Hip synovial cysts are rare. However, in patients with Rheumatoid Arthritis (RA) they present in higher frequency than in general population. Herein, we present an unusual case of a 67-year-old man with RA that presented with unilateral leg oedema and Deep Vein Thrombosis (DVT). Computed tomography (CT) scan revealed a giant cystic lesion adjacent to the right hip joint with longitudinal diameter of 14 cm. Magnetic Resonance Imaging (MRI) confirmed the characteristics of the cyst. Interestingly enough, there was evidence of osteonecrosis of the femoral head. CT guided Fine Needle aspiration (FNA) of the fluid revealed fluid consistency similar to synovial fluid, while it excluded infectious process and malignancy. Patient was finally treated with total hip arthroplasty 3 months after the initiation of low molecular weight heparin (LMWH) in treatment dose. Synovial cysts arise after penetration of the synovium in the adjacent soft tissues either because of increased intraarticular pressure or as the result of a developmental defect.2 Synovial cysts are common in joints such as the knee, ankle, hand, and wrist, whereas the hip joint is a rare site of synovial cyst formation. Hip synovial cysts are mostly associated with degenerative joint conditions. In most cases, patients are asymptomatic and cysts are diagnosed incidentally on imaging studies. When enlarged, patients complain about groin or thigh pain, reduced range of movement, gait difficulty and manifestations due to compression of surrounding structures like vein stasis, vascular compromise, bladder and bowel disturbances, and nerve paralysis. In this case we describe the rare case of an RA patient presenting with a giant hip synovial cyst which caused leg oedema due to DVT and at the same time osteonecrosis of the femoral head. The diagnostic and therapeutic challenges are also discussed.Traditionally, cystic lesions related to hip joint are thought to be rare clinical entities. Cystic lesions can be either benign or malignant. Benign cystic lesions are further subdivided in synovial cysts, ganglion cysts and bursae.Figure 1). In the differential diagnosis groin abscess, lymph node block with central liquefaction, synovial cyst with inflammation and/or possible bleeding, epidermal cyst, and lymphangioma were included. MRI confirmed the characteristics of the lesion. However, a new manifestation has appeared, in the form of necrosis of the right femoral head with inflammation of periarticular soft tissues (fat and iliopsoas muscle tendon sheath) surrounding the hip joint . Regarding the aetiology of osteonecrosis, no trauma was reported, and subsequent laboratory workup excluded the presence of antiphospholipid antibodies, hypertriglyceridemia, or hyperlipidaemia. The patient claimed no smoking or alcohol use and was not receiving corticosteroids.A 67-year-old man with past medical history of seropositive RA (Rheumatoid Factor [RF] positive and anti-cyclic citrullinated peptide [a-CCP] negative) presented in the Emergency Department reporting painless unilateral right leg oedema. The patient was receiving leflunomide and adalimumab as treatment for RA. He denied injury of the limb and fever, while he noticed the oedema of the right leg getting progressively worse over the last two weeks. From physical examination, pulse was identified in femoral, popliteal, posterior tibial, and dorsalis pedis artery. Sensation was intact while there was restriction in the range of motion of the right hip joint (mainly in flexion and abduction) due to the oedema. There was circumference difference greater than 5 cm both at the mid-femur and mid-tibia level. Well’s score for DVT was 3 indicating high risk. As far as his blood results were concerned, C-Reactive Protein was found mildly increased . Thrombosis in the proximal part of the superficial femoral vein was detected with right lower limb venous triplex. At the same time, in the right groin a large cystic lesion with 9 cm diameter was identified. The patient was started on treatment dose low molecular weight heparin (tinzaparin) and was admitted to the hospital. DAS28 score was 3.44, indicating moderate disease activity. CT scan of the thorax and abdomen with intravenous contrast was performed to further characterise the cystic lesion and to rule out malignancy and possible compression of nerves and large vessels of the pelvis. No expansion of the thrombus was seen in the large veins of the pelvis. The cystic lesion in the right groin was containing inhomogeneous fluid, had internal septa, as well as contrast enhancement of its thin wall. It was located in front of the right femoral head and the right iliopsoas muscle in conjunction with the right hip joint with axial level diameter 7x6 cm and coronal dimension of 14,5 cm. There was no evidence of compression of the large vessels of the pelvis . Tinzaparin was stopped and the patient underwent total hip arthroplasty . Leg oedema resolved rapidly with spontaneous improvement in the range of movement.Given the increased risk for perioperative bleeding due to tinzaparin therapeutic dose and the increased risk for expansion of the thrombosis and/or pulmonary embolism decision was made for CT guided FNA of the cystic lesion. The microscopic examination of the aspirated fluid revealed 5800 WBC with 96% neutrophils, while the Gram stain was negative. No organisms and no mycobacteria were grown from the fluid culture, while in the fluid cytology no malignant cells were identified. The consistency of the fluid was similar to synovial fluid and the lesion was characterised as synovial cyst. After 3 months of anti-thrombotic treatment, right leg triplex was repeated, and complete resolution of the thrombus was confirmed, while the x-ray showed that the femoral head was totally destructed . We made the assumption that the increased intraarticular fluid pressure led to critical reduction of femoral head perfusion and subsequent osteonecrosis.7 As far as the cause of the synovial cyst is concerned, RA seems to be the ultimate culprit. Excessive fluid accumulation in the synovium of the hip due to chronic inflammation probably strangulated the vulnerable perfusing vessel.In general, hip synovial cysts are believed to comprise rare clinical entity. In literature, a few cases of large cysts have been described, causing significant symptomatology like inguinal masses, paraesthesia, nerve palsy and venous outflow obstruction and DVT. What makes this case of special interest, is the presence of a giant hip synovial cyst which caused both DVT and at the same time femoral head osteonecrosis. To our knowledge, there are only two published cases of huge hip synovial cysts leading to femoral head osteonecrosis.8 A recent large retrospective study on the prevalence of avascular necrosis among patients with prior oral corticosteroid therapy, found that low cumulative doses pose a small risk of development osteonecrosis.9 The development of osteonecrosis seems to be directly related to duration and total dosage of the medication.10 After reviewing our patient’s medical records, he had no need for glucocorticoids over the last five years and his RA seemed to be quite well controlled as indicated by medical records from outpatient’s clinic and inflammatory markers in laboratory results.Osteonecrosis, as identified in pathology specimens of the femoral head, is found in 12% of RA patients undergoing hip arthroplasty and it occurs mainly in 2 forms, ie, classic avascular necrosis and degenerative osteoarthritis. Both types are correlated to glucocorticoid use.11 As stated by Angelini et al degenerative joint diseases like osteoarthritis, rheumatoid arthritis and trauma are amongst the most common causes of synovial hip cysts.12 Other less common causes are developmental aplasia, labral tear, rapidly destructive arthrosis of the hip, juvenile idiopathic arthritis, polymyalgia rheumatica and hip arthroplasty.1Ye at al. published a case series with 15 patients with femoral vein compression secondary to hip synovial cyst. In two of them there was DVT (13.3%) while all of them presented with unilateral leg oedema.13 However, aspiration and drainage under ultrasound or CT guidance remains an option despite the higher chances of regression.11 It has previously been reported that if the primary disease is RA, effective treatment may reduce the size of the cyst.14 DAS28 in this gentleman was not high but it became obvious that it did not reflect the level of degeneration of the right hip joint caused by RA. As the synovial cyst of the hip joint caused vein compression and was also complicated with osteonecrosis of the femoral head, total hip arthroplasty was the only therapeutic option. In this case, the basic challenge was the decision regarding the best time to operate. In the literature most of the large synovial cyst cases associated with significant symptomatology were treated surgically immediately. For this patient, perioperative bleeding risk due to treatment dose LMWH precluded a prompt surgical intervention. Performing radiologically guided aspiration of the cyst allowed to establish the diagnosis and most importantly excluded the possibility of malignancy and infection, thus giving adequate time to the patient to complete a full 3-month course of therapeutic dose tinzaparin.Multiple treatment options are available for synovial cyst of the hip joint, depending mainly on the severity of the symptoms due to local compression, which depend on the size of the cyst and its location. Needle aspiration, with or without injection of steroids or sclerosing agents may be an effective treatment in asymptomatic patients without vessel or nerve compression. Femoral and/or iliac vein compression, arterial compromise and nerve compression constitute emergencies and thus, they require early recognition by the clinician and immediate treatment. In the presence of thrombosis appropriate treatment should be initiated either by LMWH or even with vascular filter insertion. As far as the treatment of the cyst is concerned, total hip arthroplasty has been chosen in most cases in literature.In conclusion, we report a relatively rare case of a giant synovial cyst in a rheumatoid hip, a potential life-threatening complication, managed successfully with surgical excision and total hip replacement due to femoral head osteonecrosis.


