020 Annual Meeting. One of the two cases presented at the meeting is included next in greater detail.The patient was informed that the data would be submitted for publication and provided verbal consent over the phone.A 62-year-old woman with type II diabetes mellitus, asthma, and hyperlipidemia presented to our outpatient clinic with an enlarging mass in her right buttocks. Initial CT scan demonstrated an 8.7 x 6.4 x 5.2 cm well-circumscribed hypodense lesion in the soft tissue posteriorly at the level of the proximal femur. MRI imaging subsequently demonstrated a heterogeneously enhancing, multi-septated lesion within the gluteal musculature measuring approximately 5 x 6 x 9 cm. It was noted to be superficial to the posterior aspect of the proximal femur with a thin peripheral rind of diffuse enhancement.She complained of increasing pain in her right buttock with prolonged sitting. She also started having “electric, shock-like sensations” down her right leg. These occurred approximately two times per week with occasional numbness and tingling along the posterior aspect of her right thigh. On physical examination, there was no antalgic gait or limp noted. There was a mobile, palpable mass in the region of her right buttock. It was over her ischium and non-tender to palpation. Her neuropathic symptoms could not be reproduced clinically. She was neurovascularly intact with full motor strength and sensation.An ultrasound-guided needle biopsy was performed, and the pathology revealed a benign myxoid neoplasm. A CT scan of her chest, abdomen, and pelvis along with a bone scan was performed to rule out multiple myxoid neoplasms. After discussing the findings, she elected to have the mass excised given the pain and impact it had on her quality of life. The risks, benefits, and time course was reviewed with the patient, and surgical consent was obtained. She subsequently underwent a right subgluteal myxoma excision.The mass was sent to surgical pathology intra-operatively and found to be a benign myxoma. The patient was discharged on postoperative day 2 without any major complications. She was seen for follow-up 10 days after discharge from the hospital. She was touchdown weight-bearing and ambulating with a walker at that time. A telephone conversation was performed as her last follow up one-year post-surgery. The patient was unable to be seen in follow-up due to financial reasons. She noted that she does not ambulate with a limp and does not require the use of a gait aid. She does complain of occasional radicular-type symptoms down the posterior aspect of her operative leg, though the exact etiology is unknown since we cannot evaluate her clinically.Surgical anatomyThe gluteal lid, or the gluteus maximus, is a large, superficial muscle in the shape of a quadrangle. It originates from the posterior gluteal line of the ilium, the gluteal and erector spinae aponeuroses, the dorsal surface of the lower sacrum, the side of the coccyx, and the sacrotuberous ligament. After originating from the pelvis, the muscle fibers travel obliquely to make their insertions onto two different structures. The superficial fibers and some of the deep fibers form a fascial attachment to the iliotibial band. The remainder of the deep fibers form a bony attachment to the gluteal tuberosity of the femur between the insertion of the adductor magnus and the origin of the vastus lateralis. Several muscles are covered by the gluteal lid including part of the gluteus medius, the piriformis, the superior and inferior gemelli, the obturator internus tendon, and the quadratus femoris, as illustrated in Figure Surgical techniqueThe patient is positioned prone on the operating room table. The relevant anatomy should be drawn. A curvilinear skin incision extends from the region of the posterior superior iliac spine (PSIS) to the superior portion of the greater trochanter Figure . It is tDissection through the subcutaneous tissue to the level of the gluteus maximus muscle fascia and the iliotibial tract is then carried out. Blunt dissection is utilized to identify the inferior border of the gluteus maximus. The attachments of the superficial gluteus maximus fibers to the iliotibial band are cut Figure . The deeThe gluteus maximus is then reflected medially thereby preserving the inferior gluteal neurovascular bundle while still providing ample access to the subgluteal region Figures , 5. CareOnce the tumor resection is complete, the deep fibers of the gluteus maximus are re-approximated with heavy non-reabsorbable and absorbable sutures. The non-reabsorbable sutures are used to re-approximate the deep fascia in a figure-of-8 pattern. Following this, the superficial fibers are reattached to the iliotibial band. The deep dermis is then closed with absorbable sutures and the skin closed with nylon suture.Accessing the subgluteal region for various pathologies creates a unique challenge for surgeons. While the neurosurgical literature favors the infragluteal approach of Henry, the orthopaedic literature is scarce regarding the best approach to access this region and oftentimes utilizes the transgluteal approach. Experience and comfort is important for any surgeon, but based on our study findings and literature review, the infragluteal approach may have a theoretical improvement in clinical outcomes and lower risk of iatrogenic neurovascular injury. Though our study, presented as the abstract described earlier in this paper, is limited by size. It discussed two case reports of patients, one in this paper in greater detail, with subgluteal tumors that underwent tumor resection via the infragluteal approach. Both patients did well postoperatively without any signs of sciatic nerve damage or residual functional deficits as neither patient required the use of an assistive device on follow-up. As a quick review, the buttockectomy introduced by Malawer involves the entire resection of the gluteus maximus, creating an aesthetic deformity as well as significant functional deficits ,17. The The increased exposure options with the infragluteal approach includes access to the pelvic bone, peri-sciatic notch, distal sciatic nerve, etc. For these more extensive procedures, the curvilinear skin incision can be continued distally and medially along the gluteal crease. If necessary, the incision can also be carried distally along the hamstrings allowing a better visualization of the distal aspect of the sciatic nerve. Proximally, the incision can be extended further by following along the iliac crest to the PSIS where the entire gluteus maximus and even underlying gluteus medius can be detached from the iliac bone. This step creates an extensive pedicle and allows access to the pelvic bone and peri-sciatic notch region. While the transgluteal approach can be extended, it does not afford as much exposure as the infragluteal approach.The goal of our paper was to present an operative technique for the infragluteal approach to the subgluteal region. We also included a step-by-step procedural guide to increase awareness among orthopaedic surgeons of alternative surgical approaches to the sciatic notch. While the literature does not show superiority for either the transgluteal or infragluteal approaches, our case report highlights the infragluteal approach in a case with an excellent outcome. Though there are limitations to our study, we believe the infragluteal approach for proximal sciatic nerve injuries or sciatic notch tumors is superior to the transgluteal approach for multiple reasons. It provides options for a more extensile exposure if the pathology extends beyond what preoperative imaging illustrates. It has a theoretical decreased risk of nerve or vessel injury since it does not directly require an approach through the fibers of the gluteus maximus, and it is less disruptive to the function of the gluteus maximus.