We report an extremely rare case of ovarian high-grade endometrioid stromal sarcoma arising from a mature cystic teratoma with clinicopathologic features, and then we briefly review the pertinent literature. A 62-year-old nulliparous woman presented with lower abdominal pain that had begun 6 months earlier. Magnetic resonance imaging showed two adnexal masses with fat components, which suggested that they were mature cystic teratomas. The eccentric thick rim of the left mass showed irregular invasion of the uterus, which was suggestive of malignancy. Positron emission tomography/computed tomography demonstrated high fluorodeoxyglucose uptake in the corresponding area. The patient underwent debulking cytoreductive surgery. The diagnosis was of an International Federation of Obstetrics and Gynecology stage IIIC high-grade endometrioid stromal sarcoma arising from a mature cystic teratoma. After surgery, the patient received adjuvant chemotherapy with three courses of doxorubicin regimen. The cancer recurred 3 months after surgery, and the patient died of progressive disease. It might be helpful for clinicians to be aware of this rare disease and the poor prognosis when it is at an advanced stage. Somatic neoplasms arising from teratomas are usually benign; in rare cases, malignant tumors may develop in the elements within a mature cystic teratoma (MCT) . In suchEndometrioid stromal sarcomas (ESSs) arise mainly from endometriosis. Their genetic alterations are similar to those in uterine endometrial stromal sarcomas. The majority of endometriosis-associated ovarian cancer was endometrioid or clear cell carcinomas . PrimaryA 62-year-old nulliparous woman presented with lower abdominal pain that had begun 6 months earlier. The patient had undergone menopause at 51 years of age. The patient was diagnosed with a dermoid cyst 20 years ago using pelvic ultrasonography, after which she had not undergone a follow-up pelvic USG examination. The patient had diabetes and no relevant surgical history. Serum tumor marker studies showed that the levels of squamous cell carcinoma antigen (SCC-Ag), alpha-fetoprotein (AFP), cancer antigen 125 (CA-125), CA 19-9, and carcinoembryonic antigen (CEA) were within normal ranges. On pelvic examination, a firm, fixed longitudinal mass without tenderness was detected.Transvaginal ultrasonography revealed two cystic adnexal masses, one on each side, with echogenic nodules with distal acoustic shadowing; their widest dimensions were approximately 8.6 cm and 7.4 cm. Abdominal computer tomography (CT) depicted a fat-containing mass in each adnexa, and the left-sided mass had an eccentric thick rim A. Axial The patient underwent debulking cytoreductive surgery, including a total hysterectomy, salpingo-oophorectomy, omentectomy, and pelvic/para-aortic lymph node dissection. A solid nodule 1.2 cm in diameter in the omentum was identified, but no other metastatic site was visible in the abdominopelvic cavity.2) every 3 weeks. After three cycles of adjuvant chemotherapy, whole abdominal ECT showed new lesions in the small bowel mesentery, left paracolic gutter, paraaortic L/N, and vaginal stump. The patient developed progressive disease and was treated with a palliative VIP  regimen. However, the cancer recurred 3 months after surgery, and the patient died of exacerbation of the disease within 5 months after the diagnosis was confirmed.Gross examination of the left-sided ovarian mass revealed cystic changes containing hair and necrotic fluid. The uterus itself was convex in shape, and the endometrium and myometrium were atrophied. Microscopic evaluation revealed that the left-sided mass contained mesenchymal cells of adipose tissue and epithelial components of skin  . MCTs arMost patients with MT-MCTs  are perimenopausal and postmenopausal, typically two decades older than those with benign MCTs . SarcomaHigh serum levels of SCC-Ag, CA-125, cancer antigen 19-9, CEA, and AFP may be suggestive of malignant transformation. A high concentration of tumor markers was shown to be associated with a poor prognosis but not with tumor size . In our Previous reports of MT-MCT imaging have been limited. Some imaging characteristics on CT and MRI could indicate malignant transformation when invasive growth of an irregular border forms an obtuse angle with the teratoma wall, when a solid mass is larger than 5 cm in diameter, and when extracapsular growth extends into adjacent structures ,15.The macroscopic appearance of tumors is typically solid and cystic, with or without a recognizable dermoid cyst . DermoidESSs are low-grade mesenchymal neoplasms with a structure resembling that of proliferative types of endometrial stroma . OvarianNo specific treatment has been recommended for ovarian ESS . AffecteMalignant changes of MCTs into squamous cell carcinoma should be suspected on the basis of the patient’s age, tumor size, imaging characteristics, and serum tumor markers ,3,5. TheMT-MCTs are often managed with cytoreductive surgery followed by adjuvant chemotherapy . HoweverThe prognosis of MT-MCTs depends strongly on stage, and most data are derived from cases of squamous cell carcinomas. With FIGO stage I tumors, the prognosis is favorable; the 5-year overall survival rate is 75–85%. In contrast, the 5-year overall survival rates for stages II and III tumors are less than 50% . The proMT-MCTs are rare gynecologic malignancies. Most information about these malignancies has been provided by descriptive series and reports of cases of squamous cell carcinoma. To better understand other tumors resulting from malignant transformations, such as adenocarcinoma and sarcoma, more detailed and specific studies of these rare entities are needed. To date, ovarian HG-ESSs have not been defined as MT-MCTs. The case of our patient shows that ovarian MCTs can undergo malignant transformation into HG-ESSs in the absence of endometriosis. The case of our patient suggests that older age and advanced stage HG-ESS confer a poor prognosis.Careful close follow-up and the correct timing of surgery are necessary because the risk of malignant transformation is high in patients with MCTs who are older, have large tumors, or have elevated serum levels of tumor markers.


During the development of the coelomic cavity, there is accessible communication between the urinary bladder and the umbilical wall through the urachus. Persistence of this tract results in urachal pathologies with variable symptoms. We present a case of an infected urachal cyst presenting as an umbilical mass with clear discharge in a 19-year-old male successfully managed laparoscopically. Urachal anomalies are developmental defects that arise during the formation of the urinary bladder and if infected may cause complications. These may present at various ages. Adults may present with a variety of clinical features depending on the subtype of the anomaly. These cases benefit from an early diagnosis, however, achieving the same can be a challenge due to the rarity of presentation and non-specific symptoms. These conditions are best managed by minimally invasive surgery. Our report highlights a case of urachal sinus and how it was managed with excellent results.A 19-year-old patient came to our outpatient department with a history of excruciating pain in the umbilicus region; later, the umbilicus was swollen and leaked a yellow-colored clear discharge without any ammoniacal smell. The discharge was continuous, not associated with pain, and had no periodicity. The patient also had three episodes of fever associated with discharge, followed by subsidence of both. The patient was evaluated elsewhere and referred with an ultrasound abdomen report suggestive of an umbilical granuloma.The patient was evaluated in our department. His vitals were stable, and he was afebrile at the presentation. On examination, there was 1cm x 1cm umbilical swelling that was tender on deep palpation, non-reducible, and without any discharge or cough impulse. The patient had a soft abdomen without generalized or localized tenderness, guarding, or rigidity.On routine abdomen ultrasound, a heterogeneously hypoechoic lesion measuring 5cm x 4cm was noted in the umbilical region, with features suggestive of umbilical granuloma seen without any intraperitoneal extension of lesion or collection. A contrast-enhanced computed tomography (CECT) of the abdomen was done, subsequently showing an umbilical soft tissue nodule with a connection to the preperitoneal space with no underlying collection suggestive of an infected urachal cyst Figure .The patient was prepared for a diagnostic laparoscopy and was assessed as fit for anesthesia as per the American Society of Anaesthesiologists (ASA grade 1). Intraoperatively an infected urachal cyst was seen arising from the dome of the urinary bladder of size 5cm x 4cm with a persistent fistulous tract opening into the umbilicus Figure .Laparoscopic excision of the urachal cyst with excision of the entire fistulous tract till the umbilicus was done. The integrity of the urinary bladder mucosa was checked intraoperatively after filling the bladder with normal saline, and no leak was detected. A thin drain was placed in the pelvic cavity whose output was recorded daily: 180cc on the first postoperative day gradually reduced to 50cc on the third post-operative day when the drain was removed. On discharge from the hospital, the patient was asymptomatic. He was followed up for four months and was back to playing competitive football tournaments. Histopathological evaluation of our resected specimen with hematoxylin and eosin (H&E) stain showed a partially opened cystic structure measuring 4.6x4.2x1.5 cm. The outer surface was covered with fatty tissues. The cut section showed an irregular granular surfaced cyst wall lining. The wall was variably thickened and firm. No growth was identified. Multiple representative sections were examined, showing fibro adipose predominantly, fibromuscular tissues with focal surface flattened epithelium and mostly atrophic denuded lining. Few lymphoid aggregates and several engorged dilated and some thrombosed thin-walled vessels were seen within the cyst wall. There was no evidence of enteric lining epithelium or malignancy. All findings were compatible with a benign urachal cyst Figures -6.An embryonic connection between the urinary bladder dome and umbilicus characterizes a urachus. The urachus is a vestigial remnant of the cloaca, which is the cephalic extension of the urogenital sinus, a precursor of the fetal bladder and the allantois which is a derivative of the yolk sac. In urachal anomalies, this tract is partially obliterated and lies in the extraperitoneal plane beneath the umbilicus . This isCompared to the article by Sreepadma et al., our case is unique. We have clearly demonstrated that the laparoscopy technique of excision of the urachal cyst has benefited the patient by providing excellent results in terms of surgery with early rehabilitation . The varThis case was an unusual presentation of a urachal sinus in this age group and was diagnosed appropriately because of a high index of suspicion. The in-depth histological slides confirm that most of these urachal cysts become symptomatic only after they get infected. Excising the complete urachal sinus tract extending from the urinary bladder to the umbilicus is the right surgical principle to achieve a complete cure and prevent any recurrences. Laparoscopy has not only helped this patient by supporting the diagnosis but it has also helped in the early rehabilitation of this patient. Understanding the anatomy and imaging features of urachal remnant diseases, along with the typical locations and distributions of these diseases, is essential for correct diagnosis and proper management.


Tumour seeding along the needle tract following core needle biopsy of the parotid is a recognised complication. We present a unique case of mucoepidermoid carcinoma of the parotid in an 18-year-old patient with associated tumour seeding within the core needle biopsy tract. Tumour seeding was confirmed both histologically and radiologically on magnetic resonance imaging as early as 35 days post-biopsy. The patient was treated successfully with a combination of surgery and adjuvant proton beam therapy. This case also visually demonstrates a surgical approach to en-block excision of the mass and tract. Mucoepidermoid carcinoma represents the most common type of parotid malignancy . ClinicaThis report describes a confirmed case of core needle biopsy seeding from a mucoepidermoid carcinoma of the parotid in a young patient, including confirmatory imaging and histology. To the author's knowledge, there is no radiological evidence of tumour seeding post-core needle biopsy of the parotid in the published literature. This case also visually demonstrates a surgical approach to en-bloc excision of the mass and tract.An 18-year-old female presented with a six-month history of a non-painful fluctuant swelling overlying the right parotid gland, with no facial weakness. The patient was a non-smoker, had no other co-morbidities, and only took a combined contraceptive pill. An ultrasound of the neck demonstrated a 15x14x10 mm, well-defined, homogeneously hyperechoic lesion within the superficial portion of the right parotid gland, suggestive of a pleomorphic adenoma. A 6 mm diameter intra-parotid lymph node was noted lying superiorly within the superficial lobe, non-pathological in appearance. The rest of the parotid gland appeared normal. Two 1 cm long ultrasound-guided core biopsies were obtained using 18-gauge cutting biopsy needles. Histopathological testing and fluorescent in situ hybridisation (FISH) testing for the MAML2 gene was performed. Morphological features, supported by FISH findings, were those of mucoepidermoid carcinoma. There were no high-grade features in the biopsy.Subsequent contrast-enhanced computed tomography (CT) of the neck and chest and magnetic resonance imaging (MRI) of the neck were performed 35 days later. CT imaging demonstrated a 3 mm indeterminate subpleural nodule within the right lower lobe, unlikely to represent metastasis. Follow-up CT imaging in three months was recommended. The MRI demonstrated a 1.5 cm enhancing nodule in the superficial lobe of the right parotid gland and a linear tract to the skin surface, suspicious for local tumour extension  and fine-needle aspiration cytology (FNAC) remain established techniques in the diagnosis of head and neck masses . NumerouReviewing the literature, tract seeding is frequently reported in the assessment of breast malignancy and these commonly present late postoperatively with a palpable mass. A published case report shows MR imaging of a tract seeding preoperatively with breast malignancy . The casAdjuvant treatment in the form of proton beam therapy (PTB) can be used as an alternative to intensity-modulated radiation therapy (IMRT) for patients with salivary gland tumours, as was the case with this patient. Some studies including a 2020 study by Chuong et al. have recommended that PBT be strongly considered when ipsilateral radiation therapy is indicated for major salivary gland cancer due to a significantly lower incidence of acute toxicity and hence side effects .In conclusion, we highlight the importance of histological diagnosis in the investigation of patients presenting with parotid masses even in low-risk patients. This case demonstrates, to our knowledge, the only radiological evidence of tumour seeding post-core needle biopsy of a parotid mass. It also visually and neatly demonstrates a general principle of en-block oncological resection when two foci of diseases are involved.


Infratemporal and pterygopalatine fossae (ITF and PPF) represent two complex paramedian skull base areas, which can be defined as jewelry boxes, containing a large number of neurovascular and osteomuscular structures of primary importance. They are in close communication with many craniofacial areas, such as nasal/paranasal sinuses, orbit, middle cranial fossa, and oral cavities. Therefore, they can be involved by tumoral, infective or inflammatory lesions spreading from these spaces. Moreover, they can be the primary site of the development of some primitive tumors. For the deep-seated location of ITF and PPF lesions and their close relationship with the surrounding functional neuro-vascular structures, their surgery represents a challenge. In the last decades, the introduction of the endoscope in skull base surgery has favored the development of an innovative anterior endonasal approach for ITF and PPF tumors: the transmaxillary-pterygoid, which gives a direct and straightforward route for these areas. It has demonstrated that it is effective and safe for the treatment of a large number of benign and malignant neoplasms, located in these fossae, avoiding extensive bone drilling, soft tissue demolition, possibly unaesthetic scars, and reducing the risk of neurological deficits. However, some limits, especially for vascular tumors or lesions with lateral extension, are still present. Based on the experience of our multidisciplinary team, we present our operative technique, surgical indications, and pre- and post-operative management protocol for patients with ITF and PPF tumors. Endoscopic surgery has undoubtedly improved the management of many skull base tumors in the last two decades ,2,3,4. RIndeed, these fossae are considered among the most challenging spaces for skull base surgeons for the high number of neuro-vascular and muscular structures of primary importance for craniofacial and meninges blood supply, sensory innervation of splanchnocranium, nasal and oral glands secretion, lacrimation, and mastication. Due to their communications with several important craniofacial areas, including the middle cranial fossa, the orbit, and the nasal and oral cavities, ITF and PPF are frequently involved by tumoral, infective, or inflammatory lesions spreading directly from these nearby spaces ,2,3,4. SHowever, these approaches require extensive cervical and temporal dissection, petrous bone drilling, and eventually zygomatic bone or mandibular ramus resection. Thus, they are burdened by a significant rate of soft tissue disruption, unaesthetic craniofacial scars, and a consistent risk of cranial nerves injuries ,6. To reIn the last years, the role of these anterior routes has been extensively reconsidered, thanks to the introduction of the endoscope in skull base surgery . Indeed,The aim of this article is to describe the anatomical and surgical bases of EEA to ITF and PPF tumors, reporting our surgical technique, indications, and limits, and our pre- and post-operative patient management protocol, illustrated by three exemplificative cases.The ITF is a wide bilateral trapezoid-shaped space, under the floor of the middle cranial fossa and posterior to the maxilla, bounded: (1) laterally by the medial surface of the mandibular ramus, (2) anteriorly by the posterolateral surface of the maxilla , (3) anteromedially by the lateral pterygoid plate, (4) superiorly by the infratemporal surface of the greater wing of the sphenoidal bone , and by the squamous part of the temporal bone, (5) posteriorly by the tympanic part of the temporal bone and the styloid process  19,20].,20.19,20The muscular structures of the ITF are the lateral and medial pterygoid muscles and the tendon of the temporalis muscle ,20,22. TThe sphenomandibular ligament, one of the temporomandibular joint stabilization structures, is located medially to the condylar process of the mandible, connecting the sphenoidal spine with the lingula of the mandible (spine of Spix), located close to the mandibular foramen . It reprThe structures of the ITF are mainly supplied by the maxillary artery, which originates from the external carotid artery near the posterior border of the condylar process of the mandible . Its couAfterward, the maxillary artery runs medial to the lateral pterygoid muscle in about 30–45% of cases and lateral in about 55–70% . The pteThe ITF contains the pterygoid venous plexus, formed by two portions in communication one with each other: a superficial, lesser represented, located between the temporalis and lateral pterygoid muscles, and a deep, usually larger, located between the lateral and medial pterygoid muscles, around the lingual and inferior alveolar nerves, embedded in fat and loose areolar tissue . The deeThe main neural structure of the ITF is represented by the mandibular nerve . It passes through the foramen ovale, and within the ITF it gives a first meningeal branch, which turns back through the foramen spinosum into the middle cranial fossa to supply the dura mater ,28. ApprThe PPF is a narrow space, bounded posteriorly by the pterygoid processes, medially by the perpendicular plate of the palatine bone, anteriorly by the maxillary tuberosity, and superiorly by the maxillary surface of the greater wing of the sphenoidal bone  28,32,3,332,33. The main arterial structure of the PPF is the pterygopalatine segment of the maxillary artery, which passes through the pterygomaxillary fissure ,30. It cThe most relevant neural structure of the PPF is the maxillary nerve , which passes through the foramen rotundum, after the release of a meningeal branch . Inside ITF and PPF can be involved either by primitive tumors or by the direct tumor invasion from other nearby areas. They can also be the site of metastatization from tumors located in different organs. Among primitive lesions, benign and malignant processes can arise from all the anatomical structures described above ,35,36. AJuvenile nasopharyngeal angiofibroma (JNA), schwannoma, neurofibroma, cavernoma, pleomorphic adenoma, epithelioid hemangioendothelioma, benign granular cell tumor, and meningioma are the most common benign neoplasms described. Malignant tumors include adenoid cystic carcinoma, chondrosarcoma, osteosarcoma, solitary fibrous tumor (high grade), and rhabdomyosarcomas.Hematological lesions such as eosinophilic granuloma, diffuse large B-cell lymphoma, and plasmacytoma should be considered in the differential diagnosis ,35,36. IAll patients require a preoperative evaluation with a neurological physical examination, computed tomography (CT) scan, and magnetic resonance imaging (MRI) with intravenous injection of a gadolinium-based contrast agent. Blood bio-humoral assays are also routinely performed, and specific hematological examinations are required in case of a specific clinical suspect.For tumors protruding in the paranasal sinuses or directly in the nasal cavity, an endoscopic inspection can be performed and, when indicated, can be followed by a biopsy. Furthermore, for all patients suspected to be affected by a vascular lesion, a preoperative angiography with embolization is accomplished 48–72 h before the surgical procedure to reduce the intra- and peri-operative bleeding risks.Imaging has a prime role in the management of skull base tumors. The continuous improvement in hardware, acquisition protocols, and advanced image analysis approaches has allowed for a more precise non-invasive assessment of the anatomy and pathological changes of this region. Moreover, coupling advanced imaging with digitally aided surgical techniques, such as image-guided neuro-navigation, has revolutionized the management of skull base tumors. Indeed, accurate preoperative planning with visualization of the vasculature, neural elements, and bone structures within the surgical field and image-guided neuronavigation has increased the efficacy and safety of surgery, ensuring safe resection and sparing vascular and neural injury . FurtherCombining the information provided by a CT scan and MRI, the ITF and PPF can be thoroughly investigated. High-resolution CT scan is considered the reference standard for assessing bone structures, whilst MRI is most suited for characterizing lesions, defining their extension, and assessing the presence of perineural spread providing key information for staging, treatment selection, surgical planning, and post-treatment follow-up ,41.1-weighted (T1W) MR images, the PPF appears hyperintense due to the presence of fat with interposed rounded or linear foci of signal void related to neurovascular structures such as branches of the maxillary artery; mild post-contrast enhancement can be seen also due to small emissary veins . Th. Th12]. In our technique, the patient lies in a semi-sitting position, the thorax slightly elevated (30°), and her/his head tilted toward the first surgeon (20°). Oro-tracheal intubation with the packing of the oropharynx is necessary to prevent blood leakage into the stomach. Surgeries are carried out using HD 2D endoscopes  with a high-definition camera and with the adoption of a neuronavigation , based on a CT angiogram (CTA), processed through StealthMerge Software , and intra-operative EcoDoppler . Based on the tumor extension, a bi- or mono-nostril (with posterior septostomy) approach was chosen.The first step of surgery consists of the anteromedial maxillectomy, which requires the complete or partial resection of the inferior nasal concha. This allows the surgeon to identify the natural ostium of the maxillary sinus (semilunar hiatus), which is progressively enlarged to realize the medial maxillectomy . The froThen, the perpendicular plate of the palatine bone is drilled out, exposing the sphenopalatine artery, which is coagulated or ligated, preventing any bleeding at this site. Further exposure of PPF and ITF may be facilitated by resecting the medial pterygoid plate and the floor of the sphenoidal sinus, at the level of the pterygoid canal . The ideAfter removal of the posterolateral wall of the maxillary sinus, it is possible to open the periosteum of the ITF and PPF, obtaining access to the pterygopalatine  and infratemporal  regions . From thTumors are resected with a bimanual technique. We prefer to fix the endoscope on a holder to use a two surgeons-four hands technique. For benign lesions, the progressively central debulk of the mass is performed and then the tumor is cleaved from the surrounding anatomical structures. Conversely, for malignancies, the lesion is resected in large blocks from the periphery to the center to achieve free surgical margins, confirmed by frozen sections, eventually sacrificing neuro-muscular structures to obtain negative surgical margins. The maxillary artery requires to be legated or clipped as soon as they are identified during the tumor removal, to avoid intra- or post-operative bleedings.At the end of the surgery, the surgical access in the posterior wall of the maxillary sinus is covered by graft or a pedicled flap of mucoperiosteum from the septum or a nasal concha. Whether the inferior nasal concha was only partially resected at the beginning of surgery, it can be re-sutured and put back in its position. Nasal cavities are packed to prevent post-operative bleeding.In the postoperative course, the restoration of spontaneous breathing is obtained at awakening immediately after removal of oro-tracheal intubation. Oral feeding is resumed within 6–8 h after surgery. Nasal packings are removed 48 h later, and patients are discharged from hospital after 3–4 days. We perform a NECT at 6 h after surgery and a post-operative MRI with a gadolinium-based contrast agent within 3 days to assess the degree of tumor resection and detect early surgical complications. If no intra-operative CSF leak occurred, the patients could start a cautions mobilization the same day of surgery; otherwise, 3 days of bed rest are prescribed with antithrombotic prophylaxis.Follow-up consisted of an endoscopic endonasal medication performed within 30 days from surgery. MRI with gadolinium-based contrast agent and a neurological evaluation were repeated at 3 months. Then, clinical and neuroradiological follow-up was performed at regular intervals of 6–12 months, depending on the pathological diagnosis. For malignancies, complementary therapies (radiotherapy and/or chemotherapy) were performed based on the histological characterization of the tumor .A 53-year-old man came to our attention for the progressive onset of paraesthesiae on the left territory of the maxillary nerve for a few months. A CT scan showed an isodense mass in the left PPF, confirmed by the following MRI, which demonstrated a tumor hypointense in T1 w-sequences, hyperintense in T2 w-sequences, and inhomogeneously enhancing after contrast agent . Past meThe patient underwent an EEA for the PPF tumor through a transmaxillary-pterygoid approach. After removal of the posterior wall of the maxillary sinus, the tumor was identified. A frozen section was positive for the diagnosis of adenoid cystic carcinoma. The lesion was initially debulked, then it was removed in large blocks from the periphery to the central portion. The frozen sections from the maxillary nerve demonstrated neoplastic infiltration up to the foramen rotundum, and the nerve was consequently resected at this level . SimilarThe postoperative course was unremarkable. The patient was awakened at the end of surgery and oral feeding was resumed the same day. He was discharged 3 days later with a hypoesthesia in the V2 territory, which was unchanged in comparison to the pre-operative examination. Post-operative MRI confirmed the complete tumor resection . He perfA 69-year-old female was referred to our center for the progression of a large PPF and ITF tumor. The patient had a long history of hypoesthesia with paranesthesia in the territory of the left mandibular nerve and masticatory difficulties. After an MRI, showing the skull base lesion, a radiosurgical treatment was performed. During the follow-up, symptoms worsened, and at neuroimaging, an increase in the dimension of the mass was confirmed. At MRI, the tumor was hypointense in T1 w-sequences and hyperintense in T2-w with inhomogeneous contrast enhancement . At physA transmaxillary-pterygoid endoscopic approach was chosen. After the resection of the posterior wall of the maxillary sinus, a mass with a soft consistency was observed. A central debulking was performed and the tumor was progressively cleaved from pterygoid muscles, dura of the middle cranial fossa, and floor of the orbit. The maxillary artery was clipped during tumor resection . The hisShe was awakened at the end of the surgery, with immediate restoration of spontaneous breathing and recovery of oral feeding on the same day. The patient was discharged home 3 days later with a hypoesthesia in the V3 territory, which was unchanged in comparison to pre-operative examination. Post-operative MRI showed the radical tumor resection . At 41 mA 28-year-old female presented hypoesthesia in the territory of the left mandibular nerve and masticatory difficulties for a few months. Medical history was unremarkable. MRI demonstrated an ITF and PPF tumor, which was hypointense in T1 w-sequences and hyperintense in T2-w with a peripheral contrast enhancement . At physThe patient underwent a transmaxillary-pterygoid endoscopic approach. After the resection of the posterior wall of the maxillary sinus, a firm bleeding tumor was observed. Tumor resection was performed, starting with a central debulking. Afterward, the mass was progressively cleaved from the pterygoid and temporalis muscles and from the dura of fossa media without any intra-operative CSF leak. Resection resulted in radical preservation of the anatomical structures . HistoloThe post-operative course was unremarkable, with awakening and restoration of spontaneous breathing at the end of surgery and recovery of oral feeding on the same day. The patient was discharged home 3 days later with unchanged hypoesthesia than the pre-operative examination. The post-operative MRI showed complete tumor resection . At 38 mThe EEA is undoubtedly becoming one of the most relevant approaches for a majority of lesions involving the nose and paranasal sinuses, and for a great number of median and paramedian skull base tumors . The maiAlthough the use of a transmaxillary route for ITF and PPF lesions has been suggested since 1858, the lack of an adequate visualization system along such a long and deep corridor has prevented its use for decades ,51. It hFor these reasons, limited attempts to remove endoscopically tumors of ITF and PPF have been performed in the following years . It is oAn important requisite to approach the ITF and PPF by an endoscopic transmaxillary-pterygoid route is the anteromedial maxillectomy, which permits a great exposure of the most lateral portion of the posterolateral wall of the maxillary sinus and consequently of the most lateral portion of these fossae. An alternative to the anteromedial maxillectomy is represented by the Caldwell–Luc transmaxillary approach, as proposed by Theodosopoulos et al., to reduce the risks of cosmetic deformity and avoid the inferior nasal concha removal with less disruption of the nasal function . HoweverMoreover, EEA for ITF and PPF requires a long training curve, and it should be considered an advanced procedure, to be performed in dedicated referral centers . We stroThe EEA is providing an excellent visualization, angle of attack, and working space for selected ITF and PPF benign and malignant tumors. Its main advantages are the reduced transient and permanent morbidity with a low neurological deficits rate and absence of craniofacial scars. It is routinely adopted for primary tumors, but also for lesions deriving from nearby surrounding areas. It can be combined with other open or minimally invasive skull base approaches, such as transcranial, temporal, transorbital, or other routes, to manage also more complex tumors. Normally, it is well tolerated by patients, with quick patient recovery, reduced post-operative discomfort or pain, and, thanks to fast resuming of patients’ normal life activities, it would permit an early access to complementary treatments, when necessary.Its main limits are represented by the long training curve and by the need for excellent knowledge of the anatomy of these areas, combined with the use of advanced technological devices, to avoid injuries to nervous and vascular structures, whose formal proximal control, especially for vascular or malignant lesions, remains the main limit of this route.Careful pre- and post-operative patient management is of primary importance, and each treatment should be carefully planned and discussed in dedicated multidisciplinary skull base boards.


Pleomorphic xanthoastrocytoma (PXA) is a rare glioma that affects 1% of astrocytic tumors. It most commonly affects children and teenagers. PXA cases with an anaplastic histopathological subtype have been reported in recent years. It was recently classified as a separate subtype in the 2016 World Health Organization (WHO) classification of central nervous system (CNS) tumors. A 48-year-old healthy gentleman presented with progressive right upper limb weakness. CT and MRI of the brain were done, which showed an intra-axial supratentorial tumor. A diagnosis of high-grade glioma was initially made based on its imaging features. The histopathological study came back as anaplastic pleomorphic xanthoastrocytoma. After a discussion with the neurosurgical and oncology teams, a decision was made to treat the patient with radiotherapy. In this case report, we describe a rare case of PXA with anaplastic characteristics. The World Health Organization (WHO) added molecular characteristics to its classification of central nervous system (CNS) tumors in 2016, redefining and articulating how CNS tumors should be constructed in the molecular era. Pleomorphic xanthoastrocytoma (PXA) is a low-grade astrocytic neoplasm that accounts for 1% of astrocytic tumors , and it A 48-year-old male with no prior history of medical illness presented with evolving right upper limb weakness for one month prior to admission. His family members noted that he was also less talkative during this period. No family history of malignancy or mental illness was reported. On first assessment, his Glasgow Coma Scale (GCS) was 15/15 with preserved high cortical functions. Muscle strength of the right upper limb was reduced to 4/5 with the presence of hyperreflexia. The power of other limbs was preserved with intact sensation. Cranial nerves function was normal. CT and MRI of the brain were performed urgently. It revealed a well-defined peripherally enhanced left frontal lobe intra-axial cystic mass associated with surrounding vasogenic edema. It measured approximately 4.4 cm x 3.8 cm x 4.1 cm (anterior-posterior (AP) x width (W) x craniocaudal (CC)) Figures -1D, 2 wiPleomorphic xanthoastrocytoma occurs in both men and women in their second decade of life. Most patients with APXAs were middle-aged in the research by She et al., with an average age of 47.7 years old at presentation time . These tAPXA is rare and often has more aggressive radiological features which can mimic the high-grade astrocytomas than pleomorphic xanthoastrocytomas, but it is a distinct tumor type that needs to be identified and treated separately from PXA. Imaging and histopathological examination could guide the clinician to a correct diagnosis and treatment planning.