Purely intradural retro-odontoid synovial cysts are rarely reported in neurosurgical literature, particularly in the absence of associated bony erosions. We present the case of a 57-year-old Native American male with a retro-odontoid synovial cyst and a history of chronic refractory neck pain that was adequately decompressed via an endoscopic-assisted far-lateral approach using a C1-2 hemilaminectomy, obviating the vertebral artery (VA) transposition, bony instability, and the need for instrumented bony fusion. The patient presented to our clinic with several months of refractory nuchal and cervical spine pain and crepitation affecting his activities of daily living (ADL). MRI findings revealed an intradural cyst at the level of C2 behind the odontoid process impinging on the medulla and causing early VA displacement. Both stereotactic neuro-navigation and microsurgical visualization aided in the manipulation of the endoscope and attaining the caudocranial working trajectory. The patient remained neurologically non-lateralizing postoperatively, similar to his preoperative status. This article highlights a less invasive surgical exposure with an endoscope-assisted caudocranial trajectory obtained by a limited unilateral hemilaminectomy to achieve the desired outcome. Retro-odontoid synovial cysts are rare diseases that arise from the tectorial membrane posterior to the dens of the axis, causing high cervical cord compression and myelopathy. These occur more often in elderly patients and in those with inflammatory conditions, such as rheumatoid and psoriatic arthritis ,2. ThereIn current clinical practice, imaging modalities such as MRI are unable to effectively differentiate synovial cysts from other cervical spine pathologies, such as a pannus or calcium pyrophosphate deposits. Often, the diagnosis is not confirmed until surgical resection is complete with histologic confirmation, and patients have been reported to typically present with occipital and neck pain, numbness, headaches, and lower cranial nerve deficits ,7.Currently, three conventional strategies for the resection of retro-odontoid lesions exist, each with certain drawbacks that must be given consideration: the anterior transoral approach, which carries a higher risk of infections, particularly with transdural access; the endoscopic endonasal approach, which requires specialized neurosurgical training to access the caudal trajectory and carries a high risk of infection after durotomy; the lateral-high cervical approach, which predisposes to the possibility of vertebral artery (VA) mobilization over C1; and the posterolateral/far-lateral approach, which involves complex dissection and risks epidural bleeding and pseudomeningocele formation . In someThe intracranial denticulate ligament  can serve as an important landmark in operative approaches at the CVJ. These extensions of the pia-arachnoid layer can facilitate the delineation between the anterior and posterior spinal compartments . This liIn this report, we present the case of a middle-aged patient with a retro-odontoid cyst associated with a history of chronic refractory neck pain and no evidence of myeloradiculopathy. The cervical spine was decompressed via an endoscopic-assisted far-lateral approach for a C1-2 hemilaminectomy without fusion. The pathology report confirmed a synovial cyst and the patient was neurologically intact postoperatively. Given our patient’s history, we hypothesize the cyst's origin to be ligamentous degeneration. This article demonstrates the surgical trajectory with endoscopic guidance and reviews other surgical approaches for retro-odontoid cysts in the current literature.A 57-year-old Native American male presented with the chief complaint of persistent neck pain and crepitation in the upper neck for several months. On examination, the patient showed no signs of radiculopathy or myelopathy. Relevant past medical history included chronic neck pain, possibly as a consequence of a prior automobile accident. The patient had no symptoms of peripheral neuropathy, urinary incontinence, or improvement in neck pain. Examination of his upper and lower extremities demonstrated full strength with intact and equal sensation bilaterally but with diffusely diminished reflexes.A cervical X-ray taken four years prior to our evaluation had shown arthritic changes at the C1-2 levels with multilevel spondylosis. CT neck at the time had revealed similar changes with moderate degeneration in the cervical spine and multilevel, moderate neuroforaminal stenosis, and mild focal hyperostosis behind the dens Figure .MRI of the head and neck also showed spinal stenosis at C1-2 due to an intradural extramedullary mass (IDEM) impinging on the spinal cord at the level of dens Figures , 1C. ThiAn endoscope-assisted microsurgical cyst decompression from a left far-posterolateral C1-2 hemilaminectomy was then performed without causing any bone instability or VA transposition. After the semicircular opening