Isolated colon injuries following blunt abdominal trauma have been reported with an incidence of 0.1-0.5 %, with sigmoid colon involvement being a rare entity. The sigmoid colon is reportedly involved only in 34.8% of isolated colonic injuries. The most common cause of colonic injuries is motor vehicle accidents. Contrast-enhanced computed tomography has a role in blunt trauma-induced bowel injury evaluation, with 82% accuracy and 64% sensitivity, but its role in the diagnostic evaluation of colonic injuries is controversial.Surgical treatment comprises primary closure, resection with or without anastomosis, and/or colostomy formation. Primary anastomosis is often favored, while colostomy creation is generally required if devascularized bowel segments present or infrequently in hemodynamic instability scenarios. Subsequent gross presentation, treatment delays due to diagnostic difficulties, and scarcity of management guidelines contribute to high morbidity and mortality. Additional research is required to accurately define patient presentation and explore the benefits of different surgical treatment options.Hereby is a case series comprising three adult male patients who presented with delayed diffuse severe abdominal pain and distension following blunt abdominal trauma. Computed tomography evaluation in the latter two had findings suggestive of pneumoperitoneum. Post resuscitation, exploratory laparotomy done in each patient denoted isolated sigmoid colon perforation with and without associated mesenteric hematoma. The decision of primary closure, resection with rectosigmoid anastomosis, and resection with end colostomy creation was taken in respective cases based on intraoperative findings of contamination, vascularity, and hemodynamics. Previously documented reports have mentioned findings of associated intra-abdominal solid organ injuries, which were absent in the present case series.  Isolated colon injuries following blunt abdominal trauma have been reported with an incidence of 0.1-0.5 % , with reCase 1A 30-year male with a two-day history of diffuse severe abdominal pain, abdominal distension, and obstipation presented following a motor vehicle accident three days ago. No comorbidities/ prior surgical history was stated. The patient was alert, conscious, and oriented; temperature 96.8 F, pulse 116/min, and blood pressure 114/58 mmHg, Glasgow coma scale (GCS) was 15 (E4V5M6) at presentation. On examination, abdominal tenderness and rigidity were present, but shifting dullness or fluid thrill was absent and bowel movements were sluggish. Routine biochemical parameters  were normal. Chest X-ray (PA {posteroanterior} view) and abdominal X-ray (AP {anteroposterior} erect view) were unremarkable. The patient was hemodynamically deranged and was taken for upfront laparotomy without CECT (contrast-enhanced computed tomography) abdomen evaluation as per hospital protocol.Intraoperatively, 200 ml contaminated intraperitoneal fluid was aspirated and a 1 x 0.5 cm perforation present over the anterior aspect of the distal sigmoid colon at the antimesenteric border was noted . On examination, abdominal tenderness and rigidity were present in the lower quadrant, and bowel movements were normal. Biochemical parameters  were normal. Chest X-ray (PA view) and abdominal X-ray (AP erect view) were unremarkable. CECT abdomen with intravenous contrast demonstrated an edematous sigmoid colon loop and free fluid in the pelvis Figure , suggestIntraoperatively, 500 ml sanguineous intraperitoneal fluid was aspirated and gross fecal contamination and membrane formation over large and small intestine areas was noted. A 2 x 1 cm perforation over the anterior aspect of the distal sigmoid colon near the antimesenteric border was present Figure . A 1.5 cCase 3A 64-year male presented with a two-day history of severe lower abdominal pain following a fall from height four days ago. He was on oral medications for Type 2 diabetes mellitus for 5 years with a controlled diabetic profile. He had a history of laparotomy for gastric perforation 18 years ago. The patient was alert, conscious, and oriented, temperature 98.4 F, pulse 118/min, and blood pressure 116/64 mmHg, GCS was 14 (E4V4M6). On examination, abdominal distension, diffuse abdominal tenderness, and rigidity were noted. Shifting dullness was present and bowel movements were sluggish. Leucocytosis (27000 per cubic millimeter) was noted. Chest X-ray (PA view) demonstrated bilateral hemopneumothorax. Abdominal X-ray (AP erect view) was suggestive of possible pneumoperitoneum with distended bowel with multiple air-fluid levels. CECT abdomen with intravenous contrast was suggestive of hemoperitoneum and sigmoid colonic ischemia with distended proximal bowel loops, while pneumoperitoneum was suspected and solid organs appeared normal Figure . BilaterIntraoperatively, 1500 ml sanguineous intraperitoneal fluid was aspirated and gross fecal contamination and mental clumping near the splenic flexure and sigmoid colon region were noted. The distal sigmoid segment was gangrenous Figure . The resIsolated colon involvement is a relatively common occurrence in penetrating injuries to the abdomen, but a rare entity after blunt abdominal trauma, with the reported incidence being 0.1- 0.5% . Road TrProposed mechanisms for colon injuries post blunt abdominal trauma are (i) bowel crushing against vertebrae; (ii) rapid pressure accentuating involvement of specific narrow segments of the colon, and (iii) colonic/ mesentery shearing -5. The rNo clinical or radiological method has adequate accuracy in diagnosing blunt traumatic colon injuries . Blood-sSurgical treatment comprises primary closure of perforation, or resection of the perforated segment with/without anastomosis and/or colostomy formation -3. Most Isolated sigmoid colon perforation post blunt trauma has a low reported incidence. Diagnostic dilemmas and treatment delays subsequently increase morbidity and mortality rates. Hence high index of suspicion is required to reach a prompt diagnosis. A specific definitive management algorithm is required to be formulated. Additional research is required to define the patient population likely to benefit from surgical maneuvers and explore the application of different surgical treatment options.


Desmoid-type fibromatosis (DTF) is a rare benign lesion that usually arises from the abdominal wall or extremities and rarely from the mesentery or intrabdominal organs. Malignant peritoneal mesothelioma is also a rare, yet aggressive disease. To our knowledge, this is the first case report of desmoid-type fibromatosis in the setting of malignant peritoneal mesothelioma.An early 30-year-old female was referred to our center for large intra-abdominal mass concerning for recurrent malignant peritoneal mesothelioma after previous cytoreductive surgery with hyperthermic intraperitoneal chemotherapy and adjuvant chemotherapy. Further investigation revealed a large mesenteric mass, which was resected en bloc with the cecum and terminal ileum. Pathologic findings confirmed a surprising diagnosis of desmoid-type fibromatosis.No adjuvant therapy was offered to this patient due to negative tumor margins; however, close follow-up will be provided for recurrence of both malignant peritoneal mesothelioma and desmoid-type fibromatosis, which can be differentiated in the future via biopsy in this patient. Malignant peritoneal mesothelioma and desmoid-type fibromatosis (DTF) are rare neoplasms. Malignant peritoneal mesothelioma is an aggressive and lethal disease with overall survival of 6 months at best if left untreated , 2. On tA Hispanic female in her early 30s initially presented in 2017 with months of abdominal discomfort and distention. CT imaging showed a left ovarian lesion and marked ascites. Patient underwent a paracentesis and diagnostic laparoscopy which revealed peritoneal nodular implants with pathology confirming peritoneal mesothelioma with positivity for CK5/6, CK7, keratin AE3/AE1, and podoplanin (D2-40). Patient was referred to the USA in 2018 for treatment where she underwent a cytoreductive surgery with HIPEC with mitomycin C for well-differentiated epithelioid mesothelioma. Patient’s peritoneal cancer index (PCI) was 24, and completeness of cytoreduction score was 0. Tumor was positive for calretinin, CK5/6, and CAM5.2 and negative for MOC-31 and CEA. She was without symptoms or radiographic evidence of recurrence for 2 years, until she presented to her home hospital with fevers, hypotension, abdominal pain, and distention. On examination, she had a palpable abdominal mass with MRI showing a hypointense lesion with air fluid levels measuring 10.5 × 10.7 cm and multiple mesenteric nodules. She was taken for exploratory laparotomy, partial mesenteric mass excision, and evacuation of intra-abdominal abscess. Complete excision was not performed during initial operation due to involvement of surrounding bowel and mesenteric vessels. Immunohistochemistry was positive for podoplanin, calretinin, and CK5/6 and negative for desmin and anti-CD117. Patient was referred to our facility for further treatment, with restaging laparoscopy performed in December 2020. Due to prior incomplete resection and to potentially facilitate re-resection, five cycles of neoadjuvant cisplatin and pemetrexed were then administered. In June 2021, the patient underwent restaging CT which revealed essentially stability of the mesenteric mass (9.3 × 5.7 × 7.3 cm) with central air and fluid and multiple enhancing mesenteric nodules  were encountered when evaluating the bowel, repeat HIPEC was not performed due to substantial sclerosis associated with the deeper mesenteric nodules. Patient’s PCI was 2, and completeness of cytoreduction score was 0. Pathology revealed spindle cell proliferation in a collagenous stroma with nuclear staining positive for beta-catenin, positive calretinin and CK7, and negative DOG-1 staining. This pathology revealed a new diagnosis: desmoid-type fibromatosis.Despite concern for recurrent peritoneal mesothelioma, this patient’s pathology revealed a benign intra-abdominal tumor: desmoid-type fibromatosis. Although DTF is not malignant, it can be a locally aggressive neoplasm that causes significant morbidity and occasional mortality . While DInterestingly, there are case reports of desmoid fibromatosis diagnosed initially as malignant mesothelioma, based on immunohistochemical (IHC) calretinin positivity. Calretinin is an intracellular calcium-binding EF-hand protein that is widely used as a positive marker in diagnosis of malignant mesothelioma . The mosTreatment strategies for DTF are controversial. Historically, surgical resection with microscopic negative margins was standard of care. However, a new strategy of observation has emerged due to conflicting data on the impact of complete microscopic resection on recurrence . In factAs a result of her most recent surgery, tumor margins were negative; therefore, no adjuvant therapy was offered following surgical resection. In patients who are not surgical candidates or who undergo incomplete resection, adjuvant therapy can be considered in the form of radiation or systemic therapy. Radiation may confer some benefit in terms of improved local control after incomplete resection; however, no prospective randomized data is available . For intOverall, DTFs are rare soft tissue tumors. Because DTFs can occur in a wide variety of locations, such as chest wall or abdomen, they can simulate mesothelioma. This case illustrates the use of immunohistochemistry to differentiate similar rare pathologies in order to provide correct treatment and management for patients. Currently, our patient is alive and undergoing active surveillance for both peritoneal mesothelioma and DTF, with no signs of recurrence. In addition, due to the benign nature of the pathology and complete surgical resection, we did not feel that further systemic chemotherapy was appropriate at this time. In the future, suspicious lesions in this patient may be biopsied to accurately differentiate etiology using IHC. It is important to note that while DTFs have initially been diagnosed as malignant peritoneal mesothelioma, there have been no case reports to our knowledge of DTFs in the setting of an additional diagnosis of malignant peritoneal mesothelioma.


A 9-year-old female mixed-breed dog presented for treatment of a presumed sphenoid-wing meningioma. Clinical signs included tonic-clonic seizures lasting <1 min, which had started 3 months previously. The physical examination results were unremarkable. An eccentrically located neoplastic cystic structure in the right sphenoid bone region suggestive of a meningioma and peritumoural brain oedema was observed in pre-operative magnetic resonance imaging (MRI). Prior to surgery, a three-dimensional (3D) patient-specific pointer (PSP) was designed using computed tomography (CT) images and computer-aided 3D design software. After a targeted approach and exposure of the lateral part of the right temporal lobe by a craniectomy guided by the 3D-PSP, complete macroscopic piecemeal resection of the meningioma could be performed using endoscopy-assisted brain surgery. Post-operative MRI confirmed complete excision of the tumor. Anticonvulsive therapy was discontinued after 90 days, and the dosage of anticonvulsants was tapered 2 weeks after surgery. At a follow-up examination 225 days post-operatively, recurrence of seizures was not observed, and the absence of tumor recurrence was confirmed by a repeat MRI examination. To the best of our knowledge, this is the first report in veterinary medicine describing a successful resection of a sphenoid-wing meningioma using a 3D-PSP. 3D-PSP-assisted craniectomy may be a surgical option for some canine skull-based tumors, such as sphenoid wing meningiomas. Meningiomas are the commonest primary intracranial canine tumors, especially in large-breed dogs, representing 49–51.5% of all intracranial neoplasms . MeningiPre-operative surgical planning and accurate perioperative surgical techniques are essential to achieve good functional results , 9, 10. Very few reports of veterinary skull-base meningiomas seem to exist , 10, 15.A 9-year-old, female mixed-breed dog with a body weight of 15.1 kg and a body condition score of 5/9 was referred for generalized seizures and meningioma. The reported clinical signs included tonic-clonic seizures lasting <1 min, which had started 3 months prior to presentation, and decreased appetite. Hematological and blood investigation results were within normal limits except for the liver panel findings. The levels of alanine transaminase, alkaline phosphatase, and γ-glutamyl transferase levels were mildly elevated.At presentation, the physical and neurological examinations were normal. The computed tomography (CT) and magnetic resonance imaging (MRI) examinations performed at the referring veterinary clinic had discovered a large eccentrically located cystic structure under the right sphenoid wing. The marked uniform contrast enhancement of the heterogeneous cystic remainder was confirmed on CT and MRI. In addition, contrast enhancement revealed well-defined, broad-based tumor margins conforming to the meningeal plane. This structure showed heterogeneous, intratumoural fluid accumulation characterized by an enlarged, sharply defined outer margin with a significant hyperintense signal and peritumoural oedema on T2-weighted images. Based on the imaging characteristics , cystic The lesion resulted in mass effect, intracerebral oedema, and associated signs such as generalized seizures, which were indications for intervention in this case. CT was used to measure the extent of bony invasion or hyperostosis due to the possibility of the tumor infiltrating the skull bone. T2-weighted MRI imaging identified intraparenchymal oedema and important structures such as the cavernous sinus and optic nerve. Schematic images were prepared for pre-operative planning using CT and MRI, which demonstrated the approximate relationships among the tumor, cerebral arteries, optic nerve, and bony landmarks ,B. The tin-silico planning and in-vivo measuring techniques.In human medicine, lateral and middle sphenoid-wing meningiomas can be resected using pterional craniotomy, but this is a challenging technique due to closely located neurovascular structures such as the optic nerve, the cavernous sinus, and the middle cerebral artery . The relSurgical planning, including confirmation of the location, size, and shape of the 3D-PSP and identification of the exact location of the tumor, was performed using computer-aided 3D design software  applied to the MRI and CT images , 21. ThiPostcontrast CT images  of the patient were obtained in the DICOM file format  and converted to stereolithography files. Segmentation, 3D model reconstruction, and prosthesis design were then performed using computer-aided design software . The design process required ~1 h  according to a previously described protocol . PrintinMidazolam  and propofol  were used to induce anesthesia. After intubation, oxygen and total intravenous anesthesia were used to maintain anesthesia prior to durotomy. The drugs used for total intravenous anesthesia were propofol  and remifentanil . Anesthesia was maintained with isoflurane  post-durotomy. Plasmalyte  was administered throughout the surgery. Prior to surgery, the dog received phenobarbital , prednisolone , dexamethasone , cefazoline , maropitant , and mannitol .The surgical procedure was based on sphenoid-wing craniectomy –24. The After exposing the tumor using the pointer, we maximized visualization of the surgical site using an endoscope. Under endoscopic visualization, durotomy was performed using a #11 scalpel and micro-scissors, and the ventrolateral aspect of the lateral temporal lobe was exposed under an enhanced surgical field , 22, 23.Post-operatively, temperature, pulse, respiratory rate, capillary refill time, blood pressure, auscultation, and neurological status were monitored. Post-operative analgesia was provided with remifentanil  while observing the patient's pain reaction for the first 12 h. The analgesia was terminated the next day, and the patient was encouraged to walk. Hartmann's solution (2 mL/kg/h CRI) was administered for 24–36 h. The patient received cefazoline  for the first post-operative week, and phenobarbital  was tapered over 3 months post-operatively. The clinical features and the results of histopathological examination of the surgically resected tissue samples were suggestive of a grade 1 meningothelial meningioma .Thirty-two days after surgery, the patient was readmitted to our clinic because of fluid fluctuations at the surgical site. The owner reported that the patient repetitively scratched the surgical site at home. Ultrasound was used to discriminate the fluid, and the presumptive diagnosis was seroma. The fluid was red, and analysis showed a haematocrit level of 4.5% and total nucleated cell count of 24,910 cells/μL. The seroma responded well to surgical debridement and application of a Barovac drainage tube , which provided continuous negative pressure.The follow-up observations comprised repeated neurological and MRI examinations for 296 days post-surgery. Recurrence of seizures was not observed, and complete tumor resection with resolution of peritumoural brain oedema was confirmed by repeated MRI .This is the first case report describing a feasible, endoscopy and 3D-PSP–assisted, sphenoid-wing meningioma resection in a canine patient. The PSP allowed us to perform the craniectomy targeting the brain tumor. Complete macroscopic piecemeal resection of the sphenoid-wing meningioma was performed accurately without injuring the main blood vessels. The patient had a good clinical outcome without significant complications over 296 days of follow-up.Sphenoid-wing meningiomas are a type of skull-base tumor , 4. Ther3D-printing technology offers significant advantages for neurosurgery. 3D-printed material can facilitate presurgical planning by converting visual images into tactile models . SurgeonIn human medicine, the surgical management of sphenoid-wing meningioma is reportedly challenging because of the deep and narrow surgical site in the skull base and the proximity of critical neurovascular structures such as optic nerves and arteries , 23, 29.This study had some limitations. First, the duration of time required to design and print the 3D-PSP models was relatively long , 18, 19.We demonstrated that sphenoid-wing meningioma could be safely approached by endoscopy-assisted 3D-PSP without requiring NN. Clear visualization resulted in complete resection of the skull-base meningioma. The described method is a viable option for performing skull-base craniectomy in dogs.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Ethical review and approval was not required for the animal study because was a case report. We did the surgery. Written informed consent was obtained from the owners for the participation of their animals in this study. Written informed consent has been obtained from the owner of the animal to publish this paper.JS, YR, and HL managed the case and wrote and edited the manuscript. HL, YR, and JS performed the surgeries. YR and FF critically reviewed and revised the manuscript. JJ supervised the clinical management of the patient. All authors contributed to the preparation of the manuscript and have approved its publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Benign tumors represent less than 1% of esophageal neoplasms. Esophageal leiomyoma is a very rare tumor that arises from mesenchymal tissue.We present here a case of leiomyoma of the esophagus which was revealed by dysphagia and vomiting that was treated by surgical enucleation.This report illustrates the case of a female who presented with dysphagia and vomiting. Imageology demonstrated an esophageal mass which was treated with surgical enucleation. Histopathology confirmed the diagnosis of leiomyoma.Benign esophageal tumors are rare. Leiomyoma commonly presents as a single lesion in the middle or lower third of the esophagus. Leiomyomas located in the proximal and middle third of the esophagus can be operated on by right thoracotomy. Surgical treatment varies from enucleation to esophageal resection depending on the size and location of the mass. In our case, the tumor was enucleated by a right posterolateral thoracotomy.Esophageal leiomyoma is a benign and generally asymptomatic tumor. Surgery is the pillar of treatment. Enucleation should be performed whenever possible to avoid esophagectomy and thus decrease morbidity and mortality. •Esophageal leiomyoma is a very rare tumor that arises from mesenchymal tissue.•An enhanced computed tomography scan with oral contrast or endoscopic ultrasonography is essential to assess the diagnosis.