of the dura mater based on the VA axis and reflection of the dura flap laterally, arachnoid dissection was performed to release CSF. The first denticulate ligament served as an intraoperative landmark, the cutting of which offered simplified maneuvering of the endoscope in the limited lateral intradural space at the CVJ. This unique IDEM at the level of the C2 dens exuded a green-yellow fluid from the mass with partly yellowish, flaky material within the capsule. The tumor wall was noted to be extremely thick, yellow-white, fibrous, and firm. The final histopathology report confirmed a synovial cyst at the retro-odontoid region.The extent of dura exposure after C1-2 hemilaminectomy, limited durotomy, and close-up endoscopic view of the dura attachment after sacrificing the denticulate ligament are demonstrated as a pictorial essay Figures -2J.The greenish-yellow cyst fluid with yellow, flaky contents and the thick, fibrotic capsule with surface hypervascularity of the cyst merging with the dura is shown in Figures Exclusive dura-based ventral extramedullary cysts of the cervical spine are rare and may occur without bone erosion or neurological deficits. The differential diagnosis of such lesions in the ventral skull base may include cystic meningiomas, chordomas, pseudotumors, rheumatoid pannus, ecchordosis physaliphora, and synovial cysts of C1-2 . In our The pathogenesis of cervical intradural synovial cysts may be multifactorial. It is likely that atlantoaxial instability causing subluxation or chronic micromotion of the C1-2 vertebrae contributes significantly to its development . ConsequRetro-odontoid cysts are commonly removed surgically and, in some cases, non-surgically with percutaneous aspiration for non-surgical candidates. However, there are few case reports of synovial cysts in the atlantoaxial region in the literature to propose a definitive surgical approach. Our literature review of the PubMed database for "intradural atlantoaxial cyst" and "odontoid cyst" yielded 73 results. After the screening of results by removing the duplicates, excluding case series and reviews, removing case reports involving calcium pyrophosphate deposition, and filtering for English as the preferred language, 10 case reports involving 11 patients were identified  without sacrificing bone that would cause C1-2 instability or compression on the high cervical spinal cord. The denticulate ligament served as an anatomical landmark and its sacrifice created room for manipulating surgical instruments, including a rigid endoscope through such a small durotomy. Moreover, this approach eliminated the prospect of injury to the vertebral artery and was preferable over an anterior approach given the higher risk of infection, spinal fluid leak, longer operative time, and need for posterior instrument stabilization [Several of the case reports documented the use of a less invasive approach for the treatment of a retro-odontoid cyst. For instance, a lateral atlantoaxial joint puncture and arthrography is one approach that is minimally invasive and provides therapeutic resolution of the cyst and relative neurological symptomatic improvement over months . AnotherMadhaven et al. 2018) have reported cases of three patients, two of which were retro-odontoid cysts that completely resolved with a posterior suboccipital craniectomy and laminectomy. Interestingly, Lin et al. 2014), Meng and Liu (2016), and Ogata et al. (2007) also approached a synovial cyst with posterior laminectomy, occipitocervical fusion, and posterior fixation, respectively, but without surgical resection due to technical challenges. Nonetheless, all of them reported resolution of the patients' symptoms along with regression of the cysts over several months , Meng an,18. Mean have repTakeuchi et al. 2011) also approached a retro-odontoid cyst with a posterolateral approach with C1-2 fixation but did not completely resect the mass, which was adhered tightly to the brainstem. Nevertheless, follow-up in three months showed mass reduction without any neurological symptoms . Evident11 also aSynovial cysts of the spine, in particular of the atlantoaxial joint space, are exceptionally rare occurrences found in elderly patients and can in some instances cause myelopathy. Symptomatic retro-odontoid cysts are often treated surgically using either an anterior transoral, endoscopic endonasal, far-lateral high cervical, or posterolateral approach depending on the individual patient profile. We presented a patient with a rare case of a retro-odontoid intradural synovial cyst treated with an endoscope-assisted far-posterolateral surgical approach without needing vertebral artery transposition or instrumented C1-2 fusion. The anatomical marker used in this approach  is discussed along with the utilization of a rostrocaudal surgical trajectory given the endoscope assistance. The role of Stealth neuro-navigation and the endoscopic-assisted "fish-eye" view of the lesion are illustrated in the article.


Case Report. A 53-year-old man with a personal history of alcohol and tobacco abuse and chronic pancreatitis was admitted to the hospital for epigastric abdominal pain. A computed tomography scan showed a locally advanced neoformative lesion in the distal stomach. The patient presented melena, arterial hypotension, and 4.4 g/dl of hemoglobin. An upper gastrointestinal endoscopy showed a neoformative ulcerated lesion at the duodenal bulb without active bleeding. Biopsies were taken, and histopathological analysis did not show malignancy. A cephalic pancreaticoduodenectomy was performed, and the postoperative period was uneventful. Histopathological analysis revealed a segmental GP. Discussion. GP is an uncommon entity, and its clinical and radiological presentation mimics PC. However, with advances in imaging tests, several radiological criteria have been described to distinguish GP from PC preoperatively. Although some authors recommend a stepwise management with initial conservative therapy, a therapeutic strategy has not yet been established.  Groove pancreatitis (GP) is an unusual subtype of chronic pancreatitis that affects the groove area. Differential diagnosis between groove pancreatitis and pancreatic carcinoma (PC) can be challenging, both clinically and radiologically. Our aim is to report the first case of GP debut with upper gastrointestinal bleeding (UGB).  GP is an uncommon type of focal pancreatitis that should be considered as a differential diagnosis of PC. We report the first clinical case of GP whose debut with UGB presented a greater diagnostic and therapeutic challenge. This entity was first described by Becker in 1973 . GP is a3μl leukocytes (87.4% neutrophils), 9.4 g/dl of hemoglobin, 736 × 103μl platelets, 0.26 mg/dl of total bilirubin, C-reactive protein 0.77 mg/dl, and normal hepatopancreatic profile. The requested tumor markers (carcinoembryonic antigen and CA19.9) were normal. An abdominal ultrasound was performed, showing cholelithiasis and dilation of the extrahepatic bile duct. Subsequently, a computed tomography (CT) scan was performed which we interpreted as a locally advanced neoformative lesion in the distal stomach, which involved lymphatic nodes and gastroduodenal artery and invaded the pancreatic head, with dilatation of the distal common bile duct (A 53-year-old man with a personal history of alcohol and tobacco abuse, arterial hypertension, diabetes mellitus, and pancreatitis of alcoholic origin consulted in the emergency department with epigastric abdominal pain, not irradiated, associated with nausea and vomiting. The analysis highlights 15.9 × 10ile duct . Subsequile duct . Nuclearile duct . No infiGP is an uncommon entity, and its prevalence varies from 2.7 to 24.5% in surgical specimens of pancreaticoduodenectomies performed in patients with chronic pancreatitis , 7. Its Given its low incidence and nonspecific symptoms, GP poses a diagnostic challenge. Additionally, inflammation and fibrosis can result in a pseudotumor that mimics PC on diagnostic imaging tests . DespiteAlthough some authors recommend stepwise management with initial conservative therapy , 4, a thGP is an uncommon type of focal pancreatitis whose clinical and radiological diagnosis is challenging. Its management is not clearly established, although some authors recommend a stepped management beginning with conservative treatment. However, given the difficulty in obtaining a definitive diagnosis or, as occurred in our case, in the presence of complications, surgical resection is often required. We report the first clinical case of GP whose debut with UGB presented a greater diagnostic and therapeutic challenge.


Perianal carcinomas, though rare, are usually squamous cell carcinoma. Current literature recommends surgical excision for tumors staged T1-T2, N0 without external anal sphincter involvement, however our case demonstrated that tumors with superficial involvement of external sphincter fibers can be resected completely.A 45-year-old Caucasian male presented with a perianal mass found to be squamous cell carcinoma. Initial imaging suggested the anal sphincter was spared, however intraoperatively tumor cells were found involving superficial external sphincter fibers and a portion was excised to ensure complete removal.Perianal squamous malignancies are often misdiagnosed as more benign conditions. Treatment aims to preserve sphincter function and depends on tumor stage along with anatomical involvement.Despite superficial muscle infiltration, the T2N0 perianal lesion was curable with surgical resection alone without recurrence or functional deficits reported one year later. This suggests surgical management may be possible in some cases with sphincter involvement. All oPerianal SCC is treated as other cutaneous squamous cell carcinomas . Surgica2A 45-year-old married, heterosexual Caucasian male with a history of Asperger’s Syndrome and 60 pack years cigarette use was found to have a perianal lesion during screening colonoscopy due to family history of colon cancer. He came to our clinic for further evaluation where he reported a one-year history of bleeding, pain and foul-smelling clear discharge from the lesion, worsening over the last 3 months. External exam revealed a firm right anterior perianal lesion with everted margins measuring 3 cm without enlarged inguinal lymph nodes. Digital rectal exam was free of masses in the anal canal or rectum.Examination with biopsy under anesthesia revealed a mobile, right sided perianal fungating lesion measuring 3.5 × 3.5 cm, and 3 cm deep . The medSubsequent workup was performed. HIV testing was nonreactive. Chest CT showed small 4–6 mm bilateral necrotic pulmonary parenchymal nodules suspicious for metastatic deposits, but PET scan confirmed no evidence of local, regional, or distant metastasis. Pelvic MRI revealed the mass extended to the anal sphincter  but did The patient underwent wide local excision of his perianal SCC in a community hospital under the care of an experienced general surgeon. The procedure was performed in the lithotomy position under general anesthesia. A 1 cm circumferential margin was marked around the tumor with the medial aspect extending into the anal canal. Obtaining the medial margin involved resecting a portion of the anal mucosa, and the medial deep margin of the tumor extended to superficial fibers of the external sphincter muscle. Superficial sphincter fibers were resected to obtain negative deep margins. Circumferential 1 cm margins were obtained and ultimately the tumor measured 3.5 cm × 3 cm × 3 cm deep, extending to and involving fibers of the external anal sphincter muscle. The anal mucosa was then approximated, and the anal verge was reconstructed with appropriate approximation at the mucocutaneous junction. The lateral edge was left open and Surgicel was placed to allow drainage and prevent bleeding.He was discharged home and instructed to use Miralax 17gm and sitz baths BID to prevent excessive straining and infection. The following day he was seen for Surgicel removal. Ten days later he experienced wound dehiscence from a strenuous bowel movement after he reported stopping Miralax for 36 h. Dehiscence was managed inpatient with local wound care and systemic antibiotics and allowed to heal by secondary intention. Follow up in person was limited due to the COVID-19 pandemic however he was seen via telehealth until he could follow up in person. One year after excision his wound healed completely with scarring . Examina3While perianal SCC usually presents as an ulcerated lesion with rolled everted edges, it contains histological subtypes including basaloid, transitional, keratinizing, non-keratinizing, verrucous, etc. ,8. CurreTo identify relevant anatomy, the anal margin begins at the anal verge extending along a 5 cm radius along the perianal skin. The anal canal lies superiorly, from the mucocutaneous junction to the beginning of the rectal mucosa . The denAnatomical involvement heavily influences treatment. Well-differentiated perianal lesions up to T2, N0 without suspected sphincter involvement are locally excised with wide margins of 1 cm . ChemoraWhile TNM staging provides the most accurate predictor of prognosis, perianal SCC can recur in up to 66% of patients after local resection ,2,4,9,134Perianal SCC is often delayed in presentation or misdiagnosed as a benign condition. Consider this malignancy in patients with persistent complaints of perianal bleeding, pain, pruritis, or enlarged inguinal lymphatics without known cause. While guidelines recommend resection of moderately to well differentiated cases at T1-T2, N0 without sphincter involvement, our patient demonstrated the tumor can be completely excised with superficial sphincter fibers without functional loss of the musculature.None.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The study is exempt from ethical approval in our institution.Consent was obtained prior to writing this case report. All other details regarding patient privacy are completed as applicable.Christina Eliachevsky: Writing – Original Draft, Writing – Review & Editing. Erin Templeton: Writing – Review & Editing. Atul K. Nanda: Methodology, Writing – Review & Editing, Supervision.Not applicable.Christina EliachevskyErin TempletonAtul K. NandaNot commissioned, externally peer-reviewed.