•Surgery consists of enucleation or esophagectomy depending on the location and size of the tumor. Esophageal leiomyoma is a very rare tumor that arises from mesenchymal tissue. It is the most common benign tumor of the esophagus More than 50% of the patients are asymptomatic and are diagnosed incidentally while others may present dysphagia or epigastric pain Surgery is the cornerstone of treatment. It consists of transthoracic extra mucosal blunt enucleation. Esophagectemy is sometimes necessary in presence of giant leiomyomas We present here a case of leiomyoma of the esophagus which was revealed by dysphagia and vomiting that was treated by surgical enucleation.This work has been reported in line with the SCARE 2020 criteria 2A 47-year-old female, hypertensive, complained of dyspepsia and esophageal reflux.She presented gradually worsening dysphagia and vomiting six months earlier.The general physical examination and laboratory findings were normal.A gastroesophageal fibroscopy showed compression of the middle third of the esophagus .Fig. 1GaAbdominal computed tomography (CT) scan revealed a moderately enhancing 30 mm oval posterior mediastinal mass extending over 60 mm, displacing the esophagus in its middle third and coming into contact with the descending aorta with the pericardium .Fig. 2CTMagnetic resonance imaging (MRI) was showed a tissue mass of esophageal origin under the mucosa presenting contact with the posterior pericardium and with the anterior wall of the aorta over 10 mm .Fig. 3ChSurgery was planned and was performed by a 20-year experience surgeon.We performed a right posterolateral thoracotomy at the level of the 5th inter-costal space.The exploration highlighted a 6 cm hemi-circumferential poly-lobed whitish mass, adherent to the pericardium and the aorta .Fig. 4InMeticulous dissection was performed all around the esophagus and the tumor was enucleated.The esophagus has been checked for leaks.Histopathology revealed neoplastic spindle cells arranged in bundles without significant cellular atypia . ImmunohThe postoperative course was uneventful with a follow-up of eight months.3We reported a successful surgical enucleation for an esophageal leiomyoma. The main strength of our work is the choice for an enucleation avoiding unnecessary esophagectomy and thus decreasing morbidity and mortality.The main weakness of our work is the choice for a thoracotomy instead of mini-invasive surgery. Our choice is explained by the preoperative imaging showing contact of the tumor with aorta and pericardium.Benign tumors of the esophagus are rare and represent less than 1% of esophageal neoplasms. Leiomyoma is the most prevalent benign esophageal tumor These tumors arise from smooth muscle and have an intramural location. In some cases, leiomyoma presents as a pedunculated polyp. Around 60% develop in the distal third of the esophagus Typically, leiomyomas don't exceed 5 cm. However, giant leiomyomas of more than 20 cm have been reported Leiomyoma can occur in patients of any age, but the peak incidence is in the third to fifth decades of life. The ratio of cases in men and women is approximately 2:1 Preoperative diagnosis is difficult as esophageal leiomyoma can present as a posterior mediastinal mass on chest radiograph and can be seen as an incidental radiological finding Patients are asymptomatic in more than half of the cases Barium swallow is a widely used imaging technique for the diagnosis of esophageal lesions. It shows smooth filling defects in the esophageal lumen without mucosal damage. The tumor is generally mobile during deglutition Contrast-enhanced computed tomography (CT) scan with oral contrast is usually sufficient to confirm the diagnosis It is performed to visualize all layers of the esophageal wall. It can distinguish cystic from solid esophagus tumors. Leiomyoma appears as a homogenous, hypoechoic lesion surrounded by a hyperechoic region In our case, EUS was not realized. The diagnosis was oriented by a contrast-enhanced CT scan. A magnetic resonance image (MRI) was done to rule out differential diagnoses such as esophageal duplication cyst. It revealed a well-defined soft tissue mass on the posterior wall of the middle third of the esophagus.The use of the biopsy in the diagnosis is controversial. It is linked to many complications such as infection, bleeding, increased rate of intraoperative perforations, and technical difficulties. It is recommended to perform a biopsy in case of diagnostic doubt The main differential diagnoses include malignancies such as squamous or adenomatous carcinoma and leiomyosarcoma. Though, malignant transformation is very rare There are no clear therapeutic guidelines. Some authors recommend resection to rule out malignancy in all cases Minimally invasive surgery is a good option in tumors less than 5 cm The standard surgical approach for esophageal leiomyoma is a thoracotomy with enucleation without opening the mucosa which is easier, faster, and safer compared to resection A trans-hiatal approach can be performed for tumors located in the lower third of the esophagus An esophageal resection is appropriate for large tumors and those located at the gastroesophageal junction due to technical difficulties, poor wound healing in the defect of esophageal muscle, and lower esophageal sphincter dysfunction or loss following enucleation In our case, the contact of the tumor with the pericardium and aorta made us opt for a thoracotomy.In summary, we reported the case of a 47-year-old hypertensive patient complaining of dysphagia and vomiting due to a 6 cm leiomyoma in the middle third of the esophagus diagnosed by a CT scan and MRI. A successful surgical enucleation by a right posterolateral thoracotomy was performed.4Esophageal leiomyoma is a slowly growing benign and asymptomatic tumor. The symptoms appear when the tumor is large. The diagnosis is confirmed with a contrast-enhanced CT scan and EUS with biopsies.Surgery is the pillar of treatment. Tumor enucleation or esophageal resection can be performed depending on the size and location of the mass.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.Ethical approval for this study was obtained from the ethical committee of the hospital Mohamed Taher Mammouri.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Hazem BejiMahdi Bouassida.None.Hazem Beji and Mahdi Bouassida did the conception and design of the work, the data collection, and the data analysis and interpretation.Yassine Kallel and Mohamed Amine Tormane did the critical revision of the article.Mohamed Mongi Mighri and Hassen Touinsi did the final approval of the version to be published.No conflicts of interest.


Aggressive Angiomyxoma is a benign, slowly growing, locally aggressive and recurrent tumour that occurs in the pelvic-perineal region of females in their reproductive years. It presents as a painless, soft, gelatinous mass and metastasizes rarely. Suspicion can be made based on clinical examination and radiological imaging but final diagnosis is confirmed only after histopathology and immunohistochemistry. The choice of treatment is surgical wide local excision.2, who presented with a chief complaint of painless mass in left vulva which progressively increased in size in the past one year. Clinical examination revealed a large, cauliflower like, exophytic mass of 10 cm × 10 cm size. Radiological imaging confirmed involvement of lymph nodes. Wide local excision with adequate tumour free margin and depth was used as a treatment modality. The diagnosis was confirmed via histopathological examination of the excised specimen. There is no recurrence in the patient up to date.We hereby present a case of a 19-year, unmarried lady, with a body mass index of 21 kg/mAggressive Angiomyxoma is a rare tumour and it is most often misdiagnosed. This report highlights the importance of considering Aggressive Angiomyxoma as a differential diagnosis of vulval masses and the two-step surgical approach for its treatment in low resource setting. Aggressive Angiomyxoma (AA) is a rarely metastasizing, locally aggressive benign mesenchymal neoplasm, that presents as a painless mass involving the pelvic-perineal region of females of reproductive age –6. The s2 presented to the Gynaecological Out-Patient Department on 12th August, 2020 with a chief complaint of painless mass in left vulva which progressively increased in size in the past one year. The vulval mass was associated with difficulty in ambulation. She had no any significant co-morbidities or family history of similar vulval masses. On examination, an irregular cauliflower-like single mass of 10 cm × 10 cm, was seen arising from the left vulval region on a thick pedicle  scan of whole abdomen and pelvis was done for radiological assessment of the nature of the mass which revealed, a large exophytic, lobulated, heterogenous mass, originating from the left vulval region, suspicious of malignancy. Along with the mass, multiple subcentrimetric discrete enhancing left external iliac and bilateral inguinal lymph nodes were reported, which raised the suspicion of metastasis in the lymph nodes.She was admitted to the gynaecology ward with “vulval mass under evaluation” and a two-step surgical management plan was made due to unavailability of frozen section facility in our institute. In the first step the tumour was planned for wide local excision in view of excisional biopsy. In the second step, if the histopathological report was malignant then a revision surgery was planned to address the lymph nodes. So, after pre-operative counselling, detailed laboratory investigations and assessment of anaesthetic fitness was done, and surgery was performed on 19th August, 2020.A wide local excision was performed taking 1.5–2 cm tumour free margins all around and up to the inferior layers of the urogenital diaphragm under combined spinal and epidural analgesia , dyspareunia and change in bowel and bladder function , 6, 11. The physical examination may not reveal the true extent of tumour and internally it may invade the adjacent organs, so the diagnosis should not depend upon the physical examination . The diaOn gross examination of the tumour, it typically appears as tan pink to tan grey, uncapsulated, lobulated, solid and poorly demarcated mass with glistening smooth homogenous surface and some areas of necrosis or haemorrhage on the cut surface , 5, 11. The treatment of choice for AA is wide surgical excision , 2. HoweAA has a high rate of local recurrence, which can occur in decades, so it requires a long-term followup , 8, 11. AA is a rare, locally aggressive and recurrent, mesenchymal tumour with low metastasizing potential. It presents as a slowly growing painless mass in the pelvic-perineal region of females in the reproductive age group. Histopathology remains the gold standard tests for its diagnosis. Surgical wide local excision is the treatment modality of choice. Though AA is a rare tumour, treating it promptly, can prevent its local recurrences and invasion to local structures. This article highlights, the importance of considering AA as a differential diagnosis of exophytic/pedunculated large vulvar masses. As there are only 3 cases reported with involvement of lymph nodes, this article aids to challenge the classification of AA as a benign neoplasm and highlights the importance of further research in this case. Also, this article highlights about the two-step surgical approach based on the excisional biopsy report in low resource setting with unavailability of intraoperative frozen section.


The inflatable penile prosthesis (IPP) is a three-piece device indicated to treat erectile dysfunction. Although it is considered a safe procedure, it can result in complications, such as reservoir herniation. Literature is scarce regarding reservoir incarcerated herniation as a complication of IPP and its management. Surgery is required to reduce symptomatic hernias and properly secure the reservoir to avoid recurrence. An untreated incarcerated hernia may lead to strangulation and necrosis of abdominal organs, as well as implant malfunction. We present a rare case of a left-sided incarcerated inguinal hernia containing fat and a penile reservoir of a previous penile prosthesis implant in a 79-year-old man, as well as the technique used to correct it. The inflatable penile prosthesis (IPP) is the most common surgical treatment for erectile dysfunction (ED) and is usually indicated in pharmacologically refractory cases. The device is composed of dual intra-corporal inflatable cylinders, a scrotal pump, and a fluid reservoir ,2. It isWe present a rare case of a left-sided incarcerated inguinal hernia containing omental fat and a fluid reservoir of a previous IPP in a 79-year-old man, as well as the detailed technique used to correct it.A 79-year-old male presented to Urgent Care with a complaint of moderate intermittent pain in the left lower quadrant of the abdomen for three days. He shared that this had been a recurrent problem, with no other associated symptoms. His surgical history was significant for a penile prosthesis implant, which was performed at another service six years prior to this visit. A physical examination of the abdomen showed a non-reducible left inguinal hernia. The patient’s vital signs showed a heart rate of 66 beats per minute, respiratory rate of 16 breaths per minute, axillary temperature of 36.4°C, and blood pressure of 131/88 mmHg.A decision was made to approach this case with imaging studies. A pelvic computed tomography (CT) scan with contrast showed a fat-containing 8 cm left inguinal hernia Figures , 2. Fat The patient was taken to the operating room for a robotic transabdominal preperitoneal repair of the incarcerated hernia. A direct incarcerated inguinal hernia was encountered on the left side. The reservoir from his previous surgery was located inside the abdominal cavity, and there was a piece of omental fat trapped within the hernia sac that was entangled with the tubing that connected the reservoir to the pump of the penile implant Figure . It was Complete herniation of the IPP reservoir is an extremely unusual event, and literature is scarce in presenting detailed case reports of such complications, especially regarding incarcerated hernias, such as the one reported in this study.In the literature, the first record of inguinal hernia associated with penile implant malfunction is from 1998 in a series of two cases. One of the patients presented with a disruption of the tubing that connected the reservoir to the pump, and the other had the reservoir migrated to the scrotum. Both were associated with right inguinal hernias, and both had previous pelvic surgery; however, in contrast to our case, neither of these hernias was incarcerated .Sadeghi-Nejad et al. reviewed a database of 1,206 IPPs and found an overall herniation incidence of 0.07% to the inguinal canal or to the scrotum. Unlike in our patient, they were mostly associated with the immediate postoperative period and acute increase in intra-abdominal pressure (such as vomiting or coughing) [A cohort study of 246 IPPs performed by a single urologist reported two cases of inguinal hernia in a single patient with previous pelvic surgery. Different from our case, the hernia sac contained bowels but had no reservoir involvement. In addition, five other cases of inguinal hernias were reported in patients with no history of pelvic surgery. Of those, one hernia sac contained only bowels, and two contained partial involvement of the reservoir; the other two were asymptomatic and the doctor decided to follow up conservatively, therefore, they were not submitted to surgery .There is no consensus in the literature about whether previous pelvic surgery is a major risk factor for developing herniations. Most authors affirm that to be true because invasive procedures may cause adhesions, weakening of the pelvic muscles, and distortion of pelvic anatomy . HoweverMany IPP placement techniques have been proven to be successful, and yet there is no standard technique to assess this complication. It is evident that appropriate IPP indication, methodical preoperative assessment, and specific intraoperative and postoperative measures may contribute to decreasing the risk of adverse events .Even though IPPs are considered safe procedures with a very low rate of non-infectious complications, adverse outcomes should be studied because they are a possibility. This knowledge is fundamental to optimizing surgical outcomes and patient satisfaction.We recommend assessing the risk factors for reservoir herniation  before indicating any penile implant procedures. Moreover, we recommend a management approach that will also assure that the penile implant will continue to do its function normally without the need for any additional surgery.


Lymphangiomas are relatively rare benign congenital tumors of the lymphatic system. They are usually discovered during childhood and typically occur in the neck and axillary regions. Retroperitoneal lymphangiomas are a rare occurrence and represent 1% of all cases. Here, we presented a 70-year-old male who presented with abdominal discomfort and chronic constipation in the last three years. A computerized tomography scan showed a giant abdominal hypodense cystic mass measuring 195 x 145 mm, which laminates the abdominal aorta, the left iliac vessels, and the left ureter. The patient underwent surgical exploration. Due to the giant cystic volume, it was carefully opened, aspirated, and removed. The histopathological examination showed a retroperitoneal lymphangioma. In conclusion, giant retroperitoneal lymphangioma in an adult is a rare occurrence. The primary treatment is complete surgical excision. Histopathological examination is essential for diagnosis confirmation. Lymphangiomas are relatively rare benign congenital tumors of the lymphatic system. Usually discovered in children and localized in the cervical and axillary regions . RetropePatient information: a 70-year-old male with a medical history of hypertension and diabetes presented with abdominal distention and chronic constipation, evolving for three years with no other associated symptoms. The patient had no other symptoms such as vomiting, abdominal pain, or urinary tract symptoms.Clinical findings: on examination, the patient was afebrile with a good general condition. The vital signs were temperature: 37.3°C, blood pressure: 14/07 mmHg, and pulse rate: 90 bpm. Abdominal examination revealed a fixed painless renitent mass in the left lower quadrant of the abdomen measuring about 15 cm.Diagnostic assessment: laboratory tests showed white blood cells were 10 x 103/ml, C-reactive protein was 100 mg/dL, hydatid serology and tumor markers were negative. A CT scan showed a huge intraperitoneal hypodense cystic mass of the left abdomen, thin-walled with no proper vascularization, measuring 195 x 145 mm in width and 245 mm in length. It laminates the abdominal aorta, the left iliac vessels, and the left ureter with no adjacent organ invasion without satellite lymphadenopathies (opathies .Diagnosis: the main differential diagnosis is mesenchymal tumors, germ cell tumors, and hydatid cysts since echinococcosis infections are endemic in our country; therefore, a fine needle aspiration was not an option.Therapeutic interventions: the decision was to perform a surgical resection. The patient underwent a midline laparotomy. The cyst was found in the retroperitoneum on the left side and measured 20 x 15 cm ( x 15 cm . A monob x 15 cm . SurgicaFollow-up and outcome of interventions: the operation was complicated by a pancreatic fistula discovered on 20 postoperative days and was treated with Sansdostatine injection, radio-guided drainage, and endoscopic sphincterotomy. The patient was discharged after 27 days without complications. The histopathological examination of the specimens showed large dilated cysts lined by flattened endothelial cells, suggestive of cystic lymphangioma and a benign cystadenoma of the pancreas (pancreas . A 6 monPatient perspective: according to the patient, his experience with his disease was unexpected. Symptoms that were not intense involved diagnostic testing and surgical treatment, with an extended follow-up. At the end of the process, he is satisfied.Informed consent: written informed consent was obtained from the patient for participation in our study.Lymphangioma is a rare, benign fluid-filled cystic anomaly originating from lymphatic vessels with an excellent prognosis. It frequently appears in the head and neck, with a high prevalence in children and young adults and equivalent in males and females ,2. LymphLymphangiomas are frequently multilocular cystic masses that are anechoic or contain echogenic debris on sonography. A CT scan with intravenous contrast may enhance the cyst wall and septa. Typically, the fluid component is homogeneous and has low attenuation values. In the presence of chyle, negative attenuation values can occur. Calcification is possible but uncommon. The intra-cystic attenuation values may mimic a solid tumor mass or an abscess if bleeding occurs. Lesions can move through adjacent retroperitoneal anatomical compartments, displacing organs and vessels. They can compress and infiltrate vital structures and cause complications such as intra-cystic hemorrhage, cyst rupture, volvulus, and infection. The sonographic appearance of a septated cystic mass with clear fluid is thought to be a sign of lymphangioma. However, preoperative diagnosis is frequently difficult because there is little to differentiate them from those of other cystic masses. Because of its rarity, the lesion is usually not considered in the differential diagnosis. Cystic lymphangioma is distinguished by an elongated shape and a crossing from one retroperitoneal compartment to another. On CT, cystic lymphangioma appears as a large, thin-walled, multi-septate cystic mass. A teratoma with a considerable cystic component may depict a lymphangioma, as mentioned in our case´s CT scan -8.et al., Khan et al., and Tripathi et al. have reported similar cases in which complete excision was supported as the preferred treatment [The primary differential diagnosis of retroperitoneal lymphangiomas is hydatid cyst, mesenchyme tumors, lymphomas, and germ cell tumors . Radicalreatment ,11,12. Rreatment -15. On hreatment . The finreatment . After sRetroperitoneal lymphangiomas are a rare adult lesion. Radiological examinations can provide pre-operative diagnosis, but in cases with large cysts and advanced age, the diagnosis can be inconclusive, and the final diagnosis should be attempted by histopathological examination of the specimen, like with our patient. Surgical monoblock resection is a gold standard treatment option with an excellent prognosis, symptomatic relief, and cure.