Prolactinomas are benign tumors that make up the majority of all pituitary adenoma cases and present most commonly in women. Prolactinomas presenting in adolescents and children, however, are extremely rare. We report a case of a 17-year-old male who presented with a six-month history of headaches and a previously unrecognized visual field deficit on examination. Neuroimaging revealed a large suprasellar tumor with imaging, more characteristic of a craniopharyngioma or suprasellar low-grade glioma impinging, on the left intracranial optic nerve causing right-sided hemianopsia. Due to the extensive mass effect and bitemporal hemianopsia on examination, the decision to proceed with initial surgical debulking was made following informed consent. A subtotal resection was performed where the pathology was consistent with a prolactinoma that correlated with markedly elevated prolactin (PRL) levels obtained pre and post-operatively that have not resulted until five days post procedure.The patient was subsequently treated with dopamine agonist (DA) cabergoline therapy and is now five-years disease-free with normal neurological examination and no residual tumor on neuroimaging. DA therapy has shown high clinical efficacy and should be considered prior to any surgical intervention; however, extensive mass effect may appropriate surgical debulking to increase therapy efficacy. Our case highlights an atypical appearance of a giant prolactinoma that may mimic other more common suprasellar tumors, a presentation associated with unrecognized visual field deficits, and the importance of rapid turnaround testing for serum PRL that may aid in the upfront diagnosis and management of prolactinomas. The pituitary gland plays a critical role in the maintenance of endocrinological balance with specific regard to its development, reproduction, and growth. Adenomas impinging on the pituitary can lead to significant pituitarism, such as hyperprolactinemia caused by prolactinomas . DespiteA 17-year-old male presented with six months of headaches, and a few-weeks history of difficulty in seeing the board at school. Neurologic examination at presentation was significant for a right homonymous hemianopsia that was previously unrecognized. MRI revealed a large well-circumscribed multi-lobulated cystic and solid enhancing suprasellar mass with foci of mineralization and no evidence of reduced diffusivity on apparent diffusion coefficient sequences Figure . The tumProlactinomas are the most common pituitary adenoma presenting most frequently in the age group of 20-50 years with an approximate 10:1 female to male ratio [Prepubescent clinical presentation of a prolactinoma varies, but typically includes headaches, visual disturbances, and growth failure . DistincDA, such as bromocriptine and cabergoline, are the primary treatment for prolactinomas regardless of tumor size, patient age, or gender and are effective in controlling PRL levels shown to be proportional to tumor size and typically result in tumor size reduction that may minimize or even obviate the need for surgery . SurgicaCystic macroprolactinomas causing neurological symptoms such as visual field defects have shown to have poor response against DA therapy and are an indication of early surgical intervention ,4,9. LacBromocriptine is effective in controlling PRL levels, which are usually proportional to tumor size, and promotes tumor shrinkage. Exceptions are seen in the treatment of macroadenomas with varying results. Although PRL levels may correlate with tumor size, they do not correlate well with symptoms of hyperprolactinemia until higher PRL levels are reached ,10.Comparison of DA therapy effectiveness pre- and post-surgery is unreliable as primary DA therapy patients present with little to no visual defects that would prompt early intervention . Our casOur case highlights successful DA therapy post early interventional surgery for cystic prolactinoma in a patient with progressive visual defect. In most cases of suprasellar tumors, baseline endocrinologic studies are obtained as neuroradiographic features of suprasellar prolactinomas may mimic more common tumor types in this location and symptoms of hyperprolactinemia may be absent despite correlation of PRL levels with prolactinoma size, which may lead to change in management. Furthermore, pre-operative endocrinologic workup may potentially obviate surgical intervention in favor of DA treatments. Macroadenomas with extensive mass effect resulting in neurologic defects are exceptions in which surgical debulking prior to DA treatment may be required for successful pharmacologic therapy.


Intraosseous unicystic ameloblastoma (UA) is a rare subtype of a true neoplasm of odontogenic epithelial origin: ameloblastoma. Despite its rareness, dealing with UA is problematic. It is usually mistaken for an odontogenic cyst, and biopsy is rarely relevant because of its multiple growth patterns. The biggest challenge remains the treatment choice. When we are faced with a mural UA presenting strong similarities with a lateral periodontal cyst and having high rates of recurrence, how is the balance found between the young age, psychological fragility, postoperative process, and need for diagnostic biopsy? That was our dilemma. Our patient is a 23-year-old man with a mural unicystic ameloblastoma, diagnosed with general anxiety disorder. The final decision was to turn to a simple enucleation because of the small size of the lesion, and its radiological features strongly evoked a lateral periodontal cyst. Besides, his young age, psychological condition, and UA's proximity to the surrounding soft tissues guided us toward simple enucleation. Two years later, no sign of radiological recurrence was noted. However, we are aware of a later possibility of resection in case of recurrence. Odontogenic lesions are usually discovered through a routine radiography exam, although swelling may appear in the oral cavity. In the setting of this presentation, cysts  are the primary suspected lesion. However, ameloblastoma remains a distinct possibility.The latter lesion is a slow-growing though locally aggressive tumor representing 9% to 10% of odontogenic tumors. Its frequently reported location is the mandible (angle and ramus region), often associated with an unerupted third molar. It occurs generally during the 3rd to 4th decade of life and has an equal sex distribution .Ameloblastoma is a neoplasm of odontogenic epithelium, arising from epithelial cellular elements and dental tissues in their various phases of development . In pathAccording to the 4th Edition of the World Health Organization update, ameloblastoma is classified into four categories: conventional/multicystic, extraosseous/peripheral, metastasizing, and unicystic . On the Luminal showing a flat ameloblastic cyst liningIntraluminal characterized by a tumor growth into the cyst lumen, usually with soft luminal projectionsMural exhibiting infiltrating growth into the wall of the cyst and even beyond into the surrounding boneHistologically, we can identify three subtypes of growth patterns :LuminalUA is particularly known for multiple growth patterns in the same lesion. Hence, a biopsy might give the wrong diagnosis when the specimen shows only one of lesion's multiple growth patterns. It is a dilemma since the treatment of one can promote the recurrence of the other .Currently, conservative and radical treatments exist for UA. The conservative approach consists of a simple enucleation , or an enucleation followed by Carnoy's solution , or a maOn the other hand, radical treatment consists of surgical resection (with or without continuity defect) of the lesion and surrounding bone . The invTherefore, we will introduce a case of a mural UA in the right mandible sector of a 23-year-old man presenting a general anxiety disorder.A 23-year-old male presented to the dental unit of Sahloul Hospital in July 2019 due to the reappearance of an old swelling in his right mandible two months prior. He reported a self-resolving swelling episode that occurred one year before that. The patient was also followed in the psychiatry department for generalized anxiety disorder. No history of drug allergy was known. Extraoral physical examination revealed a swelling in the middle of the right mandible body with no associated lymphadenopathy or mouth-opening restriction.On intraoral examination, the crown of tooth 35 was distally tipped, and a swelling was located in the low vestibule between teeth 35 and 36 . It exteAn orthopantomogram ordered in 2016  revealedOn the day of the consultation, radiovisiography  was perfComputed tomography (CT) Dentascan was prescribed and showed a cystic lesion with a radiological tissue density confined in the mandible body . The bucConsidering clinical and radiological findings, a lateral periodontal cyst was strongly suspected because of the lesion's location, its small size, the vitality of 35 and 36, the lesion's radiological continuity with the 35 lamina dura, and its slow evolution since the first radiograph. Giant cell granuloma and ameloblastoma were also thought of as possible differential diagnoses because of the local aggressive features noted in the CT Dentascan.Because of the strong suspicion of the lateral periodontal cyst, the small size of the lesion, patient's young age, and his fragile psychological health, we opted for the enucleation of the lesion. We decided not to perform a biopsy since the lesion was too small. Besides, the entire specimen will be needed later to determine all the lesion's histological aspects especially in the case of ameloblastoma.The patient was informed about the therapeutic options available and the risks of each one. The patient himself asked for the less-traumatic treatment since he was very agitated and could not handle substantial postoperative recovery. Therefore, under local anesthesia, the enucleation of the lesion was performed. The specimen  had a smThe histopathologic evaluation reported a single cystic sac with a fibrous wall and the presence of a lining epithelium showing varying thickness without cytonuclear atypia or mitosis . Inside Two years after the enucleation procedure, the patient is still followed up in the outpatient dental clinic. Bone restoration in the affected area was radiologically observed , and no Unicystic ameloblastoma was first described by Robinson and Martinez in 1977 as one of the three ameloblastoma subtypes: a unique and rare de novo neoplasm. It is reported in 15% of intraosseous ameloblastoma . Eighty Nevertheless, our lesion did not have the usual frequent location reported in the literature (ramus and mandible angle)  since itIn fact, the location of the lesion, its small radiologically sized aspect, and its intimate contact with the lamina dura made us primarily consider the diagnosis of a lateral periodontal cyst. Some authors reported this same UA differential diagnosis , 15, thoTo confirm a UA diagnosis, the minimum criterion is the presence of a single cystic sac lined by variable epithelium ranging from that with typical ameloblastic characteristics to a metaplastic epithelium consisting of nonkeratinizing squamous cell layers . HoweverThe first one is a luminal UA: when the tumor is confined to the luminal surface of the cyst. Its recurrence rate is the lowest, ranging from 10% to 25% since the ameloblastic cells are contained and do not invade adjacent tissueThe second one is the intraluminal UA: a nodular proliferation into the lumen. No infiltration of the tumor cell into the connective tissue is observed as well. It is usually microscopically similar to conventional ameloblastomaThe third one is the mural UA with the higher recurrence rate, 50% to 80% risk. Invasive islands of ameloblastomatous epithelium in the connective tissue wall are observed, though they do not involve the entire epithelium. The infiltration can even extend beyond into the surrounding bone, hence its high recurrence rateAckerman et al. assessed three UA subtypes after a clinicopathologic study of 53 cases [Subgroup 1: luminalSubgroup 1.2: luminal and intraluminalSubgroup 1.2.3: luminal, intraluminal, and intramuralSubgroup 1.3: luminal and intramuralLater in 2003, Philipsen and Reichart described another UA grouping as follows :SubgrouTreatment—whether conservative or radical—is usually controversial, as it depends on pathology results which may reveal only one of the multiple growth patterns of the lesion . HoweverHowever, opting for this procedure must be well thought out and requires a balanced judgment, so its success does not lead to overtreatment , 20. ThiFurthermore, psychological fragility either in children or in adults is put to the test through this severe procedure . ActuallIn our case, our patient had a fragile psychological state as he was suffering from general anxiety disorder (GAD), a chronic disabling psychological disease, for now 10 years . In factHence, after comparing the radiological and clinical features of the lesion  to the young age and psychological condition of our patient, we opted for a simple enucleation. This procedure would involve less patient morbidity, and the effect on his quality of life is minimal. In fact, literature reported as in our case that some surgeons advocate a conservative approach, especially for young patients to prevent future problems with oral functions and esthetics , 24.Nevertheless, keeping in mind the possibility of an ameloblastoma, we paid attention not to realize a vigorous curettage of the bone as it might implant foci of ameloblastoma more deeply in the bone . A regulConcerning marsupialization, it was not an option either, because of the small size of our lesion, contrary to a 2007 case report presenting a wide lesion in the left region of the mandible managed with a marsupialization . AccordiMost of the time, conservative treatment is reserved for UA 1 and 1.2 subgroups since no infiltration of ameloblastoma exists beyond the lesion lumen . HoweverIn the end, we wanted to give our patient every chance to keep a normal life without encroaching on his already fragile psychology with a difficult procedure and postoperative convalescence. After all, considering the circumstances, the patient is out of danger and satisfied, and we still have 20% to 50% chance of total success [


Periosteal chondromas (PCs) are rare tumors composed of hyaline cartilage that are typically present in long bones and tubular bones of the hand. These lesions are easily mistaken for other, more common tumors. This study reports a case of PC located in the posterior pelvis of a 24-year-old female. The patient initially presented with a four-month history of pelvic pain with a presumptive diagnosis of endometriosis. However, when an MRI was performed, a 6.0 cm x 5.6 cm x 4.5 cm mass was found along the right posterior ilium extending to the ipsilateral sacroiliac joint. The patient underwent intralesional excision and curettage of the mass. Histologic analysis of the excised lesion revealed a proliferation of chondrocytes and abundant hyaline cartilage without chondroblasts, further suggesting the diagnosis of PC. The current study highlights the unusual location of this rare tumor and alerts the physician of the clinical presentation and differential diagnosis. Periosteal chondroma (PC) is an uncommon, benign cartilaginous tumor that typically arises under or within the periosteum of cortical bone ,2. They A 24-year-old female with polycystic ovarian syndrome presented with a four-month history of gradually worsening pelvic discomfort and pain, fatigue, weakness in gait, and sciatica-like symptoms. She initially presented to our level one academic trauma center for several days of urinary incontinence. On the current presentation, she stated that she was being worked up for endometriosis and was pending an MRI and diagnostic laparoscopy. She denied any inciting trauma or similar episodes in the past. Due to increasing pelvic pain and incontinence, an MRI was performed revealing a 6.0 cm x 5.6 cm x 4.5 cm mass found along the right ilium extending to the ipsilateral sacroiliac joint Figures -2. InterA 6 cm longitudinal incision was made in the direction of the gluteus maximus muscle fibers. The muscle fibers of the gluteus maximus were split longitudinally so that the upper 1/3 and lower 2/3 were separated to preserve the blood supply. The 6 x 5 cm mass was appreciated on the right inferior ilium extending to the sacral ala and sacroiliac joint. The mass was a well-circumscribed, multilobulated, low-grade cartilage appearing neoplasm Figure -5.The patient had an unremarkable neurovascular exam of the right lower extremity postoperatively and the pain was well controlled. At the follow-up visit six weeks later, the patient reported significant improvement in her pelvic pain. There were no neurologic deficits, weakness, or instability of the right lower extremity.PCs are rare hyaline cartilage tumors that typically account for less than 2% of all chondromas -2. The pThe pathogenesis of PC is poorly understood. However, similar to enchondroma, PC frequently harbors heterozygous mutations in isocitrate dehydrogenase (IDH) genes mostly involving IDH1 mutation at R132 -13. In aThe three fundamental radiographic features of PC are: scalloping/remodeling of the adjacent bony cortex, presence of cartilaginous matrix radiographically, and possible soft tissue mass component . On MRI,On histology, PC may show hypercellularity, nuclear enlargement, binucleation, and myxoid changes, which may resemble low-grade chondrosarcoma . PCs areThis patient also had an unusual feature of incontinence and sciatica-like symptoms, including numbness and weakness of the right lower extremity. There have been no documented cases of PC presenting with incontinence, however, other primary bone tumors have been noted to cause incontinence due to the location near the sacrum . De MoraAlthough surgical resection is recommended for PC, we chose to perform an intralesional curettage with the use of adjuvants. This was due to the significant morbidity that would be associated with this area with a wide resection. Although this likely increases the risk of local recurrence, the authors felt that an intralesional procedure would prevent the potential loss of neurologic function and bony stability.This case elucidates radiographic and histological features suggestive of PC that occurred in an unusual pattern along the right ilium extending into the ipsilateral sacroiliac joint. This unique location caused significant pelvic pain, and the patient was delayed proper treatment due to a presumptive diagnosis of endometriosis. In summary, the physician should remember this rare tumor and include PC of the pelvis in the differential diagnosis when presented with pelvic pain, altered gait, muscle weakness, and sciatica-like symptoms.


Paragangliomas are an infrequent type of neuroendocrine tumor that commonly produces catecholamines. We describe a case of a 14-year-old male with a history of uncontrolled hypertension who presented to the emergency department with a headache, palpitations, and profuse sweating. Symptoms were explained by the presence of a catecholamine-producing paraganglioma located at the right diaphragm. One year after radical surgical resection, the patient remains normotensive and does not require hypertensive medications. Paragangliomas are rare highly vascularized neuroendocrine tumors, derived from chromaffin cells in the extra-adrenal paraganglia. These tumors are usually located in the head, neck, and abdomen but can also be located in the thorax, retroperitoneum, and pelvis .The incidence of pheochromocytoma and paraganglioma range between two and eight per million with an estimated prevalence of 1:6500 and 1:2500, respectively; there is no gender predilection . The preSymptoms such as headache, sweating, and palpitations often occur when the tumor originates from sympathetic paraganglia due to an increase in catecholamines such as noradrenaline, adrenaline, and dopamine; hormones and metabolites may be measured in urine or plasma for diagnosis .We report a case of an adolescent with a paraganglioma in the right diaphragm that seems to protrude to the thoracic cavity in images taken prior to the surgical procedure.2.A 14-year-old male with a two-year history of hypertension treated with enalapril and carvedilol, who have no previous studies conducted to determine the presence of secondary causes of hypertension, presented to the emergency department with a headache, palpitations, and profuse sweating. There was no family history of paraganglioma or pheochromocytoma. Physical examination showed hypertension (150/90 mmHg), a heart rate of 100 bpm, and a low body mass index of 17.9 kg/mTotal urine metanephrine levels were elevated: 6357 μg/24 hours. Transthoracic echocardiogram was significant for left ventricular hypertrophy. Abdominal computed tomography revealed a solid lesion located between the liver capsule and the diaphragm. The lesion appeared to be in close relation with the cavoatrial junction Figure .PET/CT did not reveal metastatic lesions Figures  and 3.The patient was chronically receiving prazosin 1 mg orally every 24 hours for blood pressure control. Prazosin dose was increased to 1 mg three times daily and carvedilol was started at a dose of 6.25 mg two times daily, achieving adequate blood pressure and heart rhythm control.The operation was performed under general anesthesia. A midline abdominal incision was performed, and there was no need to perform an anterior thoracotomy. Intraoperatively, the tumor arose from the right diaphragm and was located above the VIII hepatic segment. Tumor invasion into the liver was not observed Figure .3 and had an intact capsule.The right diaphragm was partially resected and the tumor was completely removed with a 0.5-cm margin. The tumor was sized 4.5 × 5.0 × 6.5 cmDuring the surgical procedure, the patient’s blood pressure increased to 301/185 mmHg when the tissue surrounding the tumor and the tumor itself were stimulated. After the tumor was resected, blood pressure dropped to 90/45 mmHg. Neurocognitive test results were normal. These tests were solicited due to the substantial and rapid fluctuations in blood pressure that occurred during surgery.2) and is currently in a growth spurt. He remains asymptomatic and does not require antihypertensive medications.One year after the resection, the patient has gained weight and now his body mass index is within the normal range  and paragangliomas  is around 0.6 cases per 100,000 person-years . ParaganThe patient presented with the classic triad of palpitations, headaches, and profuse sweating. Other clinical manifestations may include panic attacks and generalized anxiety. Asymptomatic patients may be diagnosed when a mass is incidentally discovered or when tumors are actively searched for in a person with a genetic predisposition .Most paragangliomas are sporadic, but approximately 30% are associated with genetic syndromes such as neurofibromatosis type 1, von Hippel Lindau, Carney-Stratakis syndrome, multiple endocrine neoplasia 2A and 2B, paraganglioma syndromes 1 through 5 . The peaThe diagnosis was made upon corroboration of excessive release of catecholamines from the neuroendocrine tumor. The patient received a combined β- and α-adrenergic blockade prior to the surgical procedure in order to achieve blood pressure control and reduce the risk of intraoperative hypertensive crisis  Despite To confirm complete surgical resection, 24-hour plasma or urine metanephrines should be measured three to six months after surgery. If these levels are within normal ranges, an annual measurement should be performed in order to exclude recurrence, metastases, or new primary tumors . Follow-Paragangliomas are infrequent tumors that often manifest with headaches, profuse sweating, palpitations, and high blood pressure. These tumors may appear in any extra-adrenal paraganglia and occasionally develop in the diaphragm. Symptoms usually emerge between the third and fifth decade of life. The presence of this kind of tumor in a younger adult, adolescent, or child should raise questions about the possibility of an association with a genetic disorder. The adolescent growth spurt and puberty changes may be delayed in a patient with a hormone-producing paraganglioma and may initiate once the tumor is resected.